NURSING 7210 Applied Nursing Practice

Introduction:

In health care settings, nurses play a crucial in advocating for the safety of patients and ensuring that optimal outcome is achieved. This depends on the completion of comprehensive assessment and using critical thinking to determine the best course of action as per the patient’s situation. However, medical errors occur because of nursing negligence and omission of key actions during critical points care. This report will critically analyze the Trengove Coroner’s report, an inquest into the death of Trengove Coroner who died because of excessive bleeding after sustaining an injury and anticoagulation related complications. The paper looks at the key nursing activities leading to the issue and provides critique of nursing care given in the scenario. The key recommendations that have been suggested to avoid such events in the future are making ongoing observation compulsory, making INR testing compulsory for all patients who are on anticoagulation mediations following an injury or trauma and implementing protocols for structure escalation of care.

Brief summary of the Coroner’s findings:

The essay deals with the analysis of Trengove Coroner’s report, an analysis into the death of Mr Ian Trengove, 81 year old man who died while admitted at the St Andrews Hospital in Adelaide on 30th March 2008. As per the Coroner’s report, he was admitted previous afternoon after an accidental fall in the church and he sustained a fracture of the pelvis. He had a past medical history of multiple diseases like hypertension, congestive cardiac failure, ischaemic heart disease, atrial fibrillation, complete heart blockage and pacemaker insertion in 1981 and 2006.

He had a transurethral resection of the prostated gland too. He was on a prescription of 0.5 mg warfarin per day. His INR level was 4.6. As warfarinisation decreases the tendency of blood to clot, the patients are at risk of heavy bleeding during traumatic injury (Qiu and Grine 2017). In such condition, patient’s safety depends on the withholding of warfarin use until therapeutic level of INR (International Normalized Ratio) is achieved. INR is a measure of anticoagulation level in an individual blood and the therapeutic range is between 2 and 3 (Shikdar and Bhattacharya 2018). 

Based on Dr Gilbert’s analysis, a forensic pathologist at Forensic Science South Australia, it was concluded that Mr Trengrove was excessively anticoagulated leading to excessive bleeding. Such excess bleeding during post pelvis fracture would not have occurred in the normal case (Dager, Roberts and Nishijima 2019). But warfarin administration despite the INR level of 4.6 was identified as the cause behind the problem. Another gap in treatment was that bleeding in the retropubic space could be detected by a CT scan. However, no CT scan of the pelvis was done. In the post mortem report, the cause of death was retroperitoneal hemorrhage with contribution of warfarin anticoagulation and ischemic and hypertensive heart disease.

Other missed opportunities of care were failure to identified warning signs of deterioration. As per Coroner’s report, nurses noted adverse vital signs like bradycardia, low heart rate, hypotension and oxygen saturation level of 88%. He complained to inability to pass urine. Escalation of care should have done at night only, but this was avoided contributing to the death of patients. This failure leads to failure to be reviewed by a physician at night and failure to be transferred to ICU too. Thus, early identification of clinical deterioration is the key to patient safety.

Brief description of the pathology causing death

From the inquest into the cause of death, it has been identified that excessive bleeding due to excess use of warfarin and the initiation of the anticoagulation effect resulted in the death of patient. Adverse event is frequently encountered during the use of warfarin because of its narrow therapeutic index and inability to determine a standard therapeutic dose. High dose of warfarin leads to inadequate and excessive anticoagulation effect thus increasing the chances of bleeding complications (Patel et al. 2020). For this reason, patients using warfarin needs to be closely monitored through INR. An INR value of greater than 3 increases risk of bleeding effects and in case of Trengrove, INR value reached greater than 4 but still the dose of warfarin was not decreased (Hull and Garcia 2017). This resulted in bleeding risk and complications for patient (Shikdar and Bhattacharya 2018). In normal case, bleeding events do not cause significant problems (Ozturk et al. 2019). However, in case of Trengrove, he suffered serious complications and ultimately died because of other missed opportunities of care.

The other pathophysiology behind his death was not conducting CT scan and the initiation of cardiac arrhythmia due to blood loss. The pathophysiological change that occurs in patient post-acute blood loss is the reduction in the oxygen carrying capacity of the blood (Hooper and Armstrong 2020). Thus, his blood circulation could not keep up with the demand of heart muscles for oxygen thus leading to disruption of blood supply to the heart and eventually cardiac arrhythmia. He mainly sustained retropubic and retroperitoneal haermorrhage (Lustenberger et al. 2015).    

 Medical and nursing practice of the case:

The nurses and the medical team were involved in the care of Trengove and their action in response to patient deterioration needs to be explored. Missed opportunities of care were found in the following areas of nursing involvement Documentation and communication: Mr Trengove was looked after by the nursing overnight after his admission to the medical ward. His condition deteriorated at night with incidence of nausea and vomiting. The nurse Clayton called Dr Laxmana timely to explain that the patient had vomited pain-killing and anti-nausea tablet. Dr Lakshmanan ordered stemetil and indocid and at 5: 40 am, Nurse Clayton completed the documentation process for events that unfolded at night. The documentation process was accurate as small events were recorded and little details like history of sleep apnea and inability to void were recorded. However, Trengove was unable to void event at 4:30 am in the morning.

The nurse Clayton should have immediately communication about this problem to the medical team instead of leaving Mr. Trengove’s assessment for the early morning shift. However, documentation related concerns were found for the Nurse McKay’s who handed over Trengove in the morning. There was no record of urine output. Nursing documentation pattern is strongly linked to patient’s mortality. It enables early recognition of deteriorating symptoms followed by timely communication and response by the interdisciplinary team (Kebede, Endris and Zegeye 2017). To prevent death of patient, documenting even subtle changes in physiological state is critical (Collins et al. 2013). However, in case of Trengove inquest, incomplete documentation for changes in Trengove’s ability to void created further confusion during the inquiry.

Ethical decision-making

Ethical decision making in nursing practice involves the consideration of nursing ethical principles of non-maleficence, beneficence, autonomy and justice while taking decisions (Alba 2018). A competent nurse is one who evaluates the right and wrong of each actions and take proper steps to promote safety of patients (Torabi et al., 2018). In the context of the medical care given to Trengove, it can be said that there was lack of ethical decision making process. No serious thought was given to the fluctuation in Trengove’s condition at night. Dr Lakshmanan identified dehydration and a possible myocardial infarction as the differential diagnosis for the patient.

But there was error in decision making and the possibility of hemorrhage was not considered. This flaw in judgment violates the ethical principle of non-maleficence as poor decision making ultimately cost the life of the client (Artal and Rubenfeld 2017). For the safety of Mr Trengove, Dr Lakshmana should have ordered immediately usual blood test. But no such test was ordered. In addition, nurses working at night shift should have taken fluctuation in condition seriously and raised alarm for emergency care. Lack of ethical decision making resulted in failure to diagnose fatal haemorrhage and delay of appropriate treatment for client’s survival. Clinical decision making during acute deterioration is complex and lack of proper framework for escalation of care could also be the cause behind nursing negligence and timely escalation of care (Campling et al. 2018).

Flaw in nursing practice is seen based on way nurses respond to vital signs assessment at night. Despite recording signs of hypotension, low oxygen saturation level and bradycardia, the nurses did not escalate to the higher authority. Medicine Indocid was administered without considering about its risk of patient safety. Thus, ethical principle of beneficence was violated in this case. Nursing advocacy is critical for the safety of patients. It involves preserving human dignity, equality and promoting freedom from suffering (Gerber, 2018). In the context of Trengove’s care, nursing advocacy is missing. The Nurse Clayton at nightshift clearly witnessed changes in vital signs of patient.

Despite vomiting and complaints of no void in patient, the nurse did not raised alarm. There was no consideration for the safety of patient and this resulted in death of patient. If the nurse’s held themselves accountable for patient safety, they would have immediately escalated to the concerned team during fluctuation of his bradycardia at night. In addition, there was failure in establishing excessive anticoagulation. Lack of focus on critical assessment resulted in failure to admit Mr Trengove to high dependency unit. Thus, nurse’s critical insight related to identification of deterioration was missing and this prevented the client from having a more expert supervision and monitoring at night. Thus, nurse’s role in continuously advocating for the activation of rapid response system was important (Chua et al., 2017).

In death of Trengove is a result of flawed leadership and management of clinical deterioration. The leader in the scenario was mainly Dr Lakshmanan and his flawed diagnostic approach resulted in death of patients. As a physician, he had the capability to manage deteriorating symptoms and lead nurses and other staffs towards appropriate actions (McGaughey et al. 2017). Dr Miller in the ED do not order INR test.  In the health care setting, effective clinical leadership is needed for system efficiency and achievement of health reform objectives. They have the capability to optimize care delivery by challenging workplace culture and influencing nature of work of followers. No such team work and leader directed clinical action was seen in the scenario (Daly et al. 2014). There was no evidence of discussion between the physicians and the doctors regarding the deteriorating state of Trengove and the need to contact the Intensive Care Unit Team. This was the cause behind failure to identify complications and complete test for anticoagulation.

The culture of the organization plays a key role in the detection and response to clinical deterioration (Massey, Chaboyer and Anderson 2017). An organization supporting early detection of deteriorating patients provide staffs with effective assessment tools like early warning score and rapid response system to communicate about complications in patient (Serembus, 2014). In the inquest into the death of Mr Trengove, no specialised tools were used by nurse for identifying warning signs and there was established protocol to guide nurses regarding situations to call the MET team. However, informed by the errors in identifying anticoagulation effect of warfarin on the patients, a change in St Andrew’s culture was proposed. A protocol has been now established in the organization for over-anticoagulation of warfarin and performing INR test as part of emergency assessment of patients. In addition, regular monitoring of patients with pelvic fractures and anticoagulant state was proposed. Presence of such safety culture from the beginning would have saved the life of Mr Trengove.

The decisions and practice of the nurses played a crucial role on influencing outcome of Mr. Trengove too. The first vital issues found in the nursing are the failure to complete accurate assessment process. It was the nursing staff’s duty to look at complications for patient with pelvic fracture. Unfortunately, no assessment of bleeding complication was done. Evidence shows that in patients with pelvic fracture, hypovolemic shock is the main cause of mortality. This mainly occurs because of bleeding related complication (Taghavi and Askari 2018). Thus, the first priority for any nurse attending to a patient with pelvic fracture is to look for source of bleeding or signs of internal haemorrhage (Montmany et al. 2015). The nurses in the scenario did not made any attempts to identify the source of bleeding nor rectify it. Even if bleeding goes undetected visually, some common laboratory tests like CT scan helps in the detection of bleeding (Webb, Brant and Major 2019). There is no evidence to prove that CT scan was done.

During standards assessment of a patient with falls, the following elements are reviewed: falls history, medication review, physical examination and environmental assessments (Park 2018). In case of Trengove, no attention was paid to extensive physical examination and medication review. For instance, after pelvic fracture, no CT scan was conducted. Similarly, there is no record the nurses conducting medication review. For example, during the hospital stay, he was prescribed medications like warfarin. Furthermore, he was also prescribed Indocid without any consideration of its side-effects and potential drug-drug to interactions. As per the rights of medication administration,

it is necessary for nurses to fulfill the six rights of medication administration. This involves considering the right patient, right drugs, right dose, right time, right route and right documentation (Plutínská & Plevová, 2019). Mrs Trengove was already on warfarin and before administering Indocid to patient, the nurses should have considered about its potential effect on patient. Indocid is a class of medication that increases risk of bleeding (Waller and Sampson 2017). In addition, warfarin is also a type of medication that increases bleeding risk (Hussain et al. 2019). The risk of hemorrhagic bleeding complications increases twice in patients taking such drug (Qiu & Grine, 2017). Thus, lack of clinical insight of nurses was seen and it is nursing negligence that they took no step to further monitor the risk of hemorrhagic complications in patient.

In case of deteriorating patient, regular vital signs assessment is an important responsibility for nurses to identify and quickly respond to clinical deterioration (Lambe,  Currey and Considine 2016).  According to the NMBA standards for registered nurse, conducting comprehensive and holistic assessment is part of patient’s practice (NMBA, 2017). It is an important professional expectation for RN. However, throughout the inquiry of Mr Trengove’s death, not even once full details of vital signs of the client were mentioned. This study shows that regular vital sign assessment was not part of regular routine for nurses at St Andrews Hospital. Vital signs are those data that can give clues regarding possibility of complications and supports health professionals to timely escalate care (Lambe, Currey and Considine 2016).  

Mok et al. (2015) argues that majority of adverse events occur because of delay in identifying abnormal vital signs. Close monitoring of vital signs is a practice that helps to immediately act upon deterioration and minimize the risk of adverse events like cardiopulmonary arrest (Weenk et al. 2017). The investigation of the cause behind adverse events shows that nurse’s failure to assess and interpret vital signs is one of the major causes behind medical errors. Many nurse neglect vital signs monitoring as they do not perceive it to be important (Prgomet et al. 2016). Because of similar reasons, nurses in the case scenario would have avoided investigating about vital signs for Mr. Trengove. This is a major miss in nursing responsibility which is not professionally expected from nurses taking care of critically patients.

The physicians failed to make an order for INR test and the nurses missed to escalate about it although they were aware that the patient was taking warfarin. This was conducting INR test of patient which would have helped to identify the excessive state of anticoagulation. The INR test was conducted after the death of Mr Trengove. Thus, there was a lack of critical thinking. But as the staffs were aware that the patient was taking warfarin on a daily basis, this test should have been done after his admission to the hospital. Just because this test was ignored, the signs of excessive anticoagulation were not controlled earlier, the event of retroperitoneal hemorrhage could not be prevented.

As part of best practice, INR is a preferred test for all patients taking drugs like anticoagulants (Shikdar and Bhattacharya 2018). The quality of INR control determines the efficacy and safety of comparator drugs to warfarin (Hull and Garcia 2017). Lack of comprehensive testing by nurses created a cascade of events leading to clinical deterioration of patients too (Bereznicki, Jackson and Peterson 2013). The review of research on current strategies to minimize bleeding risk suggests that frequent testing of INR is important for hospitalized patients taking anticoagulants. This will help to ensure that the level of anticoagulant is within therapeutic limit and there are no chances of bleeding risk (Snipelisky and Kusumoto 2013). Thus, poor risk assessment skills were displayed by nurses and this is no expected while handling a patient with severe illness such as pelvic fracture.

Nurses play a critical role in documentation and communication about warning signs to the medical team (Lambe,  Currey and Considine 2016). Based on the events that unfolded on the night of admission, Nurse Clayton communicated about the vomiting up of painkilling and anti-nausea tablet at night. Dr Lakshmana prescribed stemetil and indocid. Neither the doctor nor the nurse paid attention to the safety of the new medication. The nurse did not consider about the drug-drug interaction and did not communicate about any issues with the drug. Thus, there was a tendency to just follow orders. But no evidence of team clinical round and nurse-physician communication related to patient complexity and discussion various treatment options were seen.

The nursing staffs must have the knowledge regarding how to communicate effectively and ensure that information is shared in timely manner. Amiri, Khademian and Nikandish (2018) identified inappropriate communication among health care professionals as one of the primary cause behind medical errors. Communication failure not only result in patient harm, but also result in increased length of stay and ineffective resource use. Poor collaboration between nurses and physicians result in 1.8 fold increase in patient risk adjusted mortality and length of hospital stay (Amiri, Khademian and Nikandish 2018). Thus, similar issues resulted in the death of Mr Trengove too. This could have been avoided if there was a medical team with strong communication skills and good adherence to patient safety culture (Freytag et al. 2017). 

Discussion on the coroner’s findings:

The Coroner’s finding identified several clinical flaws in the management of deterioration in patient and suggested many recommendations to prevent similar events in the future. It recommended implementing a protocol for warfarin over anticoagulation. It mentions that INR test should be performed as part of assessment in emergency department. The protocol urged clinicians to be mindful of occult or concealed bleeding even in minor trauma or fracture. Practically, such protocols can work only when clinical leaders make each nursing staffs aware about the importance of following this document. The education regarding the purpose and significance of INR testing could lead to better adherence to protocol. In addition, the Coroner’s finding recommended updating Nursing Practice Manual. The new requirement included developing a clear management plan and giving adequate description about the actions to be taken for clinical deterioration. It emphasize on increasing the frequency of observations. This step can be practically possible when appropriate nurse-patient ratio is maintained and there is no workload burden for nurses. In addition, training needs of individual nurses should be considered to change their perceived idea about vital signs monitoring. The need for support in terms of additional tools or technology should be considered too (Prgomet et al. 2016).

Conclusion:

The report summarized about the events leading to the death of Mr Trengove, who died because of bleeding related complications and cardiac arrhthymia. The analysis aimed to identify key nursing and medical practice that contributed to the adverse events in patient. Based on the critical evaluation of Trengove’s clinical situation, review of his drugs and the care given throughout admission, various inferences has been made. Firstly, poor documentation and communication about deterioration was identified. This is said because inability to void during night was not documented and there was lack of proper communication regarding it. In addition, poor advocacy and ethical decision making was seen as differential diagnosis for patient’s condition ignored the important point of bleeding complication. Lack of team work and consideration of patient safety was found. Many nursing negligence was seen as frequent vital signs monitoring was avoided and there was no attention to testing of INR. The final conclusion to rectify such events in the future was to conduct implement proper protocol for assessment of patients with clinical deterioration. In addition, making changes in the frequency of patient observation was considered important.

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