Aspects of Anesthetic Practice from the Journey of a Patient - Case Study Example

HEA 3018 Anaesthetic Practitioner Module Assignment by Edward Cunningham No. Edge Hill ' I certify that confidentiality has been maintained throughout this piece of work' Word Count 2968 HEA 3018 CRITICAL REFLECTIVE ASSIGNMENT OF AN ASPECT OF ANAESTHETIC PRACTICE DRAWN FROM A PATIENTS JOURNEY The objective of this assignment is to analyse a phase of anaesthesia within perioperative practice surrounding a critical incident during a patient's journey through anaesthesia. The critical incident involved a patient who while under spinal anaesthesia became suddenly very unwell and experienced an anaphylactic reaction in response to an intravenous antibiotic. The identity of this patient will remain undisclosed with total confidentiality in accordance with the Nursing and Midwifery Council (NMC) The Code: Standards of conduct, performance and ethics for nurses and midwives' (2008:1) states: you must respect people's right to confidentiality. The patient will be referred to as "the patient" throughout this assignment. I intend to utilise Driscoll's (2000) model of reflection (appendix 1) to discuss and analyse my role within perioperative practice and management of this emergency situation. This model provides a structured framework of three main elements with keys questions. According to Driscoll & Teh (2001:95) reflection helps practitioners to make more sense of difficult and complex practice. The first step in the Driscoll's model is "What", "returning to the situation". This critical incident occurred in a 68-year-old patient for elective hip replacement, on the orthopedic list, scheduled for spinal anesthetic with sedation. This was the last operating theatre operating late in the evening, this was the last case; therefore the department was quiet with only one team working. I was the senior practitioner on that shift. I accompanied the consultant anaesthetist on the preoperative ward round. According to Wicker & O'Neill (2006) the anesthetic practitioners role begins prior to the patient entering operating theatres and suggests the advantages of preoperative visiting helps to gain information to plan the patient's care. As part of my role prior to the commencement of the orthopedic operating list was to set up the equipment myself with a check on the operating room environment, full drugs check, anticipating any emergency (Chambers et al. 2002 : 272). All the necessary checks on monitoring and equipment were performed and documented in accordance with (The Association of Anaesthetists of Great Britain and Ireland 2004) (AAGBI) guidelines. Controlled drugs and all cupboard medication were checked in line with local policies, pharmacy "A-Z medicines required for theatre stock protocol". Wicker & O'Neil (2006:93) discuss practitioners developing safe working practices, including preparation of drugs before the operating list. The patient's journey from the ward to the operating theatre was as planned, the spinal anaesthetic was successful, patient was sedated, positioned with assistance from the surgeon, and oxygen was administered via face mask at 5 litres, then transferred to the operating theatre and connected to the monitors. "Time Out" the "STOP", moment in theatre (World Health Organization, 2009) (WHO), Surgical Safety Checklist (Appendix 2) was implemented with no allergies verbalised by me, the allergy elements on the care pathway and theatre check list were checked by the scrub practitioner and written on the theatre patient/procedure information board by me. The surgeon requested a perioperative dose of antibiotic shortly after surgery commenced; I brought in the antibiotic Cefuroxime into the theatre for administration by the anesthetist. A few minutes after this was injected, the patient rapidly became pale, clammy and diaphorectic, the monitor alarmed showing the oxygen saturation dropping from 99% to 88%, the blood pressure and heart rate reduced dramatically. The anesthetist requested a pressure bag to increase the rate of fluids. The surgeon asked what was happening and the anaesthetist requested that he stop surgery to assess the patient. The airway was assessed and the patient was making grunting and wheezing noises. As an advanced life support (ALS) provider (Appendix 3) I am aware of the signs and symptoms of anaphylaxis, especially after antibiotic administration followed by airway difficulties, with signs of shock. I expressed to the anaesthetist that this may be anaphylaxis, they agreed. Approximately 15% of anaesthesia-related anaphylactic episodes are due to antibiotics, the consequence of anaphylaxis to intravenous antibiotics may be catastrophic (Moss 2003: 521). Resuscitation Council (UK) (2008:6) states anaphylaxis is likely when all of the following 3 criteria are met: Sudden onset and rapid progression of symptoms Life-threatening Airway and/or Breathing and/or Circulation problems Skin and/or mucosal changes (flushing, urticaria, angioedema) Further adding a precise definition of anaphylaxis is not important for the emergency treatment of an anaphylactic reaction. There is no universally agreed definition. The European Academy of Allergology and Clinical Immunology Nomenclature Committee proposed the following broad definition: Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. This is characterised by rapidly developing life-threatening airway and/or breathing (Resuscitation Council (UK) (2008: 9) A structured approach using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) was used, this is the standardised approach in assessment of all critically ill patients. (Advanced Life Support (ALS) 2006:8) (Appendix 3). The underlying principles are, so a complete initial assessment, then treat life-threatening problems before moving on to the next part of the assessment. The breathing was noisy; oxygen saturation was poor, clear signs of circulatory difficulties. I exposed the chest, checked the patient's torso and there was a urticaria rash. We agreed that this was probably an anaphylactic reaction. The airway was compromised with signs of obstruction, the need for a more definitive airway was recognised and the anaesthetist requested a laryngeal mask (LMA) size 5. ALS (2006:8) state airway obstruction untreated causes hypoxia and risks damage to the brain, kidneys and heart. Inserting the LMA was difficult as the patient was position laterally for the hip replacement procedure, with tight table attachments and an open surgical wound. However, this was placed successfully, during assisting with this procedure I asked the staff nurse circulating in theatre to collect adrenaline, chlorphenamine and hydrocortisone from the anaesthetic room cupboard, cupboard number 2 shelve 2; these are the drugs required for anaphylaxis from the algorithm (Appendix 4) and are stored together for emergency use. They returned with adrenaline and stated they could not find the other drugs, chlorpheramine and hydrocortisone. I asked that they look again explaining the exact location, they were anxious at this stage and returned saying "they are not there" and stated, "this is ridiculous", I acknowledge that they were stressed. I requested they ask the recovery practitioner come into theatre, they did, they also could not find these drugs in the anesthetic room cupboard, I asked them to look in another theatre and return with the drugs as soon as possible. The recovery practitioner returned many minutes later stating, the other theatres were closed as we were the only theatre working the cupboards were locked, including the pharmacy cupboards with the keys placed in the safe in the theatre main office, and they said they were not allowed the code for the key safe as they were bank staff. The anaesthetist stated that he wanted these drugs now and could "I please get them now". I checked the anaesthetic room and these drugs were missing. Frustrated, I obtained the keys from the safe and opened the second theatre drug cupboard and obtained the drugs. This can have serious consequences for the patients which is especially true in case of drug-induced anaphylaxis where death may ensue within five minutes of the incident. The surgery was withheld temporarily, the surgeon and two scrub nurses were observers during this hectic time and remained scrubbed distanced at the back of the operating room, I assumed waiting to recommence surgery. However, I felt a strong division, a scrub team and an anesthetic team. This I presume was due to lack of orientation about what they needed to do. This perhaps needs revising since in such emergencies teamwork would be the essence of success. Just due to the fact that this was an anaesthesia related event, it did not mean that only anaesthetic staff would be involved in the care. Although I was irritated in the beginning, later I realised that this may also be due to the fact that they are also inexperienced in such an incident, and they do not know what is needed to be done to help (Catchpole et al, 2008:702). A good outcome from such care is only possible through anticipation, readiness, evidence-based care, and effective teamwork (Resuscitation Council (UK) 2008: 7). With the LMA secured, the anaesthetist asked the surgeon to continue, the surgeon explained that he intended to use uncemented prosthesis to complete the procedure more quickly. Following the drugs treatment from the algorithm the pulse was felt to be bounding and the rash reducing. Following the anaphylaxis algorithm was absolutely necessary to manage this condition. The intravenous fluid was running, and the patient quickly showed signs of improvement (Murray et al, 2005:1129). I requested that the recovery practitioner bring the difficult intubation trolley and the resuscitation trolley to theatre, the anesthetist said there is no need for these, I however felt weighing up the situation with limited staff in the department that I would like these close by, these were brought to theatre. The next phase, "So what", "understanding the context". At the time I felt I was skilled and competent to assist with the situation, with all the checks in place for drugs in emergencies. I now feel that I looked inefficient in front of my colleagues and personally at the time I felt I had let the patient down. My feelings and experiences were very acute at that time, with mixed feeling of, tension, anxiety, nervousness, although I was basically calm on the outside. The anaesthetist although irate when the necessary drugs were not available appeared very confident and this could have been due to his exposure to several similar cases and experience in management of such situations. My academic learning and training as an ALS provider made me aware that anaphylaxis in an event of anaesthesia poses challenges to the skill and competence of the anaesthetist, where maintenance and management of several vital parameters of the patient is of utmost importance. Discussions with this with the scrub and circulating practitioners after the incident was useful, they explain that they did not feel confident enough to get involved, one stated that they froze and hoped it would be resolved quickly, the qualified practitioners said they had taken the Intermediate life support (ILS) course annually, but had never need to use it and felt it was more useful for cardiac arrest. The next step in Driscoll's model (2000) involves "Now What", which essentially are measures to modify future outcomes through this reflective process. Despite a successful outcome, I think there is huge scope for change. Evaluating this reported critical incident with the pharmacist who used a root cause analysis tool (Appendix 4) to investigate why these drugs not being available why all the cupboards were locked, why the recovery practitioner did not have access to the keys. After investigations it became clear that another anesthetic practitioner removed these drugs earlier in the shift as they were needed in another theatre for a patient with known allergies, the practitioner could not locate these drugs in the theatre they were working in and removed these drugs from the theatre cupboard I was working in without informing anyone, this practice is not uncommon. Subsequently when they finished their list they locked the drug cupboards and keys in the safe. From my experiences in this event, I drove this issue in anaesthesia to be discussed in the clinical governance meeting with support from the senior pharmacist investigating this incident and now the situation has changed. This has been addressed and a local policy will be implemented stating: Borrowing drugs from another anaesthetic room has now been stopped, required drugs must be taken from the pharmacy stores, which remain open though opening times of the theatres, should these not be available the anaesthetic practitioner should request the removal of "any drug" from any anesthetic room from the anesthetist, who must approve this, the anesthetic practitioner should also be informed. In the event that this happens a critical incent will be completed and the pharmacy department will review and reassess stock levels for each theatres. Further to this meeting with the pharmacist I suggested from observations and experience working in other hospitals to have an anaphylaxis box in each anesthetic room with all the necessary drugs with the laminated algorithm contained within it. This is easily identified and can be confidently collect by anyone and easily pointed out during orientation and induction of staff the same way "emergency resuscitation drugs in red boxes" are on the resuscitation trolleys and in each anaesthetic room. This was agreed by the pharmacist and the theatre manager; this is in the process of being implemented, the medicines policy will be amended accordingly. This is supported by Lewis, (2000, 267) who suggests there may be a system that all emergency medications can be accessed from a common pool during any surgery in any theatre. A further change in practice has been agreed by the theatre manager from this incident. During any surgery all keys for each anesthetic room are given to the last practitioner on the shift (this will never be an agency or bank staff member), ensuring they have access to each anesthetic room cupboard if required. Having highlighted the need for teamwork irrespective of their areas of specialties, all staff should be involved in care during emergencies, since team work only can deliver best results. This is reasserted in the Nursing and Midwifery Council (NMC) (2008) Code of Standards, which highlights the importance of working effectively as a team for the benefit of the patient. To enable team members to feel confident, I am happy to note that all theatre staff as a part of induction and orientation will now be shown all emergency equipment and emergency medications, including the new "Anaphylaxis Box", together with the key system fully explained. One of the major reasons that the other staff did not respond proactively may be lack of knowledge (Hepner et al, 2004: 1099). Although all staff may not be able to deliver specialised care such as anaesthesia, they may get involved in making calls and collecting requested items sooner. The example where the scrub team remained scrubbed observing during this incident can be cited here, and they may should this occur again be involved in this process through proper training and orientation. As an ALS instructor I would recommend simulation of emergencies in theatres to assist and highlight the need for team member's involvement. The recovery room care is very important, where investigation after anaphylaxis are required, the usual investigations appropriate for a medical emergency, e.g., 12- lead ECG, chest X-ray, urea and electrolytes, arterial blood gases etc. These were requested and obtained by the anaesthetist and sent for analysis by the recovery practitioner. Patients who have had a suspected anaphylactic reaction (i.e. an airway, breathing or circulation (ABC) problem) should be treated and then observed for at least 6 hours in a clinical area with facilities for treating life-threatening ABC problems, local policy based on the Resuscitation (UK) (2008) guidelines, myself, the recovery practitioner or the anesthetist were unaware of these required observations and only became apparent when the patient was deemed ready to return to the ward where the ward night nurse refused to care for the patient based on the history. As this is a small hospital with no facilities of High Dependency Unit (HDU). I see a lapse in my part here. Knowing the patient's condition in the operating room, I could have alerted the ward staff earlier enabling the ward manager to arrange the staff skill mix based on workload, this event happened during handover period for ward staff from day staff to night staff with provision for stable patients only from that day's workload. I could have informed them following this event in the operating theatre, but somehow I missed this communication, this may be due to work pressure of handling the incident (Elisha, 2008: 289). I made a mental note that, next time in such events, I would inform them early so they can arrange the staffing without any sense of pressure. Evaluating this, I relate this to the already highlighted need for team work and effective communication; this must include the patient's full perioperative journey. I have since learnt the protocol for blood samples for analysis which are provided by the local NHS Trust, this has also been discussed at the theatre unit meeting. In this assignment I have maintained absolute confidentiality about the patient's identity. I selected Driscoll's framework to explore a critical incident during an event of anaesthesia in my practice and have provided the rationale. Within our hospital environment, I suggested some changes in the current practice based on my thoughts, personal feelings, experience, risk assessment, root cause analysis investigation and current evidence of care in the relevant area of practice. Anaesthetic care in a preoperative critical incident has legal and political issues, and the only way to ward off or address these issues is to deliver prompt and evidence-based care as a team. I have maintained my ethical responsibility towards the patient and the team. In every step of my reflective account, I have placed evidence from literature as a support. I have identified areas of good practice, and areas of practice within this patient's journey through this critical incident where potential risks are involved and where improvements are necessary. I have also suggested ways to drive these issues forward based on evidence and risk assessment. Thus action plans to changes in practice, have been formed which I can use in my future practice with a better outcome for all. In this way, I feel, I have demonstrated competency skills in my practice in this incident. My role, practice and communications were well delineated in this assignment. This reflection and analysis has increased my awareness of my role and responsibilities, those of other team members, the need for an effective environment for the team, patient confidentiality, education and training, and support within the team. The theatre team meetings have become more productive and practitioners are aware of developments and changes within the department. 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Waugaman, WR. and Lohrer, DJ., (2000). From nurse to nurse anesthetist: the influence of age and gender on professional socialization and career commitment of advanced practice nurses. J Prof Nurs; 16(1): 47-56. Wolf, ZR. and Zuzelo, PR., (2006). "Never Again" Stories of Nurses: Dilemmas in Nursing Practice. Qual Health Res; 16: 1191 - 1206. Working Group of the Resuscitation Council (UK) (2008). Emergency treatment of anaphylactic reactions: Guidelines for healthcare providers. Resuscitation Council (UK) London; 6-29. Appendix 1. Driscoll's (2000) Model of Reflection Driscoll, J. (2007) Practising Clinical Supervision: A Reflective Approach for Healthcare Professionals. 2nd ed. Edinburgh: Bailliere Tindall Elsevier Read More