Clinical Communiqué Editions
July 21, 2016
Following our June 2016 edition of the Clinical Communiqué, a reader has provided feedback about the use of subclavian lines for central venous access. The reader commented that although there appears to be a trend towards performing internal jugular lines, there are still many proceduralists who are more skilled in subclavian lines, and who use anatomical landmarks to insert those lines. The reader asked whether subclavian lines would still be considered by experts to be an acceptable and appropriate choice for central venous line insertion, particularly in the event of a peer review if a complication occurred after subclavian line insertion.
Our expert commentary author, Professor David Story, provided the following response –
“The reader raises the important point of subclavian lines, which have a number of advantages to internal jugular and femoral lines including lower risk of infection and easier care. There are some disadvantages however, around mechanical complications with subclavian lines. I now rarely see subclavian lines in clinical practice and wonder if there has been an ultrasound-led shift to internal jugular lines followed by femoral lines where internal jugular lines are seen as contraindicated e.g. cervical spine injury. Subclavian lines are often unpopular in anaesthesia because the insertion site is in the surgeon’s zone in cardiothoracic surgery, and concerns about having to deal with a pneumothorax in the midst of non-cardiac surgery. Nevertheless, there is growing evidence around ultrasound-guided subclavian access, particularly in the Emergency Medicine literature. This is one reason the University of Melbourne is creating a Centre for Integrated Critical Care (Anaesthesia, Emergency Medicine, and Intensive Care) to address areas of mutual interest but differing perspectives in critical care such as central lines.”
Rezayat T, Stowell JR, Kendall JL, Turner E, Fox JC, Barjaktarevic I. Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back. West J Emerg Med 2016; 17: 216-21.
Please note that we provide this additional detail as information for our readers’ consideration. It should not be construed as definitive or as being reflective of the position of the VIFM or CCoV.
June 30, 2016
Download PDF: Clinical Communiqué June 2016 Issue
In this edition
- Case #1 A LINE TOO LONG
- Case #2 AN ELUSIVE BREACH
- Case #3 NOT WHERE YOU THINK YOU ARE
- Expert Commentary CENTRAL VENOUS ACCESS
In this issue we are going to focus on the single theme of risks associated with central venous catheter insertions. A common procedure in complex patients with some recurring errors that should be amenable to system change.
First though, a chance to examine an example of real systemic change towards safer practice. You may recall the case we described in our last issue of the patient who died from complications that occurred following a liposuction procedure (Volume 3, Issue 1: Post-operative pain – When to worry). What we did not know at the time was that the Medical Board of Australia was about to issue guidelines on clinical practice for registered medical practitioners who perform cosmetic medical and surgical procedures.
The Board consulted widely with the medical profession, the industry and the community about the best way to protect consumers seeking cosmetic medical and surgical procedures. The new guidelines were published in May 2016 and will come into effect on the 1st October 2016 and apply to all medical practitioners, including specialist plastic surgeons, cosmetic surgeons and cosmetic physicians regardless of their qualifications.
Among the key points are:
- A seven-day cooling off period for all patients before major procedures,
- For all persons under 18 years there is a three-month cooling off period before major procedures and a mandatory evaluation by a registered psychologist, general practitioner or psychiatrist,
- The treating medical practitioner is to take explicit responsibility for post-operative patient care and for making sure there are emergency facilities when they are using sedation, anaesthesia or analgesia.
The guidelines also provide direction on the issues of patient assessment and informed consent, and communication about the risks and possible complications of cosmetic procedures. What is particularly encouraging is the role that clinical staff, health professional regulators, and medico-legal mortality reviews played in the development of these guidelines.
In this issue, we present three cases where complications arose following central venous catheter insertion. One catheter migrated too far, another catheter went the wrong way, and the last caused damage to its adjacent structures. Each of these are recognised albeit uncommon complications of central venous catheters, yet the cases continue to illustrate the many difficulties in the recognition of catheter misplacement.
The Clinical Communiqué welcomes a new case author from Tasmania, Ms Libby Newman, who has over ten years’ experience working with the Coroners Court of Tasmania, and we are privileged to include an expert commentary from Professor David Story who is Professor and Chair of Anaesthesia at the The University of Melbourne.
Finally, we are thrilled to announce the launch of our new website in the near future. We hope you will enjoy navigating around the site and will continue to use and recommend the site to your colleagues. Please let us know if there is anything else you would like to see on our site, and we will continually endeavour to upgrade and improve our content for our readers.
March 21, 2016
Download PDF: Clinical Communiqué March 2016 Edition
In this edition
- Case #1 POST-OPERATIVE PAIN – WHEN TO WORRY?
- Case #2 BUT THE OPERATION WAS MONTHS AGO!
- Case #3 DON’T DISMISS THE ENLARGING BRUISE
- Expert Commentary RECOGNISING VASCULAR COMPLICATIONS AFTER ANGIOGRAPHY – A WORK IN PROGRESS
In our first issue for 2016, we look at three cases where deaths occurred as a result of complications arising from day procedures. None of the cases were urgent and in two cases the procedures were sought by the patients for cosmetic benefits and perceived lifestyle enhancement.
Although the cases differed in the type of procedure being performed, common to all three was the failure to recognise rare complications. The seriousness of the evolving symptoms and signs were not fully appreciated by the patients or the clinicians until it was too late. Some of this can be attributed to knowledge gaps on the part of the doctors involved. Much of it can be related to inadequate discharge planning and poor post-operative communication.
Pain is a symptom that is often central to a patient’s presentation to their treating doctor. Pain can be difficult to describe and even more difficult to interpret. It is generally expected to occur after most surgical procedures and there can be enormous variability in an individual’s response to pain. The spectrum of pain that might be anticipated in the post-operative period is wide-ranging and depends on many different patient and procedure variables. None theless, there are three features that reliably indicate that something is clinically wrong: 1) pain that is not adequately controlled by a medication regimen that would be sufficient for the majority of patients who have undergone that particular procedure; 2) pain that is worsening in severity rather than improving over time (even accounting for anaesthetic or long-acting analgesic medications given in the peri-operative period that have since worn off); and 3) pain that is out of proportion to the physical findings. Any of these features of the patient’s pain should prompt more questions in the doctor’s mind about the possible underlying problems.
The majority of post-operative complications occur in the early post-operative period, at a time when treating doctors are more cognizant of the potential link between a recent procedure and a new symptom. In some situations however, the risk of post-operative complications can endure long after the patient has recovered from a specific procedure. As the second case demonstrates, in certain scenarios, there is a life-long need for the procedure and its latent risks to be understood by patients, and recognised by their general practitioners who will be providing care for them in the long-term.
The expert commentary in this issue has been written by Dr Nick Collins, an experienced consultant cardiologist and proceduralist. He presents an informative and practical summary of the vascular complications after angiography, and reminds us all to have a low threshold for communicating with the proceduralist.
In the upcoming months we hope to embark on an exciting project to improve the look and feel of our communiqué website. If you have any suggestions, or examples, on what you would like to see, or comments on how you would like to use the website, please email us. We are very keen to incorporate fresh approaches and new ideas based on your input and collective experiences.
December 14, 2015
Download PDF: Clinical Communiqué December 2015 Edition
In this edition
- Case #1 Wrong Place, Wrong Time
- Case #2 The Subtle Signs of Sepsis
- Expert Commentary 1: Optimising Access and Care for the Critically Ill – A Regional Perspective
- Expert Commentary 2: The Anatomy of a Modern Retrieval Service
When cases of patient deaths in hospital are reviewed at mortality case review meetings or coronial inquests, there are common themes that frequently emerge. These themes are the critical elements that need to be present, or performed well, in order to provide safe and effective patient care. They include communication, documentation, awareness of one’s skills and limitations, recognising the deteriorating patient, and following guidelines, to name but a few. Failure or sub-optimal provision of even one element, inevitably leads to a failure in a system and the potential for patients to suffer preventable harm.
What happens when another layer is added to the system? When well-functioning processes are required not only for the care of a patient in a single hospital, but also for the integration of their care between hospitals? The system becomes bigger, more complex, with more room for error. At the primary team level, communication, documentation, and decision-making should be performed as effectively as resources and personnel allow. These professional skills are just as vital however, at the interface of the referral and receiving hospitals, and at the juncture between the hospitals and ambulance or retrieval services.
The two cases in this issue explore the challenging scenarios of managing a deteriorating patient in a rural or regional setting, and the obstacles that are faced when attempting to transfer a critically ill patient for ongoing treatment. The clinicians involved in each of the cases had to deal with the medical issues of the sick patient while also navigating their way through the obvious, and not so obvious, confounding factors that arise when referring or receiving patients from distant geographical locations.
In this issue we have the privilege of presenting two expert commentaries from senior clinicians with vast experiences in regional transfers of critically ill patients. Associate Professor Matt Hooper provides an eloquent and insightful overview of critical care retrieval systems, and Professor Alan Wolff and Mr Ian Campbell share their erudite views on the priorities and actions that regional centres must take when transferring patients to tertiary services.
Our thanks go as well to our guest author, Dr Gerard Fennessy who brings his intensive care and retrieval medicine expertise to the synopsis of the first case.
The end of 2015 marks a historic milestone for us as the Communiqué website is about to reach 80,000 lifetime views. We are very grateful for the readership, the support, and the feedback we receive, as we can all learn valuable lessons from eachother in our respective healthcare communities.
As we enter the festive season, we wish everyone safe travels and happy holidays. We look forward to bringing you more cases, commentaries and educational resources in 2016.
September 8, 2015
Download PDF: Clinical Communiqué September 2015 Edition
In this edition
- Case #1 The Price of Ignorance
- Case #2 History Repeating
- Case #3 A Risk Unseen
- Expert Commentary:
Assessing Fitness to Drive in Australia
In this issue of the Clinical Communiqué we explore, for the first time in our publication, the important subject of fitness to drive. It is a question that is commonly raised for the patient who has had a seizure, stroke or degenerative muscular condition, but how often is it considered for the patient presenting to hospital with drug and alcohol-related problems, or for the patient suffering from a delusional disorder, or a ‘temporary’ medical condition such as a pulmonary embolus?
This is an area of practice that is pertinent to every healthcare professional and is not solely limited to a small group of medical experts whose role it is to determine a person’s suitability to hold a licence. Whether a patient is fit to drive is a clinical question, which should be posed every time we see a patient, whether in an acute hospital, outpatient, or general practice setting.
Many medical, psychiatric and toxicological conditions are capable of impairing a driver’s attention, decision-making abilities and reaction times. When the impairment is subtle or intermittent, the assessment of fitness to drive can be made even more difficult.
Across the country, there is no uniform approach to the reporting and assessment of fitness to drive, and the strengths and weaknesses of the various State-based systems have been strongly debated for many years. What is agreed is that assessing fitness to drive is a complex and challenging task for healthcare professionals. It is a heavy responsibility to bear. It can be a confronting scenario to advise your patient they should not hold a license, to recommend that they lose a vital part of their independence, mobility, and at times, their income. It can also be devastating to discover that one of your patients has been involved in a motor vehicle crash as a result of the medical condition you have been treating, and you had not considered the issue of driving or identified a significant risk.
This is also the first issue where senior forensic physicians at the Victorian Institute of Forensic Medicine (VIFM) have contributed to the expert commentary and two of the case summaries. The guest authors are all gazetted approved experts under Section 57 of the Road Safety Act (VIC) and medical consultants to VicRoads on matters of fitness to drive.
Each case has been selected to represent a different jurisdiction and involve a diverse range of medical conditions and practitioners. The common theme between them is that they were all, as one coroner noted, “an accident waiting to happen.” The first case depicts the condition of hypoglycaemic unawareness, the second is best described by the adage – “everything that happens once can never happen again, but everything that happens twice will surely happen a third time.” The final case is one to reflect on what might happen when your patient leaves the consultation room.
The inquests in fitness to drive cases have a distinctive format in that the investigation does not centre on the history and circumstances of the deceased. Instead, the purpose of the inquests is to examine the medical background and behaviour of the living – the drivers involved in the collisions.
June 16, 2015
Download PDF: Clinical Communiqué June 2015 Edition
In this edition
- The experience of witnesses
called by the Coroners Court
- Case #1 Familiarity is key
- Case #2 In defence of protocols
- Expert Commentary:
How to make a better medical emergency team?
This issue of the Clinical Communiqué describes two cases of patient deterioration that resulted in the activation of a hospital Medical Emergency Team (MET). The concept of a MET system was first described in a New South Wales Hospital in 1995 with the goal of improving patient outcomes through early recognition and response to clinical deterioration. The system allowed for staff to call a MET, consisting of doctors and nurses trained in advanced life support, on the basis of clinical concern alone, or on the presence of abnormal physiological variables. It was thought that through prompt intervention and medical treatment, cardiac arrest, unplanned admissions to the intensive care unit (ICU), and death, could be prevented. By 2005, approximately 60% of ICU-equipped hospitals in Australia and New Zealand reported having introduced a MET service.
Now, 20 years later, most health services nationally and internationally have implemented their own versions of the MET system, with their own sets of training guidelines, protocols and practices. Despite the ubiquity of MET systems, we are still learning, and as these cases highlight, we can still do better.
In many ways, the principles behind the MET system are applicable to all healthcare environments, not just acute hospital settings. Leadership, decision-making, communication and task allocation are all critical to the effective performance of a team responding to an emergency, whether that be in an operating theatre, a hospital ward, an outpatient clinic, or community health centres.
Included in this issue is a special feature from the Chair of the Coronial Council of Victoria, Dr Katherine McGrath, who provides valuable insight into the experiences of witnesses called to give evidence at inquest. The expert commentary from Dr Antony Tobin, a senior intensivist and expert in the effectiveness of MET and tracheostomy review teams, details the components of the MET model and the necessary skills and training required to ensure optimal team performance.
This Communiqué marks the completion of our first year back in publication and we are looking forward to presenting our next set of quarterly issues to our readers. We strive to present cases that bring about reflection, communication, and most importantly, changes in practice to improve patient safety. As promised in our first issue, we will continue to evolve and respond to feedback, to provide a resource that challenges, stimulates and educates. To do this, we have designed a short survey that will be sent to all our subscribers in July. Please spare a few moments of your time to complete the survey so that we can hear your views, experiences and suggestions. Once finalised, we will be publishing the results of the survey for our readers.
March 3, 2015
Download PDF: Clinical Communiqué March 2015 Edition
In this edition
- Case #1: Lost in translation
- Case #2: A catastrophic cascade
- Case #3: Clinical picture or digital pictures?
- Expert Commentary: Novices and experts – Bridging the gap
- List of resources
Welcome to the first edition of the Clinical Communiqué for 2015.
The three cases in this edition explore the issues of communication and decision-making at the bedside. Communication is a skill that sits at the core of our working lives. We share information with our colleagues about patients, pathology and imaging results, as well as our concerns, failures, and successes. We may be interacting with others more junior, more senior, or at the same level as us, or communicating to people in other disciplines, or other healthcare sectors. In a single day’s work, many of us will exchange information countless times by email, pager, phone, and in person. So, in a complex world of multimodal interactions, how do we communicate effectively with our colleagues? More specifically, how do we use handover to transfer critical information between people in a way that allows accurate decision-making every time?
Clinical handover is defined as ‘the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis^. Each of the cases in this edition provides an example of gaps in clinical handover and the potential effects those gaps had on the clinical decisions made at the time.
Handover encompasses a broad range of information transfer, including each time a result is
reported for a patient, when a patient’s care is transferred to another speciality team, or when a person or team arrives to provide assistance in an emergency.
The first case (‘Lost in translation’) shows the problems that arise when assumptions are made about the type of language or wording that is used in a handover. The second case (‘Clinical picture or digital pictures?’) illustrates some of the challenges that occur in handover between different specialities and between the ranks of junior and senior staff. The third case (‘A catastrophic cascade’) looks at communication between specialists and the impact of failing to communicate all the relevant information in a critical situation.
Communication is a two-way street and there are a number of factors that can affect the successful transfer of information. The language needs to suit the context (i.e. be given in a way that will ‘make sense’); the content needs to be inclusive (i.e. leaving nothing out that is relevant); and the information needs to be received and understood (i.e. the recipient has adequately processed all the information). Using opaque language, omitting crucial details, or a lack of comprehension by the recipient, are all common reasons that underlie poor
One of the most important means of ensuring that good handover occurs is to implement a system that closes the communication loop. There are a number of ways of doing this. A phonecall to verify that critical information has been received. Completing a checklist to acknowledge that everything has been covered. Providing an opportunity for the receiving team to recap the information and allowing a conversation between both parties to occur. Such systems safeguard effective handover when there is urgent or time-critical information. In addition to these processes, it is essential that all the information is documented clearly and is easily retrievable.
Finally, differences in specialist knowledge and experience between two parties may influence the quality, type and comprehension of information being communicated. Therefore, these differences must be taken into account and accommodated for. The expert commentary in this edition further explores the concepts of communication and decision-making between novices and experts.
Thankyou for your feedback, we always place great value in hearing from our subscribers. Your thoughts and insights on the cases, and on issues relating to patient safety, will help guide our future directions. Once again, we hope that this edition of the Clinical Communiqué will encourage you to think about your clinical practices, talk about the cases with your colleagues, and identify the areas that could be changed in your workplace to improve patient care.
March 3, 2015
A reader has highlighted an important point about a reference made to a ‘re-breather’ oxygen mask in Case #2 (2005/33 QLD) in our December 2014 edition. This type of mask has an attached reservoir bag and at low oxygen flows, allows re-inhalation (or re-breathing) of exhaled CO2. In comparison, a ‘non-rebreather’ maskis a high concentration reservoir mask. It has a reservoir bag attached to it that is filled with oxygen. A non-rebreather mask may deliver oxygen at concentrations up to 90% when used with high flow rates of 10-15l/min. The bag is designed to prevent, not allow re-breathing (i.e. exhaled CO2 cannot be re-inhaled). Although the masks may look alike, a high flow of oxygen will prevent CO2 retention, no matter which type is used. This is vital for patients in the acute setting who require high-dose oxygen therapy.
The term ‘re-breather’ mask is sometimes erroneously used in hospital settings when referring to any mask which has a reservoir bag for delivered oxygen. Therefore, although the coroner’s finding referred to a ‘re-breather mask’, it is unclear in this case whether a ‘re-breather’ was in fact applied by the nursing staff, or whether a ‘non-rebreather’ mask was actually used.
For clarification, in the setting of hypoxia, as in this case, it is appropriate to escalate oxygen therapy by using a NON-rebreather mask with high flow oxygen and requesting senior assistance.
For further information on oxygen delivery devices, please go to: Page vi48 of the BTS guideline for emergency oxygen use in adult patients. Thorax 2008; 63:vi1-vi68. Available at: https://www.brit-thoracic.org.uk/document-library/clinical-information/oxygen/emergency-oxygen-use-in-adult-patients-guideline/emergency-oxygen-use-in-adult-patients-guideline/
March 3, 2015
The Coroners Court of Victoria (CCOV) is conducting health and medical information sessions on the coronial process in 2015. Topics include:
-Reporting a death to the coroner;
-Victorian Institute of Forensic Medicine (VIFM) forensic pathology investigation;
-Health and medical death investigation process, and inquest.
The speakers include a forensic pathologist, a coroner and CCOV staff who investigate health and medical related deaths. This session would be of interest to general practitioners, hospital medical staff and those involved in medical education, clinical heads of departments, nurses, nurse educators and clinical risk managers. For further information, please go to:
December 2, 2014
Download PDF: Clinical Communiqué December 2014 Edition
In this edition
- Case #1: Red Flags – Think, Worry, Rethink!
- Case #2: Look for the Worst and Hope for the Best
- Case #3: Fit the Plan to the Place
- Expert Commentary: Heuristic Thinking in Clinical Decision-Making – A Psychological Perspective
Welcome to the second issue of the Clinical Communiqué.
We are thrilled by the overwhelming response we have had from the healthcare community to our return in September. We thank all our readers, new and old, for your encouragement and subscription. It is a resounding acknowledgement of the importance that individuals and organisations place on patient safety, and learning from healthcare-related deaths.
In this issue we present three cases where the lessons to be learnt relate to clinical deterioration, and the failure to recognise or respond appropriately to early warning signs. When confronted with an unwell patient, there must be strong systems in place to provide support for the individual clinician to effectively identify, escalate and safely manage the situation. Strategies to strengthen systems include protocols to aid communication, processes that support good clinical decision-making, and sufficient resources to allow escalation of care.
The process of decision-making forms the core of our work as clinicians. At the beginning of our careers we learn about clinical conditions and management options in great detail. We make our clinical decisions in a slow methodical manner, deliberating and appraising the ‘book’ knowledge we learnt.
We then spend many more years having our decision-making processes shaped by our clinical experiences. We start to take unconscious shortcuts, making decisions influenced by the familiarity of mental models formed by previous experience. The challenge in our work becomes knowing when to stop, think and most importantly ‘rethink’.
When we are fatigued, sleep deprived, or inattentive due to juggling multiple tasks, we are more at risk of errors in our clinical decision-making. External stressors of being time-poor, resource limited, working in a different environment, or with a scenario we have not encountered before, can compound these factors even more. It becomes a fine balance to find an approach to decision-making that allows us to work efficiently, but think effectively and practice safely every time.
We can all form views to which we become anchored and, once formed, a view can be difficult to shift. If that view is an incorrect diagnosis, it may continue on throughout a patient’s healthcare journey. Therefore, it is imperative to recognise that there are many ‘red flags’ that should make you stop and think, but if missed, may be catastrophic. ‘Red flags’ include patient re-presentations, when family express concerns, referrals from other healthcare professionals, disproportionate symptoms, or signs that prevail despite therapy. Each of the cases in this issue highlights some of the traps for misdiagnosis and the errors that occurred in the subsequent management. The expert commentary follows on with an incisive overview of the concepts behind decision-making processes in clinical settings.
As we approach the end of 2014, our team are excited about the future of the Communiqué and are busy planning for 2015. Please continue to spread the word to your colleagues and encourage them to read and subscribe to our publication.
Thankyou for your support and we wish you a safe and happy New Year.SUBSCRIBE