North Shore Hospital report - New Zealand Doctor

Opinion 07HDC21742Complaint Action form by [Mrs C‘s] daughterInterview notes [Registered nurse]Interview notes [Registered Nurse]Interview notes [Medical registrar]General Manager [Adult Services] letter to Complaints Manager 15 November 2007.Appropriateness of Nursing ObservationsOver the stay, [Mrs C‘s] observations were recorded TDS [three times daily] and the findingswere similar, with the blood pressure between 110–120/7550, pulse 8598, respiratory rate2024 indicating continuing dyspnoea, O 2 saturation 9097% on oxygen at 2 l/min, and apain score 0–1/10. On 26 September , [a] Nurse noted [Mrs C‘s] O 2 saturation dropped withoutO 2 therapy. The nurse on the afternoon shift of the 26 September reported [Mrs C] was shortof breath. Oxygen remained on at 2–3 l/min throughout her stay. She had continued dyspnoea,tiredness and lethargy. Oxygen was prescribed, administered and its effect monitored.The effect of the diuretic treatment for heart failure was monitored by fluid balance chart anda good response was noted following the IV 80mgs frusemide at 9.50pm on 25 September inthe ECC. On the 26 September [Mrs C] had IV 40 mg at 7am and 40 mg oral at 2pm, with aurine output of 2170mls for the 24 hours.On 27 September the urine output was 780mls with an input of 500mls. The nurses on bothAM and PMs underlined the urine output in the clinical notes. On that same morning AMround the doctor noted basal crackles and a JVP + 4 cm, with decreased pedal oedema.[Mrs C‘s] respiratory rate triggered a NEWS score of 1 throughout her stay, which accordingto Waitemata NEWS procedure required the nurse to inform the nurse co-ordinator in chargeof the ward and to record the observations two hourly to monitor the patient‘s condition. Theeight sets of observations recorded in the 49 hours of [Mrs C‘s] inpatient admission allequalled a NEWS score of 1. The score of 1 referral policy was followed once, withobservations recorded two hourly after a set. At interview [an RN] indicated the NEWSprocess was a guide for when to call a doctor for nursing staff. [She] reported ―that, given theNEWS score of 1, four hour observations were appropriate. This was fairly standard in herward.‖ This is contrary to the NEWS process that, with a score of 1, requires the nurse to―inform nurse co-ordinator‖ and to ―Increase frequency of observations to two hourly‖ toestablish a trend. There was a facility through the Critical Care Outreach Service for patientswho trigger the NEWS system regularly, or have high scores, to be reviewed. This facilitywas not used in [Mrs C‘s] case.The Waitemata DHB policy document on the North Shore Early Warning System states quiteclearly, the purpose of the ―track and trigger system is to identify the acutely ill adult at riskof deteriorating and relies on accurate recording of simple physiological variable‖. Therationale for its introduction was the increased acuity of patients in wards and ―to improverecognition and quality of care that acutely ill patients receive‖. The policy goes on to say―The total NEWS score and subsequent trending of this, through the regular recording ofobservations, provides a clear overview of the patient‘s physiological condition … Employeesof the Waitemata District Health Board who breach the Policy may be subject to performancereview, disciplinary action or compulsory retraining.‖The performance level in regards to the NEWS procedure does not meet the New ZealandNursing Council of New Zealand 2005 competency ―1.1 Accepts responsibility for ensuringthat his/her nursing practice and conduct meet the standards of the professional, ethical andrelevant legislated requirements with Indicator: Practises nursing in accord with relevantlegislation/codes/policies and upholds client rights derived from that legislation.‖ Given thereason for implementing the NEWS score was to aid nurses‘ decision-making, its lack ofsystematic use would meet with severe disapproval within the nursing profession.April 2009 85