Unexpected cardiac arrest during anaesthesia - Case Study Example

Informatics Project Introduction Case This is the case of an 80-year-old male who recently underwent a cataract surgery and intraocular lens implant. During surgery, while in the operating room in a day surgery centre, the patient had a cardiac arrest. ACLS was initiated, and the patient was brought to the recovery room. In the recovery room, the patient was intubated and was placed on ventilator. At this juncture, the patient needed a transfer to higher level of care to a hospital, where more intensive therapy can be initiated to tend to the patient's needs. Care Issues In this practice environments, the act of intubating a patient sets off a cascade of events that quickly take the patient out of care setting into the intensive care unit (ICU). This patient needs to be transferred to a hospital where intensive care can be instituted in the appropriate environment. In this setting, the fact that the patient is being treated in a day surgery centre indicates there is lack of facility, and although the patient has been placed under ventilator in the recovery room, the system is inadequate to manage such situations. Although the patient needs transfer, increasingly, hospital overcrowding leads to a delay in transfer and ventilator management falls upon the relatively inexperienced day surgery care staff. The care issues based on the above assessment data are mainly threefold. The first and foremost is to receive the safest treatment possible. Next in order is to receive it on time. Lastly, is to pay the least amount of money. Fulfillment of these issues is to formulate a patient flow based on these mutually exclusive internal and external facts into comprehensive standards that can guide clinical practice and events, ultimately leading to patient satisfaction. Obviously, this patient will have to be admitted into the intensive care unit, and intensive care cannot be seen without the continuum of care. The continuum of care spans the entire process of therapy and care for this patient. As it is exemplified here, this process would involve different treatment and care units, such as, day surgery operating room, recovery room, and most probably through the possible transfer, to a hospital emergency room followed by care in the critical care unit of that hospital. Informatics Application Current relevant research indicates that information transaction in clinical care processes are highly overloaded with information. Control of this information, appropriate analysis, and their timely implementation is necessary for the targeted and intended outcomes in terms of patient care and patient satisfaction. In healthcare arena, the number of deaths due to errors is considerable, and this surpasses the number of deaths from other major illnesses with high mortality rates. The single leading type of error is medication error. These errors result in increased charges per error, save the costs of litigations. It has been suggested and recommended that information systems could reduce the mistakes considerably (Thomson et al., 2009). The current ACLS course philosophy also goes in the direction of prevention. Despite preventive attempts, there have been occasions where critical events such as arrest occur. The main adjunct to these courses has been the necessary arrival of outreach teams. These are invariably intensive therapy unit (ITU) nurses whose role it is to assess and identify patients who are compromised and need corrective therapy. That may mean treatment on the ward or transfer to a critical care area. Taylor et al. (1976) conducted a study of 41 cardiac arrests in patients who were otherwise healthy but were undergoing elective surgery. The principal cause of these deaths was due to hypoxic, anoxic arrest. Of these 41 arrests, three were successfully resuscitated. Once cardiac arrest has been determined, one person should start CPR, another sent to call the resuscitation team if not already done so and to then bring the resuscitation trolley to the patient. The anaesthetic practitioner, as part of the resuscitation team responding to the call should, when he or she arrives, make themselves known to the person running the resuscitation attempt and then as appropriate check and use the airway management equipment they have selected. It should be noted that when ventilating the patient, before inserting a laryngeal mask (LMA) or endotracheal tube, the ventilations should be delivered with a 1-second inspiratory time. Once an LMA or an endotracheal tube has been inserted then compressions and ventilations can be independent of each other. The sequence of events is going to depend on the location within the hospital, the availability of staff and distance for the resuscitation team to travel as well as many other variables. Therefore, any success will be influenced by these factors. This patient was unconscious and was not breathing. Under this circumstance, the patient will be ventilated with 100% oxygen and have administered 10 ventilations for approximately 1 minute, and then circulation will be re-evaluated. If the patient has not recommenced breathing then another 1 minute of ventilation will be performed with a further re-evaluation. This will continue until the patient starts breathing, help arrives or the patient succumbs to a cardio-respiratory arrest, in which case chest compressions are started and the 30:2 ratio is applied. The form that help takes will depend on local protocols covering this eventuality (Taylor, , Larson, & Prestrich, 1976). Since care is not possible in this facility, the patient will need to be transferred. Emergency medical technicians will be involved in such protocol during resuscitation in the day care surgery centre and also on transfer, since the quality, facility, and standards of care are highly inadequate there. The patient safety is of utmost importance, and although transfer involves higher financial implications for the organization, in the long run, these would be beneficial for the organization. Health informatics principles suggest that the technicians while at recovery and in transit would be able to perform an in-depth patient assessment, provide advanced cardiac life support (ACLS), would be able to interpret ECGs, perform advanced airway management techniques including endotracheal intubation, administer more advanced medications as permitted by law, and operate monitors and other complex equipment. From the point of view of the patient, the issue of patient survival is the first and most important goal. Without resuscitation, cardiac arrest leads to sudden cardiac death. The public health impact of sudden cardiac death is heavy, since in the United States, the survival rates of such patients has been estimated to be between 1 and 20%. The profile of the patient is well known, and this matches with this scenario. The requirement is fast and optimal hospitalization that may increase the rate of survival. According to the type of cardiac attack, the procedure of assumption of responsibility may vary (Lindgreen & Ames, 2005). The implications for the organizations may be immense if a decision to transfer in order to institute adequate care is delayed. Evidence suggests 95% of the sudden cardiac arrest victims die before reaching the hospital. This also highlights the interest for predicting the risk of death following a cardiac arrest event and the need to analyze the events that would have occurred during care to provide prognostic information. Data mining methods and application of health informatics can provide this prognosis and delineate these factors more effectively. This could also elucidate the relationship of these variables, importance of those, and means to control or modify those variables to improve prognosis. It has been well documented that timeliness and the quality of care provided by this staff have significant implications on patient outcome. Differences in outcomes are directly related to the quality of these interventions, and these differences may have significant impacts on health outcomes and also on resource utilization (Lanken, 2001). Given the current scenario of bed availability in the ICUs, there are innovative products in the market which can provide considerable support to the resuscitative measures directed to this patient. Tele-ICU is one such innovative product which are networks of audiovisual communication and computer systems that may link intensivists to remote areas. In this system, the intensive care specialists can communicate by voice with the remote emergency resuscitation team providing the ACLS protocol and to the remote ICU personnel. It can receive televised picture of the patient and clinical data about the patient. This may facilitate direct care in such scenarios by the doctors and nurses based on instructions from the intensivists in the command center. Moreover, other systems are available which can facilitate ease of documentation where less time would be needed for charting or documentation, so more time can be provided for care. One such system is CPOE, which can be installed in the ambulances for transfer, in the day-care recovery, and in the ICU networks so sharing of information, update, and decision making may be facilitated to improve outcome. Follow up Plan In treating pulseless electrical activity the reversible causes have been codified into the 4 Hs and the 4 Ts. It should be noted that these reversible causes are not exclusive to this condition but can also be applied to the reversal of asystole and VF. If the patient is successfully resuscitated then really this is the most important phase. At this point, the patient is still vulnerable to relapsing into cardio-respiratory arrest. Therefore, all further care should be directed towards preventing this from happening. If the team is involved in a successful resuscitation attempt outside of theatre, then the patient will have to be moved to a high dependency care setting whether that is coronary, intensive therapy unit or high dependency unit (ITU/HDU). Moving a critically ill patient requires much forethought and each hospital should have clear guidelines as part of its ACLS policy on moving critically ill patients within or out of the organisation. Once the patient has been successfully moved to a definitive care setting they may well require ventilatory support, cardiovascular support as well as supportive drug therapy. If the cardio-respiratory arrest occurred within theatre, the practitioners still has a critical role to play in assisting the team in the management of the airway. The perioperative staff should all be basic-life-support competent at the very least, preferably trained to first responder level. The organisation must have clear and explicit guidelines about the management of emergencies within the theatre. Nevertheless, the issue of transportation is still an important one and should be conducted in the same way as if it were occurring from elsewhere within the hospital. The advantage however is in the shorter distance between the scenario to the intended critical care unit. The sequence of events is going to depend on the location within the hospital, the availability of staff and distance for the resuscitation team to travel as well as many other variables. Therefore, any success will be influenced by these factors. The emphasis under these circumstances is towards fast and safe treatment, especially in the patient with a shockable arrest where the use of a defibrillator is necessary (Intensive Care Society, 2002). Health informatics is driven by exponential growth of knowledge in the biomedical and clinical sciences, and associated need to structure and organise this knowledge as an accessible, up-to-date and coherent electronic resource, rapid change in social, professional, legal and organisational contexts of healthcare, associated with greater focus on cost-effectiveness, safety and governance of treatments and services. The scale and precision of operational performance of systems that is needed, the necessary clinical and technical standardization of data, systems and services and the educational and organisational development required to manage the implied change and enable effective deployment and use of the new infrastructure, by patients and professionals alike, are key aspects. Although initial implementation of such systems would incur cost, the organization would be able to meet standards of care in terms of patient survival. Moreover, since time is of essence and fast institution of management tend to ensure possibility of recovery, the money saved in litigation on civil negligence can be saved, and the difference is substantial enough not to ignore this. Reflections and Evaluation As far as I recollect, the patient had a timely intervention. This patient was a postoperative patient with the need for ventilation. In the facility of the day-care surgery unit, the facilities of such interventions are meager, and an immediate ACLS protocol was instituted. As per requirement, these facilities must have adequate number of trained staff, however, practically, due to fact that these events are very rare to occur. Consequently, out of practice cannot ensure standards of care. Mechanical ventilation is sometimes used within recovery areas and is commonly used in the intensive care setting to artificially ventilate persons who are unable to breathe spontaneously at all or are unable to provide themselves with adequate spontaneous ventilation. This was exactly the case with this patient, and since the patient was noted to be requiring longer periods of ventilation, it was decided that it would need a transfer. It is imperative for the intensive care nurse to have a thorough understanding of the principles and mechanics of mechanical ventilation (Calfee & Matthay, 2005), ODPs and theatre staff must familiarize themselves with these principles to ensure the safest care of their patients. While providing the care, however, it was clear that until the arrival of ACLS team to the facility, the care that was happening was less than adequate, and there was obvious hesitation on the part of the team what to do and what not to do. This had wasted a lot of time, until when it was decided that the patient would be transferred. There should be patient care guidelines which can be used in such cases, and all staff must be trained in simulation systems as to how to handle such situations. There are many commercial products available that can help this remote day care surgery center to take instructions from the intensivists to adequately manage this care protocol. Overall, this event was a learning exercise where academic learning is applied in clinical practice. There should be monitors available which can facilitate care. Reference Calfee, C. S. & Matthay, M. A. (2005). Recent advances in mechanical ventilation. The American Journal of Medicine, 118(6), 584-91. Intensive Care Society. (2002). Guidelines for transfer of the critically ill patient. London: Intensive Care Society. Lanken, P. (2001). The ICU Manual. Paul N. Lanken, C. William Hanson & Scott Manaker, eds. W. B. Saunders Company, p. 13. Lindgreen, V. & Ames, N. (2005). Caring for patients on mechanical ventilation. American Journal of Nursing, 105(5), 50-60 Taylor, G., Larson, P. & Prestrich, R. (1976). Unexpected cardiac arrest during anaesthesia and surgery. JAMA, 236, 2758 Thomson, R., Lewalle, P., Sherman, H., Hibbert, P., Runciman, W., and Castro, G., (2009). Towards an International Classification for Patient Safety: a Delphi survey Int. J. Qual. Health Care, Feb 2009; 21: 9 - 17. Read More