Case Based Learning - 'The single biggest problem in communication is the illusion that is has taken place '
George Bernard Shaw
In an attempt to keep the shared learning coming, I am going to try something new in this post. Rather than pull a series of cases together and combine the learning I am going to share some of the 'SBAR Incident Alerts' I produce for my ED and hospital. Again theses are ALL real incidents. The errors are genuine, and I suspect will be recognisable to all experienced EM clinicians.
The SBAR (Situation, Background, Assessment, Recommendation ) format is one that will also be familiar to many. It was originally derived from military use and is a really useful tool to aide clear communication.
Where I work we have introduced SBAR type notification as our standard form of documentation for information coming into the ED, be that paramedic alerts or abnormal investigation results.
We have also introduced it to our ED Notes as a summary page to aide handover between clinical teams and in our Clinical Decisions Unit at the end of protocols so that the referring clinicians can clearly outline their expectations for the patient
Used correctly and aye there lies the rub, SBAR use help delivers safer patient care and also protects clinicians.
I HIGHLY recommend considering using it.
Information about SBAR can be found here- NHS Institute for Innovation and Improvement on SBAR
Situation
Missed C2 Fracture
Background
An elderly patient attended from his Nursing Home having
fallen on to his face on concrete sustaining significant bruises to his face
and head. He had quite marked dementia which made assessment difficult but he
seemed to have good neck movement and complained of no localised pain there.
X-rays were taken of his mandible which was deemed to be
normal before a plan to admit to Med Eld was made. The following day he was seen on the ward round and again
had no neck pain and was deemed fit for discharge.
He returned to the ED 3 days later as the nursing home staff felt he
was more confused than normal. He was
noted to have no ‘neck tenderness’ before being sent for a CT of his head and
brain.
The CT confirmed facial fractures, small intra-cerebral
haematomas and also showed an off ended PEG (C2) fracture with cord impingement.
He was fitted in an Aspen Collar before transfer to Med Eld
for conservative treatment
Assessment
The ED teams initial failure to diagnose the C2 fracture caused
no serious harm to the patient however it certainly exposed him to risk and
despite repeated ‘no neck pain documentations’ must have caused some him some
additional discomfort
Assessing any patient with decreased ability to communicate
makes it harder to get things right first time, be that extremes of age,
language barriers, intoxication or dementia
Frail elderly people break more easily than you think.
A fall banging the forehead /face is a classic mechanism for
PEG fractures (hyperextension of the neck)
They are VERY easily missed
Recommendation
Remember ‘the head bone is connected to the neck bone’ so any facial injury puts the neck at risk
Have a lower threshold than normal for CT imaging of the
neck in patients with the right history and decreased communication abilities
Remember ’Steel’s rule of thirds’- at the level of C1 the
spinal canal consists of 1/3 Cord, 1/3 Bone (peg of C2) and 1/3 space- so there
may be no neurological signs (fortunately)
Also remember Central Cord Syndrome can occur late in this
group, even without a fracture CC Syndrome
Remember to give good discharge advice with ‘triggers to
return’ for patients or their carers
Situation
Opiate Overdose
Background
A 50 yr old lady was found face down on a golf course having
apparently taken 200mg of oramorph . Paramedics gave her IM Naloxone on scene and on the way in (800mcg
and 400mcg). On arrival at ED her GCS was 15 with normal observations but
she did de-saturate off Oxygen
She was seen immediately by a senior doctor and moved to a
visible cubicle next to the nurses’ station on a monitor where she chatted to
her family. The doctor was drawn into to resus to deal with other patients but
came back approximately thirty minutes later to perform an Arterial Blood Gas (ABG). In that 30
minutes the pt had been cannulated, an ECG performed and was conversant with
staff and relatives. The doctor noted that the pt was now very drowsy, with an
ABG showing a pH of 7.2, CO2 of 8.38 and O2 of 12 (kPa on high flow oxygen)
She was taken to resus where a naloxone infusion was
commenced and BiPAP started before transfer to critical Care. She made an
uncomplicated recovery and was discharged the following day.
The case was reported as a potential SI in view of the
patient’s deterioration, but subsequently downgraded on review of her care records
Assessment
There are many elements of good care;
Good nursing assessment with immediate discussion with a
senior doctor
Immediate review by the senior doctor
Placement of the patient in a highly visible cubicle on
cardiac monitoring
What could have been done better?
The treating doctor did not notice the first dose of
Naloxone given by the paramedics was 800mcg
Had they done so they may have considered starting an IV Infusion earlier or further bolus doses
Recommendation
Opiate overdoses should be cared for in a monitored highly
visible environment with regular documented obs
If obs cannot be measured regularly on a team the patient should be moved to resus
Always read and document what treatment the patient has had
BEFORE arrival. It
can influence what you need to do
BEWARE of re- narcotisation
Naloxone has a much shorter half-life (30 to 80 minutes) than most opiates especially methadone (4- 8 hours analgesia, 8-59 hours elimination)
Consider a naloxone infusion (BNF- 10mg (25 vials!)in 50mls of 5%dex)
