Download Clinical Governance - Luton and Dunstable University Hospital

Clinical Governance
Acute Care Unit
18/05/2009
Mrs. SB
Admitted 02/04/09
• 56, admitted at 07.23 from Nursing Home
• Diarrhoea, drowsiness, fever
• Dense left hemiplegia and dysarthria following
haemorrhagic stroke in 1995
• Function:
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Immobile
Transfers with hoist
Needs help with washing and dressing
Feeds herself
Communicates – no mention of cognitive problems
Long-term urinary catheter ? continent of faeces
DVT left leg 2006
Type 2 diabetes and Hypertension
Chronic renal impairment and anaemia
Recurrent UTIs (Allergic to Penicillin)
Diagnosis
• Sepsis – likely source:
– catheter-associated UTI
• IV fluids
• IV sliding scale insulin
• IV ciprofloxacin and IV gentamicin given
(one dose each at 12.45 on 02/04)
• Catheter changed
Progress
• Continued to have profuse, offensive
diarrhoea
• CSU and stool specimen sent
• Remained pyrexial ~ 38
• Antibiotics changed to oral, but not given:
“5. = patient nil by mouth”
• Obs. at 18.00 on 03/04: HR 113, BP
140/75, urine output 20 ml/hour
Cardiac Arrest
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20.20 on 03/04
Became unresponsive mid-conversation
EMD, briefly VT then asystole
Death confirmed at 20.45
Microbiology
• Urine – Pseudomonas and Enterococcus
• Stool – Campylobacter
• Coroner and Health Protection Agency
notified
Critique
• Delay of > 5 hours in giving first doses of
antibiotics
• Only 1 dose of antibiotics received by
patient
• Discussion in notes about changing back
to IV – no action taken
Mr. MG
Admitted 04/04/09
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57, admitted at 06.22, from own home
Increasingly painful, swollen legs
Fluid leaking from skin
2 courses of antibiotics in past 3 months
Dressings changed by Practice Nurse
once / week
• Type 2 diabetes and ischaemic heart
disease (MI in 2000)
• History of heart failure and AF (now in
sinus rhythm)
• Obesity
Medication
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Nifedipine
Frusemide
Frusemide
Digoxin
Carvedilol
Metformin
Rosiglitazone
10 mg
80 mg
40 mg
250 μg
3.125 mg
1g
4 mg
tds
o.d.
lunchtime
o.d.
o.d.
b.d.
b.d.
On Examination
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Apyrexial
HR
105
BP 117/87
Sat.
97% on air
BM
11
GCS
15/15
Heart sounds: NAD
Chest:
NAD
Abdomen:
NAD
• Legs:
– Oedema to knees
– Erythematous
calves
– Areas of broken
skin
– 2 ulcers on left calf
(not deep)
– Pedal pulses not
palpable
Investigations
ECG – Sinus rhythm, rate 112, bifascicular block,
poor R-wave progression
CXR – Cardiomegaly, upper lobe venous distension
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Hb
WBC
Neut.
Plt.
MCV
• INR
12.1
8.7
6.55
254
84.2
1.6
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Na
K
Urea
Creat.
Bil.
Alb.
CRP
126
5.5
13.9 (6.7)
145 (105)
37
29
8.6
Management
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Analgesia
IV Tazocin – first dose given 2 p.m.
IV fluids - had total of 1 litre
Digoxin stopped, frusemide dose reduced
Surgical opinion:
– Pulses present on Doppler
– ?DVT
• Echocardiogram / renal tract ultrasound
Cardiac Arrest
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17.00 on 04/04/09
VF then asystole
Death confirmed 17.20
Referred to coroner
Cause of death
1.a. Left ventricular failure
1.b. Ischaemic heart disease
2.
Hypertension, diabetes,
congestive cardiac failure
Critique
• Diuretics were not given
• IV fluids were given
• Delay in giving first dose of antibiotics
(? relevant)
• Appropriateness of Tazocin (or any
antibiotic)
• Not prescribed prophylactic Clexane
Mr. RR
Admitted 18/04/09
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59, admitted at 07.05 from home
Lives with wife
Breathlessness and haemoptysis
Known to oncologists at Stoke Mandeville:
– Ca bladder diagnosed 18 months ago
– Resected and ileal conduit fashioned
– Adjuvant chemotherapy – 6 months
– 3 weeks ago – cerebellar metastases
– Completed 5 # DXT 4 days ago
– On dexamethasone 8 mg o.d.
• DVT left leg November ’08 – treated with
Tinzaparin (stopped 3 weeks ago)
On Examination
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Apyrexial
HR
155
BP
125/88
RR
24
Sat.
92% on 15L
BM
25.4
GCS
15/15
• Heart sounds: NAD
• Chest:
NAD
• Abdomen: distended,
lower laparotomy
scar, iliostomy
• ECG – 136, sinus
tachycardia
Bloods
Hb
WBC
Plt.
13.6
10.1
127
INR
1.1
D-dimer
>1000
Na
K
U
Cr.
Bil
Alb
134
4.9
13.0
156
28
28
CRP 283.8
pH
pO2
pCO2
HCO3
BE
Sat.
7.237
10.9
2.23
6.9
-19.5
93.7%
Treatment
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IV fluids (received 3 litres in 12 hours)
IV sliding scale insulin
CT-PA requested – arranged for that evening
Observations at 17.45:
– T = 37.8
– HR 137
– BP 105/77
– RR 32
– Sat. 89% on 15L
Course
• Blood pressure continued to drop, despite
fluid resuscitation
• Discussed with ITU – not for intubation
• Reteplase 10 units IV given – no
improvement
• Cardiac arrest ~ 18.15
• Death confirmed 18.27
Critique
• No antibiotics given despite evident sepsis
• Not given Tinzaparin despite suspicion of
PE
Discussion
Common Theme:
Should any of these patients have
been subjected to a resuscitation
attempt?