About Jane Shufro

Jane Shufro is the owner of Legal Nurse Collaborative consulting with attorneys, insurance firms, and other legal nurses on both plaintiff and defense medical-related legal cases. She specializes in cases requiring surgical anesthesia, sedation and monitoring, pain management and rapid response or code events.

Help Patients Prepare for Anesthesia Care

2way street          

The American Society of Anesthesiologists says most patients know little about the exact role anesthetists play in their care, beyond putting them to sleep, and need to be better informed about how they can work with providers for safer surgery and sedation.

Check out the full article at this link:

http://www.outpatientsurgery.net/newsletter/eweekly/2015/01/20#3

The medical record should contain good documentation of a pre-op discussion by an anesthesiologist, along with proper consents and clearly written medication orders.  There should also be a plan of care for type of anesthesia such as general, regional or a combination of different interventions that the patient has been made aware of before surgery.

If a patient receives a medication ordered by anesthesia that they will be using at home such as nausea or pain patch, appropriate documentation of patient teaching is necessary. Communication between anesthesia and the post-op nurse to coordinate this care is an important way to speed the recovery process, and help prevent post-op surgical readmissions.

 

Complications of Nerve Blocks

syringe

Courtesy of Sasha from Fotolia.com

Complications of an Interscalene Nerve Block for the Shoulder

Last Updated:| By Rae Uddin

Interscalene nerve block before shoulder surgery can cause complications.

An interscalene nerve block is a form of local anesthetic used prior to shoulder surgery. This anesthetic is applied to specific nerves within the shoulder by an anesthesiologist using a thin needle. Immediately after interscalene nerve block application, a treated patient’s shoulder and arm begins feeling heavy and numb. A surgeon can then perform shoulder surgery and the treated patient will not feel pain or discomfort during this procedure. Patients should discuss the potential complications of an interscalene nerve block with a doctor before having shoulder surgery.

Breathing Difficulties

Patients who receive an interscalene nerve block before shoulder surgery can develop breathing complications, explains Dr. Stephen Breneman with the American Association of Orthopaedic Surgeons. Affected patients can experience shortness of breath or may have difficulty inhaling deeply. This complication of an interscalene nerve block can occur if this anesthetic numbs a portion of a patient’s diaphragm, the large muscle involved in lung expansion and contraction. Rarely, a lung may be punctured during interscalene nerve block administration. If this occurs, affected patients can experience severe breathing difficulties that require prompt medical attention

Vocal Hoarseness or Difficulty Swallowing

Approximately 15 percent of patients experience vocal hoarseness or difficulty swallowing as complications of an interscalene nerve block for shoulder surgery, ShoulderDoc medical professionals report. Administration of the interscalene nerve block can numb a patient’s vocal box, which can cause her voice to sound unusually quiet, raspy or rough. Numbness within the throat following interscalene nerve block treatment can limit a patient’s ability to voluntarily swallow. These complications of an interscalene nerve block are typically temporary and subside once this anesthetic medication wears off.

Seizure or Heart Rate Abnormalities

Rarely, patients who receive an interscalene nerve block can develop seizure complications. Approximately 0.3 percent of patients treated with interscalene block prior to shoulder surgery developed seizure complications, reports Dr. Hector Herrera and colleagues in a February 2009 article published in “The Internet Journal of Anesthesiology.” Certain patients may also develop heart rate abnormalities following interscalene nerve block administration. These complications most frequently occur if the interscalene nerve block is inadvertently injected into a patient’s bloodstream.

Bleeding, Infection or Bruising

Infrequently, patients can experience unusual bleeding, infection or bruising complications after receiving an interscalene nerve block. Such complications typically arise at the site of injection and may require additional medical treatment to resolve.

Permanent Nerve Damage

Permanent nerve damage complications following interscalene nerve block are extremely rare, affecting approximately one in 10,000 treated patients, Breneman reports. Affected patients can experience chronic sensations of numbness, tingling or weakness within the treated shoulder or arm.

The role of legal nurses in a regional block case:

I have reviewed cases involving nerve blocks and complications and my role often includes teaching because many factors have to be considered when this occurs.  Patient selection, medical history need to be assessed as some patients are more high risk for an adverse event. The skill of the anesthesiologist, the use of digital ultrasound and reducing risk of adverse events by the following: use the least dose required to achieve the desired results, using a “test” dose to identify intravascular injection, careful aspiration prior to each injection while observing for blood, and most importantly vigilant monitoring observing for signs and symptoms of toxicity between injections and after completion.  Signs of toxicity can be delayed up to 30 minutes. Patents must be engaged in reporting anything they are experiencing so frequent communication is important.

Most often, the issues arise around what was or was not done when signs of toxicity are reported. The lack of proper monitoring or management plan for treating complications are often at the core of these bad outcomes as the treatment of local anesthetic system toxicity differs from other cardiac arrest scenarios .

Contact me for more information on this subject or if you’d like an opinion on a case of Local Anesthetic System Toxicity.

Jane Shufro

jane@janeshufrolnc.com

 

 

 

 

 

 

Discharge Readiness

Locate ExpertsByJane Shufro September, 2014                      

Part 2.

In last month’s Blog I outlined a popular current discharge scoring system, the modified Aldrete, and the use of established safe discharge criteria in the PACU setting.   The scoring system evaluates 5 key parameters to ensure the safe transfer or discharge of the patient post operatively.

The clinical scoring system provides a reliable guide for nursing assessment, has been widely supported by The Joint Commission and proven to be efficient to use over the years. A well documented standardized discharge scoring system can prove to be a valuable asset, if you know what it means and where to find it in the medical record review.  Both paper PACU records and EHR integrate the scoring system into the nurses’ assessments area.  You will also find the information on the discharge nursing note.  In performing a medical record review, it’s prudent to compare the numerical scores with what else is documented in the same time frame.  For example, does the patient have a score of “2” for awake and alert but the nurse’s notes state the patient is sedated?   Validate that the scoring reflects what was really going on.

Not just a number…..

Now that you have a good basic idea of how numerical scores for discharge are used, let’s put it together the way you would when doing a case review.  Say, for example, a PACU nurse documents at 2 pm that the patient is responsive but sleepy on supplemental O2, unlabored resps, moving well with a blood pressure of 98/68. The patient’s baseline BP was 130/70 so he should have an Aldrete score of “7”. (Sleepy=1, activity=2, resps=2, O2 sat=1, and hemodynamic=1) You note a discrepancy because a score of “8” is documented instead.   Does it matter?  The answer is:  that depends.

The use of discharge criteria reinforces the value of having a system to maintain high standards of care, but there are limitations.  First, the criteria are broad and miss certain parameters that need to be assessed before readiness can be determined.   For example, vital sign ranges and expected pain or nausea levels and whether the patient needs to void are not included. Post- operative vital sign parameters may be inaccurate if preoperative values were abnormally high for the patient due to anxiety or other causes. Expecting the postoperative blood pressure to be within 20% of an elevated blood pressure may not be appropriate.

In the example above, it’s clear one needs to look beyond the numerical scoring data when analyzing a medical record review of a surgical patient.  The data alone does not replace the critical thinking or professional judgments of the nurse.  A patient may seem to fit all of the discharge criteria, yet a safe discharge requires an assessment on a case-by-case basis.  There are times when it’s reasonable to err on the side of caution as discharge goals can fail patients when used as a stand -alone measure.

Safe ambulatory surgery includes appropriate patient selection and timely discharge.  Discharge protocols must be established and consistently followed using scoring criteria and individualized assessments.

Hospital and unit based discharge policies should be requested and reviewed. Obtain copies of the scoring systems used as each facility has their own way of documenting these and they vary.  Pain, Sedation and Discharge are common types of scales that can be requested.   Websites such as American Society of Anesthesiologists (ASA) and American Society of Perianesthesia Nurses (ASPAN) are a good source of current practices.

Reviewing postoperative records can be a challenge.   It’s necessary to have an understanding of current discharge practices and protocols because limitations exist that have important implications for nursing.  Guidelines are evolving and are sometimes inconsistent, adding to the burden of finding literature to support the standards of care in this area.

If you need more information or have a question, contact me anytime.

Is Your Day Surgery Patient Ready for Discharge?

To reflect current technology and anesthesia practice, the American Society of Anesthesiologists have standards of care that require that a physician accept responsibility for discharge of patients from the unit. This is the case even when the decision to discharge the patient is made by the bedside nurse in accordance with the hospital-sanctioned discharge criteria or scoring system. If discharge scoring systems are to be used in this way, they must first be approved by the department of anesthesia and the hospital medical staff.  A responsible physician’s name must be noted on the record.

PADSS photoThe American Society of Perianesthesia Nurses (ASPAN) neither requires or endorses any particular scoring system, and leaves the frequency or interval between scores to the individual facility policy. Typically, the minimum assessment would be done on admission to the PACU and on discharge for each level of post anesthesia care. Perianesthesia nurses everywhere, however, recognize the use of  post-op scoring as an integral part of their discharge criteria.  Written discharge criteria should be developed by the department of Anesthesia.  The criteria states a certain acceptable post-op score be achieved prior to discharge.  There are several widely accepted post-anesthetic discharge scoring systems, the most common being the modified Aldrete.

Consciousness Awake and oriented
Arousable with minimum stimuli
Non responsive to tactile stimuli
2
1
0
Activity Able to move extremities
Mild to moderate weakness in extremities
Unable to move extremities
2
1
0
Respiration Able to deep breathe and cough, with no tachypnea
Tachypnea, but able to cough adequately
Dyspnea and unable to cough
2
1
0
Hemodynamics Blood pressure ±15% from pre-procedure level
Blood pressure ±30% from pre-procedure level
Blood pressure ±50% from pre-procedure level
2
1
0
O2 saturation Maintains saturation >92% on room air
Needs to inhale oxygen to maintain saturation ≥90%
Saturation <90% in spite of oxygen therapy
2
1
0

The numerical scores of each category are added up at each assessment and a total patient score of “8” or above must be reached to be able to go home.  There is of course some variability to each facility.  There are also some disadvantages to using the scoring system and many situations rely on good clinical nursing judgement.

In order to be able to determine whether a patient was appropriately discharged, a discharge ” score” system provides a tool- but that’s only a piece of what determines a patient’s overall readiness.  You must know how to interpret the anesthesia and PACU medical records, and know where to focus.

Learn more about how to better evaluate whether discharge criteria was met and where to locate this information in the medical record in my next Blog……part 2

The Importance of Medication Reconciliation

Hughes RG, editor. Patient Safety and Quality: An Evidenced- based Handbook for Nurses.

According to the Institute of Medicine’s Preventing Medication Errors report, the average hospitalized patient is subject to at least one medication error per day. This confirms previous research findings that medication errors represent the most common patient safety error. Thus, the topic plays an important role in my practice both as an RN and as a legal nurse consultant.

Reviewing medications is an important role of the RN in order to provide safe, competent care to our patients. It’s a necessary process in avoiding the pitfalls that occur when we fail to ensure we have an accurate list of all patient medications; however, recent studies have shown that these errors are more prevalent during patient transitions rather than the result of having an incomplete medication list.

In an effort to avoid the errors of omission, duplication, incorrect doses or timing, and adverse drug-drug interactions a more formal process called Medication reconciliation was introduced as a National Patient Safety Goal by The Joint Commission in  2005.

Medication reconciliation is a formal process that compares a patient’s medication orders to all of the medications that the patient has been taking. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care.

Safety Vulnerabilities Necessitate Medication Reconciliation.  Factors such as patients’ lack of knowledge of their medications, clinician’s workflows and lack of integration of patient health records across the continuum care have all contributed to the potential for error. When specialty health care providers are focused on one aspect of care, it’s easy to overlook medications that may cause an adverse event when combined with a new medication or different dosage.

What medications should be included and why?   A comprehensive list of medications includes all prescription medications, herbals, vitamins, supplements, over-the –counter drugs, even diagnostic and contrast agents and intravenous nutrition.  Interestingly, most clinicians do not consider over-the –counter drugs or dietary supplements to be medications and often do not include them in the record. Interactions can occur between various types of medications so they need to be part of the history.

What are the roles and responsibilities in Medication reconciliation?  To start, there are many ways to gather, organize and communicate medication information and several disciplines involved in this process-medicine, pharmacy, and nursing- with little agreement on each other’s roles and responsibilities with respect to this process.  Problems with duplication of data, documenting data in different places in the medical record from different sources can create discrepancies that rarely get resolved by any of the disciplines.  Lack of a standard for reconciliation and what constitutes a comprehensive medication history has contributed to the creation of an unsafe medication environment in the acute care setting, and is only exacerbated by the movement towards electronic health records. Anyone who routinely reviews medical records can attest to the confusion and frustration of finding a patient’s medication list documented in many  areas such as nursing admission, the medication administration record, the physician history or pharmacy profile.  Often there are gaps and omissions in information, thus the data is only as accurate as what has been entered.  Health care professionals need to clearly identify team responsibilities for the medication reconciliation process including location in the record where the medication history is kept and who will enter the data and document any changes.

Can Standardized systems address the Challenges?   Many settings have found the use of a standardized medication form facilitates a more accurate list that is accessible and visible. Numerous examples of standardized medication forms are available on The Institute for Healthcare Improvement (IHI) website.  Having a process in place for timely medication review and education programs to involve patients and families can be of value. Recognizing that much of the information is being gathered from laypeople, patient education needs to be a major focus going forward if they are to serve as advocates in their own medication safety.

Top 10 Patient Safety Issues for 2014

Do you have a case that may hinge on a safety issue?

An interesting article by the Patient Safety Movement:
This article goes beyond talking about creating a culture of safety in hospitals, and how using technology isn’t enough. Legal  nurse consultants who are current  use their experience  to navigate the  medical records  and define any facts that support their case.

[Read more…]