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Clinical Governance

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: Immobile Transfers with hoist

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Clinical Governance

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  1. Clinical Governance Acute Care Unit 18/05/2009

  2. Mrs. SB Admitted 02/04/09

  3. 56, admitted at 07.23 from Nursing Home Diarrhoea, drowsiness, fever Dense left hemiplegia and dysarthria following haemorrhagic stroke in 1995 Function: 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)

  4. 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

  5. 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

  6. Cardiac Arrest • 20.20 on 03/04 • Became unresponsive mid-conversation • EMD, briefly VT then asystole • Death confirmed at 20.45

  7. Microbiology • Urine – Pseudomonas and Enterococcus • Stool – Campylobacter • Coroner and Health Protection Agency notified

  8. 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

  9. Mr. MG Admitted 04/04/09

  10. 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

  11. Medication • Nifedipine 10 mg tds • Frusemide 80 mg o.d. • Frusemide 40 mg lunchtime • Digoxin 250 μg o.d. • Carvedilol 3.125 mg o.d. • Metformin 1 g b.d. • Rosiglitazone4 mg b.d.

  12. 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 On Examination

  13. Hb 12.1 WBC 8.7 Neut. 6.55 Plt. 254 MCV 84.2 INR 1.6 Na 126 K 5.5 Urea 13.9 (6.7) Creat. 145 (105) Bil. 37 Alb. 29 CRP 8.6 InvestigationsECG – Sinus rhythm, rate 112, bifascicular block,poor R-wave progressionCXR – Cardiomegaly, upper lobe venous distension

  14. Management • 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

  15. Cardiac Arrest • 17.00 on 04/04/09 • VF then asystole • Death confirmed 17.20 • Referred to coroner

  16. Cause of death 1.a. Left ventricular failure 1.b. Ischaemic heart disease 2. Hypertension, diabetes, congestive cardiac failure

  17. 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

  18. Mr. RR Admitted 18/04/09

  19. 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)

  20. 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 On Examination

  21. Hb 13.6 WBC 10.1 Plt. 127 INR 1.1 D-dimer >1000 Na 134 pH 7.237 K 4.9 pO2 10.9 U 13.0 pCO2 2.23 Cr. 156 HCO3 6.9 Bil 28 BE -19.5 Alb 28 Sat. 93.7% CRP 283.8 Bloods

  22. Treatment • 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

  23. 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

  24. Critique • No antibiotics given despite evident sepsis • Not given Tinzaparin despite suspicion of PE

  25. Discussion Common Theme: Should any of these patients have been subjected to a resuscitation attempt?

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