Case Study, Actual Clinical Scenario

A 47 year old previously well male underwent a semi-elective thoracotomy for an empyema. The surgical procedure and anesthetic were uneventful. The patient returned to the ward at 1500 hours with a heart rate of 130 beats/minute. His observations were otherwise unremarkable. The surgical registrar was concerned about the patient's heart rate and inability to pass urine post-operatively. She instructed the intern to insert a urinary catheter if the patient failed to pass urine by 1800 hours. At 1800 hours there was still no urine output, and the heart rate was 140 beats/minute. Despite the intern's insistence the patient refused to have a urinary catheter inserted. The patient was otherwise stable. The day intern handed over the patient's care in a verbal report to the night RMO at 2200.

The night RMO was summoned urgently to see the patient at 2330 when the patient's blood pressure dropped to 85/60 mmHg. The heart rate was now 150 beats/minute. The RMO felt that the patient was hypovolaemic and administered 2 litres of hartmann's solution, and ordered a blood transfusion. With this intervention the blood pressure improved and the RMO went about his other tasks. There were no further observations recorded for the patient until 0230 when the blood pressure was found to be 75/55. The RMO again responded promptly and commenced further fluid resuscitation. Again there was a transient improvement in the patient's condition.

At approximately 0400 hours the RMO was sufficiently concerned about the patient to telephone the on-call surgical registrar (offsite, on-call due to financial restraints). The RMO described the patient's condition to the registrar. The registrar was concerned and stated that he would come in early at 0700 to review the patient prior to the commencement of his operating list.

At 0530 the patient lost consciousness, and the nursing staff put out a cardiac arrest call. Despite the best efforts of the anaesthetic registrar and the ICU registrar, the patient could not be resuscitated and he was declared deceased at 0600. During the entire post-operative period there was no Medical Emergency Team ('MET') call, consultation with the treating surgeon or on-call intensive care specialist.

The coronial inquest found that the patient died as a result of hypovolaemic shock secondary to sepsis and post-operative haemorrhage. The failure of the on-site nursing and medical staff to call for the MET or for consultant intervention was noted by the coroner.

In this, case Patientrack would have intervened to alert bedside staff that there was a serious problem. Failure to resolve the problem would have resulted in automatic MET notification whereby the appropriate responsible senior medical staff would have been informed in a timely fashion.