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Interventions to Improve Patient Care on Surgical Ward Rounds: A Systematic Review

• Scientific Review
• Open access
• Published: 19 October 2023
• Volume 47 , pages 3159–3174, ( 2023 )

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• Reuben He   ORCID: orcid.org/0000-0001-8541-5464 1 ,
• Sameer Bhat 1 , 2 ,
• Chris Varghese 1 ,
• Jeremy Rossaak 3 ,
• Celia Keane 1 ,
• Wal Baraza 1 , 4 &
• Cameron I. Wells 1 , 4  

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Ward rounds are an essential component of surgical and perioperative care. However, the relative effectiveness of different interventions to improve the quality of surgical ward rounds remains uncertain. The aim of this systematic review was to evaluate the efficacy of various ward round interventions among surgical patients.

A systematic literature search of the MEDLINE (OVID), EMBASE (OVID), Scopus, Cumulative Index of Nursing and Allied Health (CINAHL), and PsycInfo databases was performed on 7 October 2022 in accordance with PRISMA guidelines. All studies investigating surgical ward round quality improvement strategies with measurable outcomes were included. Data were analysed via narrative synthesis based on commonly reported themes.

A total of 28 studies were included. Most were cohort studies ( n  = 25), followed by randomised controlled trials ( n  = 3). Checklists/proformas were utilised most commonly ( n  = 22), followed by technological ( n  = 3), personnel ( n  = 2), and well-being ( n  = 1) quality improvement strategies. The majority of checklist interventions ( n  = 21, 95%) showed significant improvements in documentation compliance, staff understanding, or patient satisfaction. Other less frequently reported ward round interventions demonstrated improvements in communication, patient safety, and reductions in patient stress levels.

Conclusions

Use of checklists, technology, personnel, and well-being improvement strategies have been associated with improvements in ward round documentation, communication, as well as staff and patient satisfaction. Future studies should investigate the ease of implementation and long-term durability of these interventions, in addition to their impact on clinically relevant outcomes such as patient morbidity and mortality.

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Introduction

Ward rounds are an essential component of surgical and perioperative care [ 1 ]. They allow doctors to communicate with patients, assess progress, and develop treatment plans [ 2 ]. The quality of ward rounds may directly impact on patient outcomes [ 3 , 4 ], with documentation being a key method of communication between clinical teams [ 1 , 5 ].

Regulatory bodies have provided expected standards of communication and documentation in doctor-patient consultations [ 6 ]. Multiple studies have found that documentation during surgical ward rounds consistently fails to achieve these standards [ 3 , 4 ].Shortfalls may lead to delays in diagnosis, precipitate preventable complications, medicolegal challenges, and ultimately result in worse outcomes for patients [ 1 , 7 , 8 ].

Ward round checklists and proformas have been developed in an attempt to improve patient care through better documentation of patient progress and management plans [ 9 , 10 , 11 , 12 ]. Studies have demonstrated improvements in perioperative care through reductions in rates of error and failure to rescue (i.e. death after the development of a postoperative complication), when ward round checklists were utilised [ 11 , 12 ]. Telerounding and the use of bedside nursing summaries have also been suggested as adjuncts to the standard ward round for surgical patients [ 13 , 14 ].

Current literature demonstrates a wide variety of different interventions to improve the quality of surgical ward rounds [ 9 , 13 , 14 , 15 ]. However, there is uncertainty surrounding their relative effectiveness, ease of implementation, and impact on patient satisfaction. The objectives of this study were to systematically review and assess the efficacy of previously documented interventions. This may aid in the design and implementation of perioperative quality improvement strategies.

The protocol for this review was prospectively registered on PROSPERO (ID: CRD42022359414) [ 16 ]. The review complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines (refer Supplementary Appendix S1 for the PRISMA checklist) [ 17 ].

Data sources and search strategy

A systematic literature search of the MEDLINE (OVID), EMBASE (OVID), Scopus, Cumulative Index of Nursing and Allied Health (CINAHL), and PsycInfo databases was performed 7 October 2022. The search string consisted of key words and Medical Subject Headings (MeSH) terms for various surgical specialties (e.g. ‘cardiothoracic’, ‘otorhinolaryngology’, ‘vascular’), medical staff members (e.g. ‘attending’, ‘consultant’, ‘registrar’), and ward rounds (e.g. ‘ward round’, ‘bedside round’, ‘morning round’), among others. These terms were combined using the ‘AND’/‘OR’ Boolean operators (refer to Supplementary Appendix S2 for an exemplar search string using the MEDLINE database).

Databases were searched from their date of inception. The results were restricted to studies published in English. There were no limitations on patient age, geographic location, or study design. Reference lists of included studies and relevant systematic reviews were also hand-searched to identify additional studies for inclusion.

Study selection criteria

All original studies investigating quality improvement strategies implemented during an inpatient surgical ward round were eligible for inclusion. Surgical ward round was defined as any setting or situation in which member(s) of a surgical team assessed patients as part of perioperative care, regardless of surgical specialty. Only studies reporting quality improvement interventions with a measurable outcome on an individual patient (e.g. patient satisfaction, understanding, and/or interpretation of quality of care) or hospital/department (e.g. duration of ward round, time spent per patient, documentation completion rate, and/or percentage of clinical information considered), and those where the majority (> 50%) of included patients were under surgical care, were included.

We excluded case reports (with< 5 patients), articles without an accessible full-text and/or conference abstracts without a full-text publication. Reviews and studies published in languages other than English were also excluded.

Screening process

Article records from the database searches were exported into EndNote X9 (Clarivate, Philadelphia, PA, USA) and de-duplicated using validated methods [ 18 ]. Two investigators (RH, SB) used the Rayyan web application to independently screen titles and abstracts, with relevant full texts then considered for final inclusion [ 18 , 19 ]. Any discrepancies were addressed through discussion with input from a senior author (CW), until consensus was reached.

Data extraction

Relevant data from included studies were extracted into a proforma Google spreadsheet by a single investigator (RH). These data were independently validated by a second investigator (SB), with any disagreements resolved via mediation with a senior investigator (CW) until consensus was reached. Extracted data comprised study characteristics, conflicts of interest, study funding, surgical specialty, number and designation of medical staff involved, sample size (pre and post-intervention), description of intervention and method of implementation, as well as the comparator intervention. Individual patient and/or hospital/departmental level outcomes were also extracted. Data that were reported in the form of graphs and/or figures were extracted using WebPlotDigitizer (version 4.5; Pacifica, California, USA) [ 20 ]. Attempts were made to contact corresponding authors in cases of ambiguous or missing data [ 21 ].

Quality assessment

Two authors (RH and SB) independently performed methodological quality assessment of included studies, with disputes resolved through discussion. The Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool [ 22 ] and Joanna Briggs Institute (JBI) Critical Appraisal Checklist [ 23 ] were used to appraise prospective and retrospective cohort studies, respectively, while the Cochrane Collaboration’s Risk of Bias 2.0 (ROB2) tool was used to assess risk of bias within randomised controlled trials (RCTs) [ 24 ]. ROBINS-I results were depicted pictorially using the Risk-of-Bias Visualization (robvis) package in RStudio (R Studio, Boston, MA) [ 25 ].

Data were analysed via narrative synthesis according to major reported themes among the included studies. Simple descriptive statistics were used to quantitatively report data where possible.

Search results

The database search yielded a total of 3362 results, from which a total of 28 studies were included in the qualitative synthesis (Fig.  1 ) [ 3 , 5 , 9 , 12 , 13 , 14 , 21 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ].

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram showing the selection process for studies included in the systematic review

Study characteristics

Characteristics of the 28 included studies are provided in Table 1 . Other than three studies, the remainder were published within the last decade [ 21 , 31 , 35 ]. Most were cohort studies ( n  = 25, 89.3%), followed by RCTs ( n  = 3, 10.7%). Most studies were conducted in the UK ( n  = 11, 39.3%), followed by the USA ( n  = 6, 21.4%), and Aotearoa New Zealand ( n  = 4, 14.3%). All were single-centre studies, including patients from a range of surgical specialties; general ( n  = 8, 28.6%) and orthopaedic surgery ( n  = 6, 21.4%), surgical intensive care unit (including general surgical, trauma, and burns patients; n  = 3, 10.7%), trauma surgery ( n  = 3, 10.7%), and urology ( n  = 3, 10.7%) were the specialties assessed most frequently.

Quality assessment results using the ROBINS-I tool are depicted in Supplementary Figure S1 . Four prospective cohort studies were judged to be at critical risk of bias, principally due to the impact of unmeasured confounding variables [ 13 , 30 , 34 , 38 ] Outcomes were measured through valid and reliable means, with sufficiently long follow-up duration, in 12 of the 15 (80%) retrospective cohort studies (Supplementary Appendix S3). However, none of the authors identified or statistically adjusted for any confounding factors in their analyses. The RCTs were mostly at high risk of bias ( n  = 2 studies, 66.7%) [ 9 , 14 ], resulting from outcome assessors who were unblinded to the ward round intervention of interest (Supplementary Figures S2–3).

Ward round interventions

A range of quality improvement interventions were implemented during surgical ward rounds. In total, 22 studies used some form of a ward round checklist or proforma (refer to Supplementary Appendix S4 for an example of a ward round checklist). Other interventions included a ‘surgeon of the week’ rounding system ( n  = 1) [ 26 ], additional telerounding on postoperative patients ( n  = 1) [ 14 ], involvement of a specialist radiologist during the ward round ( n  = 1) [ 31 ], digital record keeping ( n  = 1) [ 36 ], mobile tablet use during inpatient services ( n  = 1) [ 37 ], and implementation of active breaks during the ward round ( n  = 1) [ 30 ].

Checklists and proformas served as a guidance for information that should be covered in a surgical ward round, or a template to ensure adequate documentation of essential ward round points. Of the 22 studies that employed a checklist or a proforma, most introduced physical stickers or forms which were placed in a patient’s medical record (82%, 18/22), whereas information printouts displayed throughout the ward were trialled in three studies (Table 2 ) [ 34 , 44 , 46 ].

Main findings and limitations of included checklist/proforma studies are summarised in Table 2 . Supplementary Appendix S5 provides a summary of findings and limitations of all included studies grouped by theme of intervention.

Documentation criteria

Four studies implemented a ‘Plan, Do, Study, Act’ (PDSA) cycle design, whereby ward round interventions were iteratively reviewed and improved after each study [ 5 , 13 , 27 , 32 ]. Proforma checklists were used in all of these, in addition to completion of a pre-intervention audit to evaluate baseline documentation compliance against agreed documentation criteria. All studies demonstrated significant improvements in most criteria, such as the documentation of date and time, clinician leading ward round, impression, management plan, and venous thromboembolism (VTE) assessment. Alamri and colleagues [ 28 ] reviewed compliance against a proforma sticker utilised in a previous study [ 27 ]

Resources and personnel

Yorkgitis et al . [ 46 ] introduced a laboratory tests and chest X-ray imaging section on their daily intensive care unit (ICU) checklist. There was no significant difference in the mean number of chest x-rays and coagulation tests requested each day. There was also no significant change in the mean daily number of complete blood counts, chemistry panels, arterial blood gases, and red blood cell transfusions ordered.

Baker et al . [ 31 ] reported that presence of a consultant radiologist on the surgical ward round resulted in a significant reduction in the number of nuclear medicine scans, ultrasound scans, body computed tomography (CT) scans, barium enemas, and upper gastrointestinal (GI) series performed. The average hospital length of stay also decreased from 21.4 to 18.4 days. Interestingly, the number of abdominal plain films obtained increased when a consultant radiologist was present.

Staff and patient satisfaction

Pre- and post-intervention surveys were completed by staff and patients to measure satisfaction levels. Generally, ward round quality improvement strategies were well received by staff and patients. Two studies found that checklists had utility as a tool for learning and guiding ward round documentation [ 3 , 21 ]. Krishnamohan et al. [ 3 ] found ward round checklists to be a useful method for deconstructing power hierarchies and encouraging junior team members to ask questions regarding patient care.

Non-checklist interventions also elicited positive responses. Interventions such as the institution of active breaks during the surgical ward round [ 30 ], adjunctive telerounding [ 14 ], and use of electronic patient records [ 36 ] all demonstrated improved staff satisfaction compared to standard surgical ward rounds. In addition, Chaudary and colleagues [ 36 ] explored how electronic patient records created extra opportunities for junior staff to learn imaging interpretation techniques amidst the ward round. Abbas et al. [ 26 ] concluded that a ‘surgeon of the week’ rounding system was beneficial for both staff and patient satisfaction, and also patient safety and efficiency of the surgical ward round. Following implementation, there were a reduction in the total number of safety complaints, an increase in work relative value units/revenue, and an increase in both employee satisfaction and parental satisfaction in a paediatric surgical unit.

Communication and documentation

Five studies investigated the impact of checklist interventions on communication between staff and patients. Alazzawi et al. [ 29 ] reported that all surveyed staff members ( n  = 10) preferred a proforma to standard ward rounds due to improved clarity of information. Banfield et al. [ 32 ] demonstrated improvements in communication and understanding of diagnosis and management plans among junior team members when a proforma was used during the post-acute surgical ward round. Brown et al. [ 34 ] observed improvements in patient understanding of their management plans when a surgical communication checksheet was used. Al-Mahrouqi et al . [ 27 ] demonstrated that although improvements in ward round documentation were seen with a post-acute ward round proforma, there was no statistically significant impact on nurse certainty of dietary plans, and the number of times surgical teams were contacted. Shaughnessy and colleagues highlighted that patient communication required further improvement, despite a verbal checklist demonstrating improved nursing clarity and reduced plan omissions being used [ 13 ]

Surgical ward round efficiency

Significant reductions in overall ward round duration were observed through the use of mobile tablet technology [ 37 ] and a ward round checklist [ 21 , 38 ]. Aydogdu et al . [ 14 ] found that adjunctive telerounding did not result in a statistically significant difference in mean ward round time which was consistent with two other studies that employed a ward round proforma [ 44 , 45 ].

Patient outcomes

Only two studies investigated the impact of ward round interventions on perioperative patient outcomes [ 1 , 3 , 14 ]. Krishnamohan et al. [ 3 ] identified that use of a ward round checklist reduced errors in medication prescriptions, antimicrobial administration, fluid balance monitoring, patient observation charts, and the number of venous thromboembolism (VTE) cases diagnosed. Pucher et al. [ 1 ] found that general surgery trainees who utilised a ward round checklist committed significantly fewer critical errors compared to standard surgical rounding, with critical errors defined as the ‘failure to adhere to critical processes in the management of postoperative complications’.

Few studies described the durability of surgical ward round quality improvement strategies [ 3 , 27 , 28 ]. Results were inconsistent in two studies; Al-Mahrouqi et al . found that compliance was low six months post-intervention (75% proforma usage), whereas Alamri et al . observed comparatively higher compliance with documentation criteria up to two years post-intervention (> 80% completion across most documentation criteria) [ 27 , 28 ]. In contrast, Krishnamohan et al . observed a mild decrease in compliance with documentation criteria in the three-month period post-intervention, from 79 to 72%.

Surgical rounding is an important aspect of perioperative care, with deficiencies in ward round communication and documentation associated with poorer patient outcomes [ 3 , 5 , 28 , 38 , 44 ]. This systematic review summarised the results from 28 studies which implemented different surgical ward round interventions to improve perioperative care, with significant improvements shown in the quality of documentation and communication during ward rounds. Studies implementing active ward round breaks, telerounding, and digital patient records demonstrated positive feedback from staff and patients. Checklists or proformas were used most frequently to guide ward rounds and were typically associated with significant improvements in ward round documentation. This is consistent with advice from both The Royal College of Physicians and The Royal College of Nursing, who emphasise the utility of checklists in reducing medical errors, establishing rigorous documentation, and promoting cost-effective strategies for punctual discharge [ 47 ]. Other studies have also demonstrated the benefit of checklists for patient documentation and communication [ 3 , 28 ].

Few studies measured the impact of ward round interventions on patient morbidity and mortality. However, implementation of ward round checklists led to significant reductions in prescribing errors and critical errors related to the management of postoperative complications [ 1 , 3 ]. It was not possible to determine which of these factors were associated with the greatest impact on patient outcomes. This is an important consideration given that quality improvement strategies targeted at ‘high impact’ interventions are likely to result in disproportionately greater improvements in patient morbidity and mortality. The lack of assessment of clinically meaningful outcomes is a missed opportunity in context of the work required to develop ward round tools.

Subjective improvements in staff and patient communication were demonstrated with the use of checklists or proformas during the surgical ward round [ 13 , 27 , 29 , 32 , 34 ]. Documentation during the ward round is an important means of communication between clinical teams, with improvements in communication shown to mitigate medical errors and improve patient safety and outcomes [ 2 , 9 , 38 , 48 , 49 ]. Future studies should aim to develop more objective measures of staff and patient communication to improve assessment of different perioperative quality improvement strategies.

Only three studies assessed longitudinal outcomes of their ward round interventions over time [ 3 , 27 , 28 ]. Any successful ward round intervention should be simple and practical to implement, and consider all parties involved in order to achieve long-term engagement and compliance [ 14 , 30 , 36 ]. Further study into the durability of different perioperative ward round interventions would aid understanding of how improvement is maintained, which factors contribute to long-term adherence, and what strategies may overcome barriers of implementation.

Timing and efficiency of the surgical ward round is another consideration, with some staff apprehension about the extra time required to complete quality improvement interventions [ 50 ]. However, evidence regarding the impact of perioperative interventions on ward round timing is conflicting. Use of mobile tablets during the ward round led to a significant reduction in the ward round duration, suggesting that digitalisation may reduce time consuming activities such as finding physical notes or leaving the bedside to view investigation results [ 37 ]. Some studies found that checklists reduced ward round time [ 21 , 38 ] possibly because they provided a set ward round structure. This could be useful as checklists provide a comprehensive ward round agenda, thus reducing the risk of omitting important considerations.

There are several limitations to this review. Data were derived from single-centre studies, with short follow-up durations and infrequent reporting of clinically relevant patient outcomes (e.g. morbidity and mortality). The predominance of observational studies (~ 90% of studies) also introduces considerable selection and confounding bias, limiting the reliability of our conclusions. Most studies also used non-validated questionnaires to measure staff and patient satisfaction. The heterogeneity in outcomes and reporting of data between studies made it difficult to perform meaningful quantitative analyses. In addition, potential impacts of the Hawthorne effect (the phenomenon where an individual may alter or change their behaviour when they are aware of being observed) on outcomes was not accounted for in any of the studies [ 47 ], which could be contributing to poor long-term durability of some interventions. Finally, ward round checklists or proformas were the most frequently studied intervention, which possibly relates to their relative ease of development and implementation. Thus, the impact of intervention selection bias could not be determined, despite a systematic and broad search of the surgical literature being performed. This suggests that barriers such as the lack of funding and/or resources may exist, ultimately inhibiting transformative interventions from being trialled in the setting of a surgical ward round.

Future research into the impact of different perioperative interventions should focus on larger patient cohorts, longitudinal follow-up of results, and objectively assessing for improvements in clinical outcomes via audit. The clinical and organisational framework for an optimal ward round are also important considerations, with key aspects being communication, early detection of complications, resilience to staff changes, staff well-being, efficiency, and regular auditing of ward round practices.

Different types of ward round interventions have been implemented to improve the quality of patient care during the perioperative period. Use of checklists or proformas, telerounding, mobile tablet use, electronic patient records, a ‘surgeon of the week’ ward rounding system, as well as the introduction of active breaks during ward rounds have been associated with improvements in ward round documentation, communication, and satisfaction among staff and patients. Future studies should specifically investigate whether these different interventions are feasible to maintain in the long term, and their impact on clinically relevant outcomes such as patient morbidity and mortality.

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Reuben He, Sameer Bhat, Chris Varghese, Celia Keane, Wal Baraza & Cameron I. Wells

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Sameer Bhat

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He, R., Bhat, S., Varghese, C. et al. Interventions to Improve Patient Care on Surgical Ward Rounds: A Systematic Review. World J Surg 47 , 3159–3174 (2023). https://doi.org/10.1007/s00268-023-07221-z

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Published : 19 October 2023

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8.6: Surgical Ward

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Time: 08h00

Place: surgical ward.

“Dr. Baker, can we speak?”

Dr. Baker turns to see the social worker for the Surgical Department standing behind him with her arms crossed. “Ok, Nancy. You look serious.”

“I am. I believe we need to meet with Fred Johnson and discuss the next steps for his treatment and how best to support everyone. His partner, Eric, says they haven’t had an update from you since surgery.”

“That is correct. I’m waiting for the specimen results. Let’s check together for the results, and if they’re back, plan to meet with them both later today.”

Dr. Baker signs into one of the nursing station computers and quickly navigates to Fred Johnson’s results, “Ok, they’re back. Now, let’s see…”

Dr. Baker looks through the results and sees that Fred has a terminal diagnosis with the spread of his cancer.

“Ok, Nancy. This is not good. I knew it would be pretty bad, but not terminal.”

“Oh. That makes it very important for us to talk with him today. What are his options?”

“I’m thinking that we could offer radiation to a couple of the areas, along with chemo. All this would be palliative and could extend his life another six months to even a year. No treatment, he probably has less than a year. So the pain of chemo may be worth it, but it’s up to them to decide.”

“I agree that it’s their choice, and I’ll support them to make this decision. Is there a rush on this decision?” asks Nancy.

“No, I don’t believe so. A few days here or there is not going to make a big difference. I do need to consult with the Cancer Agency to make sure that I’m correct. I’ll call them now. Can you set up a meeting for later today with the Johnsons and the nursing staff caring for him?”

“Yes, I’ll talk to the charge nurse now and get things set up. Say 3pm?”

“Good. I will have more answers then. Thank you.”

Time: 15h00

Fred and Eric meet with Dr. Baker and the nursing staff, along with Nancy, to discuss goals of care and the next steps in treatment. Fred’s children attend by speaker phone so that everyone can hear firsthand the results of the tests and the suggested treatments and outcome.

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A conversation with Prof. Saugel on patient safety on surgical wards and future trends in ward monitoring

Patient safety after surgery is a crucial topic in modern healthcare. Despite its significance, it is not always widely recognized, so raising awareness about it is essential.

In this regard, we are thrilled to have the opportunity to speak with Professor Bernd Saugel, a highly influential Key Opinion Leader in this area and a passionate advocate for patient safety. Together, we will engage in a thought-provoking conversation about this critical issue.

Meet Professor Saugel, a highly-regarded specialist in perioperative and intensive care medicine. He has earned board certification in anaesthesiology, intensive care medicine, and internal medicine. He presently serves as Professor of Anesthesiology and Vice Chair of the Department of Anesthesiology at the Center of Anesthesiology and Intensive Care Medicine in the University Medical Center Hamburg-Eppendorf, Hamburg, Germany. 

His primary field of research centres around optimising haemodynamics for patients undergoing high-risk surgeries or those critically ill. He strongly emphasises individualised hsemodynamic management to enhance patient outcomes in perioperative and intensive care medicine. Currently, he is Editor for the British Journal of Anaesthesia. He has published a multitude of original articles and didactic reviews in peer-reviewed journals. On researchgate.net, his impressive collection of 271 research items has garnered a Research Interest score of 3,293, 6,079 citations, and an h-index of 43.

In the following pages, Professor Saugel presents valuable insights gained from years of dedication to improving surgical outcomes and reducing postoperative complications. Through this interview, we will explore the many aspects of patient safety, including the challenges that continue to evolve, the innovative strategies being developed, and the ethical principles that guide this critical area of healthcare.

The healthcare industry constantly evolves with the latest surgical techniques, technology, and patient expectations. In light of this, it is essential to understand the importance of patient safety after surgery and the significant role played by Professor Saugel in shaping a safer and more secure future for surgical patients worldwide.

Are patients treated on general wards after surgery safe?

When surgery has ended, and patients are transferred to the general care ward, patients and their families naturally assume that the most dangerous part of the “perioperative experience” is over. This assumption is wrong. Over the last decades we did a great job in reducing intraoperative major complications and mortality  [1] . However, complication and mortality rates in the first days and weeks after surgery are still high. Postoperative mortality is 100 times more common than intraoperative mortality  [1] . About 2% of patients having inpatient surgery die within the first months after surgery  [1, 2] . Two thirds of these patients die in the hospital before discharge  [1] . Three quarters of patients who die after surgery are not admitted to the intensive care unit at any stage after surgery  [2] . This means: After surgery, most patients who die, die on the general care wards. This contrasts with the assumption that a hospital ward – specifically the “patient’s room” – is a safe place of recovery. 

Postoperative deaths are a consequence of major complications – such as bleeding or cardiovascular and respiratory complications. Abnormal vital signs –hypotension, tachycardia, or hypoxemia – are clinical symptoms of these complications and often occur hours before a patient crashes. However, vital signs are not closely monitored on general care wards.  

Why would close monitoring of vital signs be important?

Critical cardiocirculatory or respiratory events usually do not appear suddenly. These critical events appear to happen suddenly because we recognize them suddenly – usually during rounds. We know, however, that life-threatening complications are usually preceded by subtle vital sign alterations that occur hours earlier  [3-5] . Subtle changes in respiratory rate, heart rate, blood pressure, or oxygen saturation are early signs of clinical deterioration eventually leading to critical events. Continuously monitoring vital signs could allow us to recognize these early signs – instead of just noticing that a patient “suddenly crashed”. Continuous ward monitoring may thus improve patient safety on general care wards. 

What is the standard for ward monitoring in major academic hospitals in Europe and the US?

Monitoring on general care wards – outside the operating room and the intensive care unit – is still basic and intermittent. Vital signs are not closely monitored on general care wards but rather checked sporadically. Nurses usually perform spot checks at intervals of 4-8 hours. Notably, it is astonishing that monitoring on general care wards has hardly changed over the last decades, although patients in hospitals are now older, sicker, and frailer than previously. This is true for both large academic centers and smaller hospitals – and in my experience it is true throughout Europe and the US. 

Why are spot checks not the right answer to post-operative monitoring?

Spot checks at intervals of 4-8 hours leave patients unmonitored for most of the time, thus fail to identify early vital sign alterations and patient deterioration. For example, it has been shown that spot checks miss hypoxaemia, hypotension, tachycardia, and tachypnoea  [6-9] . Additionally, respiratory rate (that is an important predictor of clinical deterioration  [10] ) is often not assessed at all  [11] – and if it is, it is assessed inaccurately  [12] .

What is the solution to detect patient deterioration on wards?

Continuous vital sign monitoring could allow recognizing subtle vital sign changes early and recognize clinical deterioration well before serious adverse events occur  [13] . Continuous ward monitoring thus seems likely to identify deterioration earlier than current spot check monitoring. 

How would an ideal ward monitoring system look like?

Continuous ward monitoring requires small, untethered, “wireless” monitoring systems with sensors to monitor various physiologic variables – including heart rate, oxygen saturation, respiratory rate, blood pressure, body position, activity, and location  [14, 15] . The ideal continuous ward monitoring device needs to be small, wireless, and wearable  [15] . Ward monitoring systems need to be validated rigorously to ensure that their measurement performance is clinically acceptable  [16] . Further, ward monitoring will only improve patient-centred outcomes if monitoring data are processed and analysed in real-time and trigger an immediate response by clinicians. There are “before-and-after” studies suggesting that implementing automated monitoring systems on general care wards and linking in combination with notification systems results in improvements in patient-centered outcomes  [17-20] . We will need robust trials showing that continuous ward monitoring improves outcome compared to current routine monitoring. 

What are the obstacles on the way to implementing continuous ward monitoring systems into clinical practice? 

Continuous ward monitoring seems to be the key to detect patient deterioration on general care wards. However, a huge effort is needed to implement continuous ward monitoring in clinical practice. This will not only require profoundly changing the way we think about ward monitoring but also overcoming technical obstacles  [13, 21, 22] : Sensors need to monitor the patient continuously – without limiting patient comfort and mobility. Measurement artifacts need to be filtered to avoid alarm fatigue. Ward monitoring systems need to be integrated into existing electronic medical record systems. We will need to establish response strategies when ward monitoring indicates that a patient deteriorates. In other words, monitoring systems need to direct the alert to the right person – the ward nurse or a Rapid Response Team. Further, we will need to get insights into how continuous patient monitoring affects the workload of nurses. 

Conclusions:

As we wrap up our insightful discussion with Professor Saugel, it is glaringly evident that ensuring patient safety following surgery should be given utmost priority. Professor Saugel's deep understanding of the subject has shed light on the intricate post-surgical care landscape, highlighting the significance of collaborative efforts, continuous learning, and the use of advanced technologies to safeguard the health of patients.

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• Sessler DI, Saugel B: Beyond 'failure to rescue': the time has come for continuous ward monitoring . Br J Anaesth  2019, 122 (3):304-306.
• McGillion MH, Duceppe E, Allan K, Marcucci M, Yang S, Johnson AP, Ross-Howe S, Peter E, Scott T, Ouellette C et al : Postoperative Remote Automated Monitoring: Need for and State of the Science . The Canadian journal of cardiology  2018, 34 (7):850-862.
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• Saugel B, Hoppe P, Khanna AK: Automated Continuous Noninvasive Ward Monitoring: Validation of Measurement Systems Is the Real Challenge . Anesthesiology  2020, 132 (3):407-410.
• Bellomo R, Ackerman M, Bailey M, Beale R, Clancy G, Danesh V, Hvarfner A, Jimenez E, Konrad D, Lecardo M et al : A controlled trial of electronic automated advisory vital signs monitoring in general hospital wards . Critical care medicine  2012, 40 (8):2349-2361.
• Subbe CP, Duller B, Bellomo R: Effect of an automated notification system for deteriorating ward patients on clinical outcomes . Critical care (London, England)  2017, 21 (1):52.
• Taenzer AH, Pyke JB, McGrath SP, Blike GT: Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study . Anesthesiology  2010, 112 (2):282-287.
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• Khanna AK, Hoppe P, Saugel B: Automated continuous noninvasive ward monitoring: future directions and challenges . Critical care (London, England)  2019, 23 (1):194.
• Flick M, Saugel B: Continuous ward monitoring: the selection, monitoring, alarms, response, treatment (SMART) road map . Br J Anaesth  2021.

Prof. Bernd Saugel

Highly-regarded specialist in perioperative and intensive care medicine. He has earned board certification in anaesthesiology, intensive care medicine, and internal medicine. He presently serves as Professor of Anesthesiology and Vice Chair of the Department of Anesthesiology at the Center of Anesthesiology and Intensive Care Medicine in the University Medical Center Hamburg-Eppendorf, Hamburg, Germany. 

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Care of the surgical patient: part 1

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This article provides clinical guidance on the care of a patient undergoing an elective surgical procedure. It discusses preoperative care and the preparation of the patient. It aims to provide an awareness of the complications associated with perioperative care. Through the use of a patient case study, the authors demonstrate the care required across the full perioperative journey from diagnosis to discharge.

Surgery is an inevitable and important part of health care that can offer individuals life-changing interventions for a range of medical conditions ( Wicker, 2015 ). With increased developments in surgical techniques, such as laparoscopic approaches, and innovative strategies delivering better outcomes for surgical patients, surgeries that were once deemed high risk are now considered routine across a wider range of surgical specialties ( Dejong and Earnshaw, 2015 ). As a consequence, the number of surgeries being performed rose by 27% between 2003/2004 and 2013/2014 ( Royal College of Surgeons of England (RCS), 2020 ) and it is now estimated that more than 12 million surgical procedures are carried out in the UK every year ( Abbott et al, 2017 ).

This article aims to provide the reader with clinical guidance for the care of a surgical patient from diagnosis to discharge. It will also examine some of the complications that can occur within the perioperative care continuum (see Glossary for definition of terms) and explore the management strategies that may be used. Because hernia repair has been identified as one of the most common procedures performed in the UK, with over 100 000 of these procedures carried out every year ( RCS, 2013 ), a case study ( Box 1 ) has also been included to help illustrate the care required across the patient journey.

Preoperative care

Initial investigation or contact.

Preoperative care starts at the point of diagnosis and referral and is the first opportunity for health professionals to ensure that comprehensive preparation for the surgery begins. This should be from both a physical and psychological perspective because patients should be provided with the opportunity to ask questions about the surgery and aftercare to help reduce any fears and anxieties that they may have (Wicker and O'Neill, 2013). Consequently, primary care staff, including GPs and practice nurses, have a major role to play in the preparation of individuals for surgery, which can positively impact on postoperative outcomes, such as perceived levels of pain and behavioural recovery ( Powell et al, 2016 ). GPs are also responsible for making the initial referral to a surgical specialty and ensuring that comprehensive background information (ie medical history and specific details of the condition) are communicated to the surgical team so that an outpatient consultation clinic appointment can be arranged ( Royal College of General Practitioners, 2018 ).

Outpatient consultation

Delivering a high-quality clinic requires a holistic approach and the most effective and appropriate way to deliver this is to remain focused on the quality of service and ensure that the patient is treated as an individual with particular values, concerns and wishes ( RCS, 2018 ). The surgeon may decide to go through the process of obtaining informed consent at this appointment, which incorporates discussion of the details of the surgical procedure and comprehensive exploration of the risks and benefits of having the procedure; however, the patient must have the capacity to understand the information given and competence to decide on whether to proceed ( Anderson and Wearne, 2007 ). Following the consultation, the surgeon will list the individual for the required surgery and organise a preassessment appointment. In some cases, this could be on the same day, if the service incorporates one-stop clinics, which have been initiated in some areas to help streamline the service and ensure that most of the patient's preoperative care needs are addressed in a single visit ( RCS, 2018 ).

Preoperative assessment

The process of preassessment is essential for identifying any underlying comorbidities that would increase the risk of complications when having a general anaesthetic, as well as anything that may influence the surgical procedure itself ( Gray et al, 2018 ). However, it also provides the ideal opportunity for the early identification of, and attention to, individual patient needs, for patient concerns to be addressed before admission and for patient education about surgical preparation and aftercare ( Association of Anaesthetists of Great Britain and Ireland (AAGBI) 2010 ; AAGBI and British Association of Day Surgery, 2011 ; Wicker, 2015 ; Martin, 2016 ) ( Box 2 ). The investigations conducted at the preoperative assessment would usually include a full blood count (FBC), electrocardiogram (ECG), and lung function tests, but exactly which investigations are needed mainly depends on the level of the surgery (elective surgical procedures are classified as minor, intermediate or major ( Table 1 ), and the comorbidities of the individual ( Table 2 ) ( National Institute for Health and Care Excellence (NICE), 2016a ). The American Society for Anaesthesiologists (ASA) developed a Physical Status Classification System (often referred to as the ASA Grade) ( ASA, 2019 ) which is also used to determine the level of investigations that need to be conducted at the preoperative assessment and communicate patient comorbidities to the anaesthetic and surgical team ( NICE, 2016a ).

Surgical site marking is required in an attempt to reduce errors and must be performed only by an appropriate professional, undertaken with an indelible ink pen, using an arrow at or near the intended incision, which must be unambiguous and clearly visible because the site will be checked on three more occasions (leaving the ward, entering the operating department and prior to the incision) ( World Health Organization (WHO), 2009a ). Wherever possible, written consent must also be obtained before the surgery and anaesthetic, which needs to be clearly documented (no abbreviations) and retained in the patient's notes so they can be accessed by all the health professionals ( NHS website, 2019 ).

Nursing and other healthcare staff will care for the patient in the immediate period leading up to the surgery and will ensure that venous thromboembolism prophylaxis, ie antiembolism stockings, are put into place, that preoperative medication (gastric acid suppression and pre-emptive analgesia) is administered, that the patient is showered or bathed and warmed, that protocols have been followed to minimise surgical site infections, jewellery and body piercings have been removed or taped and that the preoperative checklist has been fully completed ( Dunn, 2016 ; WHO, 2016 ; NICE, 2016b ; 2019 ; 2020 ) ( Box 4 ).

Glossary of Terms

• Day surgery: term used to define the admission of patients to hospital for a planned surgical procedure when they will be returning home on the same day (less than 24 hours)
• Inpatient: a person who stays one or more nights in the hospital and receives treatment, lodging, and food
• Perioperative: the period around surgery including before, during and after
• Preoperative: a period from the time the surgery is scheduled until the time the patient is transported from the ward to the theatre operating table
• Intraoperative: the period of care during the operation and ancillary to that operation
• Postoperative: the period of care when the patient is returned from the operating department to the ward

Intraoperative care

The safe surgery process continues within the operating theatre and begins with the perioperative team (ie surgeons, anaesthetists, nurses, operating department practitioners (ODPs) and healthcare assistants (HCAs)) discussing the surgical procedures that are listed for the day and any specific patient requirements, eg allergies and equipment requirements ( Wicker, 2015 ). Once the patient arrives at the department a member of the team will admit the patient by checking the surgical safety checklist that was commenced by the staff on the ward, because the ‘check-in’ part of the form must be completed before the induction of anaesthesia ( WHO, 2009a ; 2009b ) ( https://tinyurl.com/yybrj4tl).

This checklist, which can be tailored to the needs of the clinical area, was created to reduce the number of adverse events by improving communication between the perioperative team and, since its introduction, there has been a marked improvement in the quantity of recorded adverse events within the operating theatre ( Walker et al, 2012 ). This is supported by Tang et al (2014) , who found, from their literature review, that effectively implemented surgical safety checklists can help in avoiding complications and reduce postoperative mortality.

The intraoperative process begins with the orientation of the patient to the anaesthetic room, the application of essential monitoring (ECG, pulse oximeter) and the induction of general anaesthetic, using a range of drugs to ensure that the patient is sedated, pain free and, if necessary, paralysed ( AAGBI, 2012 ). On transfer to the operating room, the ‘time out’ element of the surgical safety checklist will be undertaken before the surgical incision in the patient's skin. All members of the team must be present and attentive at this stage because all areas of potential risks are discussed in detail and this is the last opportunity for adaptations to be made to the surgery to prevent unnecessary harm ( WHO, 2009a ). As well as the safe surgical checklist, several considerations also need to be addressed by the perioperative team ( Box 5 ): surgical positioning, skin and nerve damage, patient warming.

Because patients, in most cases, are not able to advocate for themselves, all members of the intraoperative team must ensure that these elements of care are undertaken to reduce harm and achieve high-quality perioperative care ( Cousley, 2016a ). Surgical positioning is of particular importance, not only for ease of surgical access but also to minimise any adverse physiological effects, such as pressure ulcers and nerve damage, which can extend hospitalisation, delay patient recovery and increase costs to the patient and the NHS ( Wicker, 2015 ). These can be avoided with the use of pressure-relieving equipment, use of safe moving and handling techniques and devices, frequent skin assessments and effective communication between the perioperative team ( NICE, 2014 ). The importance of being an advocate for the surgical patient cannot be overstated, especially in an environment as complex as the operating theatre ( Sundqvist et al, 2016 ). The health professional must fully consider any potential risks to the patient and develop a strategy to minimise these risks ( Box 5 ).

Following the completion of the surgical procedure, the intraoperative team undertakes the ‘sign out’, which includes confirmation of the performed surgery, surgical counts of instrumentation, swabs and other supplementary items and any key concerns for recovery or postoperative care ( WHO, 2009a ). These details will be handed over to the post-anaesthetic care unit (PACU) specialist nurse, along with a record of the patient's vital observations while in theatre ( Simpson and Moonesinghe, 2013 ). The PACU practitioner will regularly check the patient's condition, monitor their vital signs, ensure they are comfortable and, if necessary, warmed ( Box 6 ) ( Wicker, 2015 ). They will also pay particular attention to pain relief and the reduction of postoperative nausea and vomiting, which are often the elements of perioperative care that patients most fear before surgery; as a consequence, these must be minimised to increase patient satisfaction but also to promote recovery and reduce the associated postoperative complications ( Liddle, 2013a ).

Postoperative care

Before the patient is transferred back to the ward a comprehensive handover must take place between the PACU nurse and ward staff, including details of the procedure, the patient's condition, level of responsiveness, airway and breathing, oxygen therapy, circulation, wound dressings and drains, fluid output and input, pain levels, medication and any other special instructions ( Liddle, 2013a ; Wicker, 2015 ). As well as the standard nursing roles and responsibilities, nurses caring for surgical patients also need to have a deep understanding of the potential complications that can arise following surgery, such as surgical site infection, pain, hypothermia ( Box 7 ) and how they can minimise risk or recognise early signs of development ( Primiano et al, 2011 ; Liddle, 2013b ; NICE, 2014 ; 2016b ; 2019 ).

Nurses in primary and secondary care are therefore in a unique position and offer a valuable contribution to the care of the surgical patient because they have a major role to play in minimising the risk of harm and ensuring that the patient is returned to normal functioning as soon as possible, depending on the individual's condition and surgical intervention ( Liddle, 2013b ; Cousley, 2016b ).

Due to the high level of iatrogenesis in surgery, patient safety poses a significant problem and almost half of all recorded adverse hospital events are related to surgical care ( WHO, 2020 ). Consequently, because patient safety is ‘at the heart of quality care’ ( Fisher and Scott, 2013: 6 ) it is paramount that health professionals minimise the risk of adverse events occurring by undertaking appropriate risk assessments and effective teamwork ( AAGBI, 2010 ).

• For the surgical patient, preoperative care involves preoperative processes and tests and the identification of patient concerns and needs
• Intraoperative care should follow a surgical safety checklist. After surgery, particular attention should be paid to preventing postoperative nausea and vomiting, and providing adequate pain relief
• In the postoperative period, nurses should be alert to the potential complications that could arise and provide patients with the information they need for discharge

CPD reflective questions

• What aspects of surgical preparation do you think are the most important and how can you improve your own practice in relation to preparing patients for their upcoming surgery?
• Reflect upon your own practice and consider how postoperative care can be enhanced from the perspective of patient satisfaction and safety

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Postoperative Complications

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#30764: Postoperative Complications

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CASE STUDY 1

Patient A is a man 37 years of age who arrives in the PACU following surgical removal of his gallbladder. Surgical intervention using the laparoscopic approach is successful.

Patient A's airway and ability to maintain respiratory stability are evaluated immediately. His respiration is 16 breaths per minute, and his heart rate is 78 beats per minute. Oxygen is being administered at 2 liters via nasal cannula. A pulse oximeter is placed on his left forefinger, and his oxygen saturation is measured at 95%. The patient is arousable but easily drifts off to sleep.

A transfer of care report on the patient is received from the operating room staff. His operative course was unremarkable. Patient history obtained during the preoperative phase of care showed that he was a 2 pack per day smoker, and he denies taking any prescribed or over-the-counter medications. Patient A's weight is documented as 110 kg.

Further assessment of the patient demonstrates normal skin perfusion with good capillary refill in all extremities. He has a drain in his abdomen with a small amount of yellowish discharge. The wound site and sutures are clean and dry without bleeding or discharge. No Foley catheter is in place; when questioned, he denies the need to void. Completing a head-to-toe assessment shows no other alterations from Patient A's baseline.

Patient A wakes when the second set of vital signs is obtained. He reports that his pain is 6 on a 10-point scale. He states that he has pain in his shoulder and pressure in his abdomen. Morphine (5 mg) is ordered for the pain, and 4 mg is administered IV. His wife is in the waiting room, and she comes into the unit to visit and sits by his bed reading while the patient dozes off.

Repeat vital signs are obtained every 15 minutes for the first hour. At 45 minutes after admission, the patient's oxygen saturation is noted to be 90%. PACU staff suction secretions from the patient's throat, and he is instructed on how to use the incentive spirometer. His oxygen flow is increased to 4 liters/minute by nasal cannula. No change in the patient's oxygen saturation is noted over the next 15 minutes despite compliance with the respiratory exercises.

At one hour after admission, the patient's oxygen saturation remains at 89% to 90%, his respiratory rate is 16 breaths per minute, and he is more difficult to arouse. The nurse notifies the physician of the changes in Patient A's status. Oxygen delivery is changed again to a face mask at 4 liters/minute without improvement in the oxygen saturation level. All other parameters remain stable, demonstrating a readiness for discharge.

Despite the improvement in the patient's status, the oxygenation issue remains worrisome. The patient is admitted for an overnight hospital stay, and respiratory exercises are continued, eventually demonstrating an improvement in oxygen saturation to a high of 94%. The next morning, the patient is discharged home.

The assessment of Patient A was thorough and well-organized. The ABCs were evaluated upon admission to ensure the stability of the patient. The history was ascertained, and vital signs were obtained on the recommended basis. However, despite this excellent care, the patient did not demonstrate adequate improvement in his status to be discharged on the same day.

The patient's history of smoking may be the cause of the respiratory insufficiency. Whether the patient was honest in his assessment of his smoking habit could be debated; many patients do not fully and honestly report their cigarette and/or drug and alcohol use. In addition, the patient may not have reported the feelings of nasal congestion and signs of a developing "cold" to the anesthesiologist prior to surgery. Had this been shared, the surgery may have been postponed. The patient may have been instructed to cut back on cigarette use and wait until the cold symptoms subsided prior to having surgery. When patients underreport or are dishonest during the preoperative phase of care, the staff caring for the patient in the postoperative phase is put at a disadvantage.

CASE STUDY 2

Patient B, a woman 31 years of age, is admitted to phase I PACU after undergoing an abdominal hysterectomy. During the preoperative assessment, the patient noted that she is a nonsmoker, has a history of motion sickness, and is quite anxious concerning the surgery and her future prospects, as she will be "sterile" upon recovery. The report from the operating room is that the patient received inhalation anesthesia and a neuromuscular blocking agent during the procedure. Prior to discontinuing the anesthesia, the patient was administered 4 mg of ondansetron for PONV prophylaxis. Also noted was a period of hypotension caused by a significant amount of blood loss requiring the intraoperative infusion of two units of whole blood.

Upon awakening, Patient B is quite agitated. She is moving from side to side and is not yet oriented to place and time. When questioned, Patient B states that her pain is 7 on a scale of 10. The PACU nurse administers 2 mg hydromorphone IV per order. The narcotic appears to begin to take effect, and when questioned, Patient B's pain is now reported as a score of 4. However, she is now complaining of nausea and asking for an emesis basin as she is afraid she will vomit. The nurse asks her to take slow deep breaths through her mouth and encourages her to relax.

When Patient B's complaints of nausea do not recede, the nurse contacts the physician who orders another dose of ondansetron, which is administered. Thirty minutes after medication administration, the patient's complaints of nausea have not subsided and the nurse again requests an order for an antiemetic. At this point, the physician orders a scopolamine patch be placed on the patient. Subsequent to patch placement, Patient B notes that her nausea is resolving.

Case Study Discussion

Preoperative management of Patient B's nausea was handled well. The staff had ascertained the pertinent information; had a risk factor identification scale been utilized, the patient would have been ranked at a very severe level of risk for PONV. The anesthesiologist recognized this risk and treated Patient B with an appropriate dose of antiemetic prior to the termination of surgery.

There were omissions in care that could have reduced the risk of PONV development in this patient. Prior to the first dose of ondansetron in the operating room, a dose of dexamethasone could have been administered to enhance the effectiveness of the serotonin antagonist.

During the PACU phase of care, the nurse caring for Patient B instituted measures to manage both the patient's pain and nausea. However, there were extenuating circumstances that were not considered and could have reduced the development of this complication. It was noted in the operative report that the patient had an episode of hypotension and blood loss; this volume depletion most likely increased the risk of PONV. In addition, the patient may have remained volume-depleted into the PACU, and no note of this was made.

The physician ordered the second PACU dose of ondansetron, which was administered without benefit. The recommendation for rescue management of PONV is to change drug classes if one is not adequate; thus, another drug should have been ordered. The scopolamine patch seemed to have a beneficial response; upon further questioning of the patient, it was discovered that whenever she had previous bouts of motion sickness the patient used patches to help her manage her symptoms. Had this information been ascertained in the preoperative phase, the patch could have been applied preoperatively or in the operating room. It is critical to gather as much information as possible to reduce these types of delays in patient management.

CASE STUDY 3

Patient C is a high school senior. During the opening drive in the Friday night football game, Patient C is hit from behind. When he falls, he sustains open, comminuted fractures of his left tibia and fibula. Because he is unable to stand, an ambulance is brought onto the field to transport the young player to the hospital for evaluation.

Upon arrival at the emergency department, Patient C's leg is examined, x-rayed, and evaluated by the orthopedic surgeon on call. It is determined that prompt stabilization and cleansing of the wound would be optimal for the best possible outcome; thus, Patient C is prepared for surgery. His parents, who were at the game, arrive in the emergency department just moments after the ambulance and are available to give permission for the operative procedure. As Patient C has been medicated for pain, a history is obtained from the parents. There are no notable problems; Patient C is a healthy young man in excellent physical condition. He has not had previous operations and no previous exposure to anesthesia.

Patient C is transferred to the operating room. The anesthesiologist gives the patient a number of preoperative medications, including those to prevent PONV. The anesthesia of choice is enflurane (Ethrane), a volatile gas. The patient first receives succinylcholine prior to intubation, followed by the anesthetic gas. Within minutes, the anesthesiologist notes that Patient C's carbon dioxide levels are beginning to rise. Just as the surgeon is to begin, the patient sustains a cardiac arrest.

The anesthesiologist immediately stops the insufflation of the gas and begins to administer 100% oxygen. A code response is initiated by the remaining members of the operating team. The rescuer performing chest compressions notes that the patient's skin is warm. While resuscitative efforts continue, blood for laboratory evaluation is obtained. The arterial blood gas results demonstrate a pH of 6.9, partial pressure of oxygen (PaO 2 ) of 110 mm Hg, and a partial pressure of carbon dioxide (PaCO 2 ) of 55 mm Hg. At this point, the anesthesiologist's suspicions are confirmed; the patient is experiencing an episode of malignant hyperthermia.

As soon as the diagnosis is confirmed, the staff is ordered to administer dantrolene at a dose of 2 mg/kg. The operating room personnel contact the PACU to ask for assistance in drawing up and preparing the dantrolene. Only one nurse is available to leave the PACU, and she assists with mixing and administering the dantrolene as soon as it is prepared. Additionally, the patient requires repeat doses of sodium bicarbonate to combat the falling serum pH.

Within 15 minutes of administering the dantrolene, the patient begins to demonstrate a perfusing rhythm, although this is punctuated by frequent runs of premature ventricular contractions. Antiarrhythmics are administered to control cardiac complications.

Simultaneously, the patient is cooled with external cold packs applied to the groin and axilla areas. The leg wound is dressed to prevent further contamination during the resuscitative efforts. Repeat blood is obtained for laboratory analysis. The patient's potassium is elevated, and the patient is started on a glucose-insulin drip.

After the patient's cardiac condition is stabilized, the operating room staff request transfer of the patient to the PACU for further management. The patient is moved, and the PACU staff becomes responsible for managing the patient. The antiarrhythmics, the glucose-insulin drip, and the cooling measures are continued. During the first 30 minutes in the PACU, the patient's urine is noted to be a deep red color, indicative of developing rhabdomyolysis and potential renal failure. The patient is given 100 mg furosemide, and fluids are increased to 150 mL/hour. Within 20 minutes, the urine lightens in color, although it retains a reddish tinge.

Approximately three hours after the first cardiac arrest, the patient suffers a second arrest with the development of ventricular fibrillation. A second code response is called, and the patient is again resuscitated with dantrolene, antiarrhythmics, and sodium bicarbonate. Once again, the patient responds to treatment and regains a perfusing cardiac rhythm.

The patient is ordered to receive dantrolene every 4 hours for the following 48 hours to ensure that another episode of malignant hyperthermia does not develop. The patient is subsequently stabilized and transferred to the ICU, where he remains for 72 hours.

Patient C is a perfect candidate for the development of malignant hyperthermia. He is a young male with well-developed musculature. He has had no previous exposure to anesthesia, so his history was not negative for anesthesia complications; it was incomplete. The onset of cardiac arrest was quite rapid in this patient. This devastating complication can be quick in onset, as demonstrated here, or may be delayed and occur later during the operative procedure. The first indication of the development of malignant hyperthermia in this patient was the rising carbon dioxide level. The skin temperature remained normal during the early phase of development; the first person to note the rise in body temperature was the rescuer performing chest compressions.

The patient was managed appropriately. The staff was required to perform a number of actions to save this patient's life. Administering medications, preparing those medications, cooling the patient, and monitoring blood laboratory values is only part of the picture. The additional PACU nurse pulled to the operating room to help with the resuscitation was instrumental in providing the additional hands and expertise needed in this case.

Upon arrival in the PACU, the patient continued to require extensive stabilization measures. The repeat dantrolene had been ordered but had not yet been administered when the patient sustained the second cardiac arrest. It is imperative that the administration of repeat doses of dantrolene be continued to prevent this type of occurrence. Fortunately, the patient was young and healthy and responded to the treatment.

The long-term outcome for this patient was excellent. The resuscitative efforts were exceptional, and the patient did not sustain any long-term neurologic deficits. It is important to point out that the patient did not have his fracture stabilized at this time. Subsequent surgery was delayed to ensure the stability of the patient. Once stable, the patient had the orthopedic repair performed with epidural anesthesia. Although the risk of developing malignant hyperthermia again while undergoing epidural anesthesia is small, dantrolene was used prophylactically to ensure patient stability throughout the procedure.

CASE STUDY 4

Patient D is a male patient, 32 years of age, undergoing an uncomplicated bowel resection to repair damage and scarring of the bowel secondary to a traumatic automobile accident five years prior. The patient is a healthy, active male who states that he has smoked a pack of cigarettes a day off and on for the last 15 years. He had quit smoking after his auto accident but started again three years previously. His history is unremarkable for cardiovascular disease, and his anesthesia provider has reviewed his previous surgeries, performed at the time of the accident.

During surgery, the patient receives general inhalation anesthesia, intravenous narcotics, and neuromuscular blocking agents. The procedure runs approximately four hours in length. During the procedure, the patient has one short episode of hypotension that was managed with volume replacement.

Upon arrival in the PACU, the patient's vital signs are: blood pressure 118/62 mm Hg, pulse 78 beats per minute, respiratory rate 22 breaths per minute with shallow respirations, temperature 36.5°C, and oxygen saturation 91%. The patient had been extubated in the operating room just prior to transfer to the PACU. The nurse caring for the patient notes the signs and symptoms of respiratory distress, including the high respiratory rate, the shallow respirations, and the low oxygen saturation level. When the patient awakens complaining of pain, the nurse is hesitant to give too large of a dose of the narcotic that had been ordered.

After 30 minutes, the patient's respiratory rate is 18 breaths per minute, the oxygen saturation is 93%, and the patient is more alert. However, the patient continues to complain of ongoing pain, and the nurse leaves the patient's bedside to obtain the narcotics. Upon returning to the patient, the nurse finds the patient dozing. When the patient wakes, the nurse asks him to use the incentive spirometer; he had been instructed in its use in the preoperative phase of care. The patient complains of increasing abdominal pain and refuses to use the spirometer. At this point, the nurse chooses to administer 3 mg of hydromorphone as ordered for pain by the surgeon.

After receiving the hydromorphone, the patient again dozes off and appears to be comfortable. When obtaining the next set of vital signs, the nurse notices that the oxygen saturation has again dropped to 91%; however, as the patient's respiratory effort appears to be adequate, the nurse assumes this low saturation is a consequence of his smoking history. The patient has oxygen supplied by nasal prongs, and the nurse chooses not to intervene further. The patient is left sleeping while the nurse assists in the admission of another patient to the PACU.

Forty-five minutes after arrival in the PACU, Patient D experiences a respiratory arrest. The nurses immediately call a code and initiate resuscitative measures. The patient is administered naloxone, and positive pressure ventilation is initiated. However, bagging the patient is extremely difficult; the pop-off valve goes off with each ventilation, and the patient's chest is not rising as hoped.

Fortunately, the anesthesia provider responds and immediately asks for an endotracheal tube to reintubate the patient. When attempting to intubate the patient, the anesthesia provider finds it very difficult as a result of the patient developing laryngospasm. Succinylcholine is administered, and high positive-pressure oxygen is given via a jet vent. After another two attempts, the patient is successfully intubated. The patient is then placed on a mechanical ventilator with positive-end-expiratory pressure applied to help reduce the buildup of fluid in the lungs. He is started on a course of antibiotics and steroids and admitted to the ICU. After two days, the patient is extubated, moved to the surgical floor, and at day 6, is discharged from the hospital.

Patient D is a typical postoperative patient. He was healthy and had an uncomplicated surgical event. He should have progressed through the recovery period without a problem; however, he sustained a respiratory arrest and his recovery was prolonged. Fortunately, he survived without long-term sequelae.

The nurse caring for Patient D made assumptions about his condition based upon his preoperative history. The smoking history allowed her to be lulled into a sense of security knowing that smokers have altered oxygen saturations. His appearance of ease was comforting, and she became complacent in her vigilance.

When Patient D sustained the respiratory arrest, the initial cause was unknown. He had numerous risk factors; the arrest may have been caused by the dose of narcotics, in which case, naloxone would have been a treatment of choice. This was tried but without a successful response. He was hypoxemic upon arrival in the PACU, as evidenced by his low oxygen saturations. This hypoxemic state may have precipitated the respiratory arrest. In addition, he had received neuromuscular blocking agents in the operating room and the arrest may have been secondary to residual paralytic agent. However, upon intubation he was noted to have developed laryngospasm, which may indicate that he sustained an episode of NCPE. He was a candidate for NCPE due to his age, preoperative health status, and early extubation.

Whenever a patient sustains a life-threatening event such as a respiratory arrest, it is critical that care providers work to determine the cause. Identification of the cause can lead to the appropriate choice of a resuscitative effort. In this case, the nurse acted appropriately in administering the naloxone, although it was later determined that this was not the cause of the arrest. Despite the fact that NCPE was not considered until the patient was found to have a laryngospasm, the measures undertaken were appropriate. The only error was the complacency that the nurse exhibited towards the patient's status upon arrival in the PACU and the first 45 minutes of care. Early attention to the hypoxemic state may have prevented the development of the arrest, although this does not always make a difference in cases of NCPE.

Patient D should be educated prior to discharge regarding the development of this side effect. If further surgeries are needed, it is imperative that he be able to relate this information so that measures can be instituted to reduce the risk of respiratory compromise.

CASE STUDY 5

Patient E, a man 74 years of age, is undergoing surgery for a blockage in his left femoral artery. The patient has a history of significant vascular compromise of his left leg secondary to the blockage. A stent is placed during surgery, and the patient is subsequently transferred to the PACU. Upon arrival in the PACU, his vital signs are: blood pressure 162/86 mm Hg, pulse 80 beats per minute, respiratory rate 16 breaths per minute, core temperature 34.5°C, and oxygen saturation 90%. The patient was extubated prior to arrival in the PACU. After the patient is stabilized and an assessment is completed, he is warmed using a warm air convection device. To combat his low oxygen saturations, his oxygen flow is increased to 6 liters per nasal cannula.

Fifteen minutes after arrival, the patient complains of severe pain in his left leg. His peripheral pulses are good, and his color is pink. However, as this was the surgical site, the nurse immediately contacts the surgeon. The surgeon speculates that the pain is secondary to new perfusion in this leg and the removal of sequestered by-products of circulation. He orders the patient to receive 3 mg hydromorphone for pain, which helps resolve the patient's complaints.

One hour after admission, the patient's vital signs return to preoperative values; his body temperature is now 36°C. At this point, he complains of pain in both lower extremities. Upon assessment, it is found that his peripheral pulses are weak in the right leg and the color of this extremity is dusky and cool to touch. His left leg remains warm, pink, and with good peripheral pulses. The patient's legs are elevated on a pillow to improve blood return to the heart, and he is again administered hydromorphone. After the second dose of hydromorphone, the patient drifts off to sleep. When he wakes, he continues to complain of pain in both extremities. The right leg remains cool, dusky, and with poor peripheral perfusion. The nurse again contacts the surgeon, who determines that the patient is possibly developing a DVT in the right calf. The patient has graduated compression stockings applied to the right leg to reduce the risk of further clot formation. As the patient had been heparinized in the operating room, no further anticoagulants are ordered.

The patient is discharged from the PACU to the surgical ward. At day 3, when he is ambulating in the hall, Patient E suffers a cardiac arrest and is not able to be resuscitated. He most likely sustained a pulmonary embolus secondary to the DVT in the right leg. The ambulation may have caused the clot to be knocked loose, allowing it to travel to the pulmonary vasculature.

This patient was at high risk for DVT formation both due to the type and extent of surgery as well as his history of peripheral vascular disease. As he was anticoagulated in the operating room, no further interventions were instituted. However, the guidelines for management and prophylaxis of this type of patient recommend the institution of graduated compression stockings or intermittent pneumatic compression devices in addition to anticoagulation [50] . It can be speculated that this may have reduced his incidence of DVT formation; however, due to his extensive vascular history, he was at high risk prior to, during, and after surgery. It would be speculation to determine if this event may have been preventable.

The nurse caring for the patient performed her job according to policy. The only change that may have been recommended is the placement of the graduated compression stockings on the right leg prior to surgery or after the patient was stabilized in the PACU.

CASE STUDY 6

Patient F, a woman 47 years of age, has sustained a comminuted fracture of her left tibia and fibula after falling on wet grass. Patient F is transferred to the emergency department, where the determination is made to take her to the operating room for internal fixation and subsequent casting.

Following surgery, Patient F is admitted to the PACU with a cast on her left leg. The leg is elevated on top of pillows to ensure adequate drainage. Upon awakening, the patient complains of pain of 9 on a 10-point scale. She is medicated with hydromorphone and falls back to sleep. Forty-five minutes later, she again complains of continued pain. At this point, she receives 3 mg of intravenous morphine. While reviewing the patient's chart and medication orders, the PACU nurse discovers that the patient has a history of frequent narcotic use and is labeled a "complainer" who is frequently seen in the emergency department or physician's office with vague complaints of pain and requests for refills of her narcotics.

After two hours in the PACU, the patient is transferred to the orthopedic floor for continued recovery. Other than her complaints of pain, her PACU stay is uneventful. When giving report to the nurses on the floor, the PACU nurse relays her findings regarding the patient's complaints of pain and repeat requests for pain medications.

During the remainder of the day and into the evening shift, the patient is monitored every four hours. She is medicated as ordered, but within one to two hours after receiving her medications she calls the nurse for additional analgesia. She continues to complain of pain, stating that she feels a burning sensation in her left leg. Her cast is checked and appears to be intact, without peripheral swelling of her leg, and peripheral pulses are present but weak.

At midnight, the patient calls the nurse with continued complaints of pain. The nurse notes that the cast is tight; the patient is no longer keeping it elevated as instructed. The orthopedist on call is contacted, and the decision is made over the telephone to bivalve the patient's cast to ensure adequate circulation. This is accomplished, and the patient appears more comfortable, although her reported pain score remains at 6.

The following morning the patient is seen by the orthopedic surgeon, who notes the bivalved cast and continued complaints of pain. The surgeon orders the cast to be replaced, which is accomplished. That evening the patient again complains of pain, this time giving a score report of 10. The physician is again contacted by telephone, and additional pain medications are ordered. Throughout the night, the patient continues to complain of pain despite frequent doses of narcotics.

The patient is scheduled for discharge in the morning. When seen by the surgeon prior to discharge, it is noted that the patient's foot is cool to touch and peripheral pulses remain weak. She has continued complaints of pain and does not want to be discharged at this time. At this point, the surgeon considers the possibility that the patient may be developing a case of compartment syndrome. The cast is removed, and the extremity is tense and cool, with poor color. The patient is immediately taken to the operating room, where a fasciotomy was performed. Upon opening the compartment, it is noted that there is extensive necrotic tissue that requires debridement. The remaining amount of muscle is minimal. The patient eventually recovers but with severe disability in her ambulatory capabilities.

This patient sustained a long-term disability secondary to rapidly developing compartment syndrome. As discussed, rapid assessment and intervention is required to prevent this type of sequelae. The classic sign of compartment syndrome is pain that is out of proportion to the injury. This patient had continued complaints of pain; however, due to her history as someone who was always complaining of pain, her complaints were not taken seriously. All patient complaints should be addressed and believed; the lack of attention to these complaints led to a long-term disability in this patient.

Compartment syndrome is a common complication following fracture, and the possibility of this complication should have been recognized earlier. In fact, the first evening, when the first cast was bivalved, compartment syndrome should have been considered. It was more than 36 hours before the diagnosis of compartment syndrome was made, enough time for severe tissue necrosis to develop. Had the patient undergone a fasciotomy rather than bivalving the cast, the outcome may have been different.

This case demonstrates the need for prompt recognition of patient's complaints and consideration of all potential complications, regardless of the patient's previous history. The nurses and physicians in this case neglected the patient's pain complaints because of her prior history. The patient should have been given the benefit of the doubt, which may have allowed for earlier intervention.

This case subsequently went to litigation. The physicians involved in her care admitted to malpractice in neglecting to recognize and diagnose the development of the compartment syndrome earlier in her care when the potential for complications may have been decreased. The nurses admitted to malpractice as they chose to disregard the patient's complaints when further investigation should have been undertaken. It is a sad outcome, especially as it was a preventable complication.

CASE STUDY 7

Patient G is a man, 83 years of age, who is undergoing colon resection for removal of cancerous nodes. The operative procedure proceeds without complication, and the patient is transferred to the PACU without incident.

During the first postoperative hour, the patient is noted to be hypotensive, with a systolic blood pressure of 80 mm Hg. A review of the patient's history indicates that his normal systolic pressure on admission was 160 mm Hg. The patient is noted to take furosemide, hydrochloride thiazide, metoprolol, and lisinopril for blood pressure control. With this information in mind, it is obvious that the patient's systolic pressure is significantly lower than anticipated.

Upon awakening, the patient is confused and disoriented. He needs continual reminders to help orient to person, place, and time. He is not compliant with postoperative instructions and tries to remove the dressing from his abdomen. He complains of pain when asked but is not able to rate the pain on a scale of 1 to 10. He requires wrist restraints to prevent him from disrupting the surgical site.

The patient is also noted to have a history of congestive heart failure following a myocardial infarction many years ago. While fluid resuscitation would be the first step in supporting the patient's blood pressure, the risk of developing further cardiac failure should be considered. Prior to instituting further management, the patient's history and medication use is reviewed.

The patient stated upon admission that he had been NPO after midnight, as instructed. He was told to take his medications in the morning with a small sip of water prior to arriving at the hospital, to which he complied. His wife told the nurses that he did not eat the food recommended on his bowel prep program the evening before surgery; he was anxious and wanted to ensure that his colon had been cleaned out sufficiently. His wife also noted that he had complied with the bowel prep cleansing as instructed.

The patient is administered additional intravenous fluids at a rate of 75 mL/hour. He is finally discharged from the PACU five hours after surgery and transferred to the surgical ward. On the surgical ward, his blood pressure remains low, with an average systolic pressure of 90–100 mm Hg. The patient is discharged on day 3 with a blood pressure of 102/86 mm Hg.

This case presents the typical complication of under-resuscitation and subsequent volume depletion. The patient's response to this complication was the development of a prolonged hypotensive episode, complicated by confusion and disorientation upon awakening.

Further history should have been ascertained from the patient and the patient's wife prior to surgery. The staff was unaware that the patient had been NPO for such a length of time. When asked if he complied with the bowel cleansing as ordered, the patient replied yes; no further questions were asked to ensure how he complied, when he last ate, etc. This assumption increased the risk of compromise.

In addition, the patient took his normal blood pressure control medications prior to surgery. While holding of these medications is often done on the day of surgery, the nurses needed to recognize the potential risk this offered. Ensuring adequate resuscitation and volume status in the preoperative and operative phases of care should have been instituted.

Anesthetic agents are vasodilators. This combined with the administration of blood pressure reducing agents caused a significant drop in the patient's systolic pressure. The patient's systolic pressure remained low even at the time of discharge; it is critical to alert this patient to this development and ensure that the patient follow up with either the surgeon or the cardiologist. As the drugs cleared from the patient's body, the normal systolic pressure should have been achieved.

The confusion and disorientation that developed in the PACU was most likely a consequence of low perfusion pressure within the cranial cavity of this patient. There are several reasons for postoperative confusion in the elderly; those reasons should be identified and treated. In this case, had the patient received fluid resuscitation earlier in the course of care, this neurologic development may have been avoided.

Managing an elderly patient with a history of multiple disease processes, medication use, and anesthetic administration is challenging. Further in-depth evaluation and history taking is critical to ensure safe care delivery throughout the operative period.

CASE STUDY 8

Patient H, a man 34 years of age, is admitted to the PACU following abdominal surgery for colitis. In the operating room, the patient's disease was found to be extensive, and he now has an ileostomy for stool drainage. He had a large mid-line incision reaching from the pubis to the distal sternum.

Upon admission, his vital signs are: blood pressure 102/60 mm Hg, pulse 72 beats per minute, respiratory rate 16 breaths per minute, oxygen saturation 94%, and core temperature 35°C. He is somnolent but opens his eyes upon repeated commands. The formation of the stoma was discussed with the patient prior to surgery as a last choice option; however, he was unaware at that point in his care of the extent of his disease and the need for the ileostomy.

After 15 minutes, the repeat vital signs are unchanged except for the blood pressure, which is 90/58 mm Hg. His body temperature remains at 35°C. Measures to rewarm the patient are undertaken. He continues to sleep, although he is arousable. After 30 minutes, the patient's blood pressure drops to 84/48 mm Hg. It is also noted that urine output is only 5–10 mL of dark yellow urine in the Foley catheter tubing. The physician is notified, and she orders a fluid challenge of 100 mL.

After the fluid challenge, the patient's blood pressure rises to 92/60 mm Hg. Although this is below baseline, it does show improvement. However, urine output remains the same; there is no recognizable response to this fluid challenge. The ostomy drainage does increase and is measured at 100 mL of very light yellow liquid.

Two hours after admission, the patient remains in the PACU. His core body temperature remains low, and his blood pressure is below baseline. Little urine output has been noted, but ostomy output is at 250 mL since surgery. Bowel tones are heard as high-pitched squeaks. Additionally, the patient remains significantly sleepy and slow to respond to commands.

After three hours, the patient is transferred to the surgical inpatient unit. His blood pressure is 98/60 mm Hg, pulse 70 beats per minute, respiratory rate 16 breaths per minute, core body temperature 35°C, and oxygen saturation 96%. Urine output totals 30 mL since the end of surgery; ostomy drainage totals 350 mL. The patient is arousable but sleeping when not stimulated.

That same evening, approximately seven hours after surgery, the patient is awake and complaining of severe abdominal pain. His abdomen is distended; ostomy drainage now measures an additional 300 mL, and urine output is 150 mL. The surgeon is notified, and the patient is evaluated. At this point, the surgeon speculates that there may be leakage at the stoma site. The patient is prepped for the operating room for further evaluation.

While waiting for the surgical team to arrive, the patient begins passing a significant amount of gas into the ostomy bag. The amount of drainage remains high, but with the passing of the gas the distension begins to resolve and the patient notes that his pain has diminished. It is determined that the surgery will be delayed pending resolution of the abdominal distension.

The patient remains in the hospital for another four days. He receives instructions on how to manage his stoma and ostomy. His stoma drainage remains high for the first two days. He tries solid foods on day 3 but develops severe abdominal cramping and distension yet again. His diet is changed to soft foods, and over the course of the next week, he is eventually able to tolerate a normal diet.

This patient was admitted following an extensive abdominal procedure. Upon arrival in the PACU, his core body temperature was low; however, this is common in patients undergoing an open abdominal procedure of extended length. The only error in care was the delay in beginning to warm the patient. Rewarming measures, using forced air warming, should be the standard of practice for this type of patient.

The patient developed hypovolemia, as evidenced by his low blood pressure. This period of decreased circulating volume could have potentiated the risk of subsequent ileus formation. The fluid challenge of 100 mL was ordered without awareness of the ostomy output. This output should be included in the volume assessment of the patient prior to reporting his vital signs. Most likely, a large fluid challenge would have benefited the patient and could have helped to prevent the ileus formation.

When the patient complained of severe pain while in the nursing unit, it was appropriate to consider the risk of failure of the stoma sutures. This is not an uncommon complication in this type of surgery, especially with the distended abdomen. However, the patient required a more detailed evaluation prior to being prepped for surgery. Ileus formation was not considered because the patient had audible bowel tones. While most patients with postoperative ileus do not exhibit bowel tones, these tones are not uncommon for patients with a stoma and significant changes in their GI tract. One procedure that may be beneficial for these patients is the insertion of a tube into the stoma. However, with the concern of disruption of the sutures, this was not an appropriate course of action for Patient H and was not performed.

While the patient did exhibit postoperative complications, the development was not unexpected. The assessment of the patient could have been better; assessing the intake and output beginning before surgery may have alerted the staff to the hypovolemic state. If this had been recognized and treated earlier, the ileus formation may have been averted. However, it is not uncommon for this patient type to develop an ileus, so it is difficult to determine whether it was a controllable complication. The patient's ultimate outcome was not affected by these complications, but his recovery period could have been more comfortable and without risk had certain assessment parameters been monitored more closely.

CASE STUDY 9

Patient I is a girl, 5 years of age, undergoing a surgical intervention to correct a congenital cleft lip and palate. She is small for her age and has had multiple difficulties with food intake. During the first year of life, it was nearly impossible for her to suck either at the nipple or on a bottle due to the shape and size of the defect. Despite multiple attempts and alternative methods of feeding, her growth has been slowed due to malnourishment. As she became able to ingest solid foods, she had difficulty with swallowing and had multiple bouts of sinus infections due to food particles being forced into the open sinuses.

In the preoperative phase of care, Patient I is noted to be quite anxious, crying in her mother's arms and shying away from the caregivers. She does not want an IV line started and throws a tantrum when this is attempted. Despite her young age, she is well aware of the multitude of interventions that occur in a hospital setting and she is determined to maintain some control over these developments. Her mother comforts her and does not appear to have much control over Patient I's behavior.

The corrective repair progresses without complication, although the surgery is long, more than six hours in length. When Patient I is transferred to the PACU, she is intubated and asleep. The surgeons do not want her to awaken abruptly and risk dislodgement of the endotracheal tube and/or damage to the surgical site. Her vital signs are stable compared to those obtained during the preoperative phase of care. She has an IV line in her right forearm, a Foley catheter, and cardiac monitoring electrodes on her chest, along with the endotracheal tube.

After Patient I is stabilized in the PACU, her mother is allowed in to see her and sit at the bedside. The mother is instructed to watch the patient and notify the nurses if she starts to awaken and reach for the tubes. The mother is overwhelmed by the change in her daughter's appearance, something she has dreamed about for the last five years.

After 30 minutes in the PACU, Patient I begins to move in bed. Her eyes remain closed but she appears to be awakening and somewhat agitated. The orders are to administer narcotics to the patient for pain; however, the patient is unable to use any type of pain scale due to the decrease in cognition. The mother is holding the child's hand when the child pulls her hand away and starts to reach for her mouth. The nurse sees this happening and is able to grasp the child's wrist and prevent her from reaching the tube and surgical site. Wrist restraints are applied to ensure that the patient is not able to repeat this potentially life-threatening action.

At 60 minutes, the patient begins to open her eyes and starts to move from side to side. She is pulling against the restraints and trying to sit up so she can reach the endotracheal tube to remove it. The nurse instructs the patient that she must lie still and that the tube must remain in place. The nurse attempts to use an illustrated pain scale, but the patient refuses to cooperate, continuing to pull at the restraints.

During this combative period, the patient's blood pressure and pulse rate continue to rise and blood is noted on the dressing around her mouth. It is imperative that something be done to reduce the risk of damage; the nurse decides to medicate the patient with the narcotic ordered to help control the agitation and allow the child to relax and perhaps fall asleep. This objective is achieved, and the patient falls asleep and appears relaxed. Her vital signs again return to preoperative values.

Ninety minutes after surgery, the surgeon enters the PACU to examine the patient. While touching the patient's dressing, the patient's eyes open; she grasps the hand of the surgeon and tries to grasp the endotracheal tube. She is shaking her head violently from side to side, and the dressing on her face begins to loosen. The physician yells for assistance, and the nurse holds the head of the child still so the tube and dressing can be re-stabilized and secured. The look in the eyes of the child is one of pure terror. By now the only way the patient is able to lash out is to kick her legs, and she is thrashing about in the bed. Her mother is trying to calm her, but the child does not appear to recognize her mother or at least does not respond to the mother's efforts.

The surgeon orders a dose of midazolam in an effort to calm the child and ensure the safety of the tube and surgical site. After administration, the child does calm down and is no longer struggling; however, she does not appear to fall asleep. She continues to have a very scared look in her eyes, and she does not appear to be fully aware of what is going on around her. Within 20 minutes, the child is dozing quietly and appears to be much more comfortable.

Two hours after surgery, the patient again awakens and is calm and cooperative. She is responding to her mother and is receiving comfort from her mother's presence. She is again instructed as to the need for the restraints and is not pulling against them. She tries to talk and begins coughing against the endotracheal tube. The surgeon has ordered that the patient remain intubated for at least the first 48 hours post-surgery to ensure adequate time for the wound healing to begin. This is going to be a challenge with this patient as she is trying continually to either remove or talk around the tube.

The patient is stable at three hours and is transferred to the ICU, as she remains intubated. Report is given to the staff. While the patient is being moved to the ICU bed and her hands are free, she grabs the endotracheal tube and pulls. Fortunately, she is prevented from removing the tube, although the tube is checked to ensure proper placement. At 48 hours, she is extubated and transferred to the pediatric floor. Within four days she is discharged home without further complication.

This child presents a number of challenges to the PACU staff. Airway management is always the first step in stabilizing a patient who has arrived from the operating suite, and this patient did have a secure airway at the time of transfer. The concern developed when the patient began to awaken and tried to remove the tube. Had she been successful at pulling the tube, this could have been a life-threatening complication. Attempting to mask ventilate the child would be challenging with the surgical repair site preventing the achievement of a good seal with the mask. Re-intubation would have to be performed with extreme caution to prevent damage to the surgical repair.

The child was initially stable, and the recovery appeared to be without incident. However, after the child started to awaken she demonstrated many of the signs of emergence delirium, which is more common in children than adults. She was thrashing about, pulling on her restraints, and uncooperative with instructions. Her mother did not appear to be able to calm her, indicating the possibility that she was disoriented and confused.

While the nurse was aware of the need to protect the child, she chose to administer the narcotics as ordered rather than receive an order for a different medication. It may have been that the narcotic was the right choice; the patient could have been in pain, although this was not assessed due to her behavior. On the other hand, the narcotic could have caused the second bout of combativeness noted upon the surgeon's arrival. When the patient was able to grasp the endotracheal tube, it was determined that the mother had released the restraint while holding her daughter's hand. This could have been another life-threatening complication; the nurse needed to not only ensure that the mother understood the need for the restraints but also check for proper placement of the restraints when her vital signs were obtained.

Midazolam was the drug that was able to allow the child to fall asleep and awaken in a more controlled state. Although midazolam may be a cause of emergence delirium and confusion in children, it is also one of the first drugs considered in its management. For this patient, it was the right drug, although the right time may have been during the first episode of combativeness. Not all children must be medicated; however, with the risks of tube dislodgement and surgical site disruption being quite high in this child, the administration of midazolam in the earlier phase of care may have been a better choice.

This case demonstrates the multitude of issues in dealing with pediatric patients. Although patients are educated prior to the surgical intervention, this education is not fully understood and the child may not follow instructions as directed. The mother was an excellent source of comfort to her child but also put her child at huge risk by untying the restraints. Parents should have continual reminders of their place in the care of their child.

The risk of postextubation croup was not addressed but could have presented a significant challenge to this patient either in the ICU or once on the pediatric unit. The risk of this form of croup increases when the patient has remained intubated for a length of time and/or when the child fights against the tube, both risk factors in this case. Fortunately, this did not occur and the patient was eventually discharged without further incident.

Children present challenges regularly in the PACU. Their risk of compromise is greater, and the complications are different. Astute care will allow for safe recovery during this period.

CASE STUDY 10

Patient J is a man, 87 years of age, undergoing surgical repair of a fractured hip. He was living at home independently when he slipped and fell in the bathroom, fracturing his right femoral neck. He was on the floor for an indeterminate amount of time prior to being found by a neighbor who checked on him when he had not been seen for a number of hours. Emergency service personnel were called. They found the patient on the bathroom floor in a confused state. He was unable to accurately note the date or time, and he had no recollection of how he ended up on the floor. During the head-to-toe assessment, it was noted that Patient J had sustained a small scalp laceration over his right temporal region, which was clotted by the time the ambulance personnel arrived. His leg was in a displaced position, and a fractured hip was suspected. He was also noted to have a healed scar on his sternum, indicative of a previous open-heart procedure.

Upon arrival in the emergency department, the patient is evaluated by orthopedic, cardiology, and neurology specialists. His history is reviewed and reveals a previous open-heart procedure eight years prior to admission, a long history of smoking prior to the cardiac procedure, and a history of lifelong obesity. The patient's skin condition is poor; he has multiple bruises in varying stages of healing. He has multiple folds of fatty skin, and between these folds, the skin is quite dirty and foul smelling, indicating a poor hygienic state. He has a list of medications in his wallet, which identifies the following drugs: digoxin, simvastatin, furosemide, potassium chloride, amlodipine, and lisinopril. Due to his current state of confusion, the accuracy of this list and the last time the patient took his prescribed medications are unable to be determined.

Patient J's greatest immediate need is stabilization of the fractured femur. The neurologist deems that it is appropriate to perform the surgery under general anesthesia and that postoperative neurologic assessment should be initiated. The cardiologist agrees that the patient is stable from a cardiac standpoint and that he will most likely be able to tolerate the effects of anesthesia. The orthopedic surgeon performs the fractured hip repair.

Upon transfer to the PACU, the patient is still asleep; he was extubated in the operating room, has a cardiac monitor on and a Foley catheter in place, and his hip is positioned for optimum healing. His vital signs are: blood pressure 162/100 mm Hg, pulse 80 beats per minute, respiratory rate 22 breaths per minute, oxygen saturation 89% on 4 liters nasal prongs, and core temperature 34.5°C. No urine is noted in the Foley catheter. The greatest initial concern is the lower oxygen saturation; the nasal prongs are replaced by a face mask at a flow rate of 6 liters per minute. Within 15 minutes of switching the oxygen delivery device, the oxygen saturation increases to 91%.

Thirty minutes after arrival in the PACU, the patient remains asleep. His vital signs are stable; however, his body temperature remains at 35°C despite forced air warming. He is not moving nor does he appear to be in any discomfort. His skin condition does not appear to have improved. His lower extremities are cool to touch, and peripheral perfusion is poor.

At approximately 40 minutes after arrival in the PACU, the patient sustains a cardiac arrest. Resuscitation efforts continue for approximately 20 minutes without success, and the physician in charge pronounces the patient dead.

This patient is representative of the typical postoperative geriatric patient. He has multiple health issues and takes many medications. His physical status is compromised by his nutritional status, in this case, obesity. He was living independently prior to this event; he did not have family close by, and his history was only ascertained by the information that his neighbor and the first care responders were able to locate. Even with that, the accuracy of this information was questioned. Prior to the fall, the patient had been happily living his life, which was subsequently lost after the surgery.

After the patient was pronounced dead, it was speculated that he had developed a clot that occluded his pulmonary vasculature. If this was indeed the case, the outcome would not have changed despite the resuscitation efforts. However, due to his advanced age and condition, a postmortem exam was not performed and the cause of death was never confirmed.

The patient's condition was compromised by numerous factors. He had a positive cardiac and smoking history and may have sustained a neurologic event at the time of the fall, or a neurologic event may have precipitated the fall. His obesity presented a number of issues. His skin condition was quite poor, and his apparent lack of hygiene would increase his risk of postoperative infection. While he was considered to be independent, his current health state was definitely not optimal.

Had this patient survived, in all likelihood, he would not have been able to return to an independent living environment. He would have required care in a rehabilitation facility to learn to ambulate post-surgery. Whether he would be strong enough to recover to a fully independent state was questionable.

This case demonstrates the many issues and challenges in managing the elderly patient. The lack of concrete information in the preoperative stage can impact the decisions that are made in the operating suite. Patient J's poor health status put him at increased risk for complication development. Even if the patient had survived, his long-term outcome would have been significantly different than the lifestyle he had prior to the injury. Preparing the patient and family for these less-than-optimum outcomes should be considered part of the preoperative care measures.

CASE STUDY 11

Patient K is a woman, 42 years of age, who weighs 432 pounds. She has a BMI of 62 and is scheduled to undergo a restrictive bariatric procedure. Her history is positive for hypertension, diabetes controlled with two to three insulin injections daily, gastroesophageal reflux disease, and obstructive sleep apnea. She is nervous prior to surgery, yet anxiously awaiting the new life that she sees in her future.

The operative course of care is unremarkable. The patient has a gastric band placed, creating a small pouch. She is transferred to the PACU having been extubated. Her vital signs upon admission are: blood pressure 182/112 mm Hg, pulse 82 beats per minute, respiratory rate 24 breaths per minute, core temperature 35°C, and oxygen saturation 91%. She remains very somnolent but opens her eyes with loud verbal stimulus.

Upon admission, the concern for this patient is the low oxygen saturation. She maintained a saturation of 94% during the procedure but the postoperative saturation remains 90% to 91%. Oxygen is being delivered by nasal cannula at 4 liters/minute. The nurse caring for the patient is unsuccessful at awakening her for more than a few seconds. The oxygen delivery system is changed to a face mask with a liter flow of 6 liters/minute. Little improvement in the patient's status is seen with this change.

It would be optimal to awaken the patient to have her participate in respiratory exercises; however, she remains quite sleepy while in the unit. Elevating the head of the bed may help her oxygenation but does little to increase her oxygen saturation values. Arterial blood gas analysis is obtained; the results are pH of 7.34, PaO 2 of 74, and PaCO 2 of 47. With these results it is obvious that the patient is hypoventilating, most likely secondary to pressure on the diaphragm limiting her respiratory excursion effort.

The patient remains somnolent for the next four hours. Her oxygen saturation values remain around 91% despite the efforts of the staff. After four hours in the PACU, she is transferred to the inpatient unit for an overnight stay. She remains hypoxic until the following afternoon.

The patient in this case study demonstrated one of the more common complications following bariatric surgery: hypoventilation. The upward displacement of Patient K's diaphragm prevented full expansion of her lungs, causing carbon dioxide levels to rise while oxygenation values remained low. Although the levels were low, they were not to the point of being life-threatening.

One measure that may be used to improve oxygenation in patients following surgery is respiratory exercises to help expand the lungs and encourage the patient to expel secretions. To accomplish this goal, the patient should be cooperative and have an appropriate cognitive level to follow the commands. As this patient remained somnolent for a lengthy period, efforts at obtaining her cooperation were unsuccessful. It is not uncommon for obese patients to experience a delay in awakening following anesthesia. The drugs are absorbed into the fatty tissue, and release occurs over an extended period. One measure that may have been successful in arousing the patient more quickly is a fluid challenge. This extra fluid can often help circulate the remaining anesthetic and speed the metabolism of the medication, allowing the patient to awaken more quickly. While this may not always be the answer to delayed awakening, it is often successful in obese patients.

Fortunately, this patient did not experience any of the other postoperative complications that are common following bariatric surgery. After her respiratory status improved, she was able to meet the criteria for discharge and was sent home the next day.

In follow-up with this patient, she lost more than 100 pounds in the first year following surgery. She started an exercise regimen and is determined to continue with her weight loss. While 100 pounds is quite a bit of weight to lose, her weight is now 330 pounds; therefore, she remains at risk for the complications of obesity. Her diabetes has not resolved, yet she remains hopeful that with continued weight loss, she will one day be free of insulin injections. Morbidly obese patients have a long and often arduous path ahead of them and should not expect miracles to happen overnight.

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Case Study #6: Sepsis

Day 1: Medical Ward

Time: 12h00, place: medical/surgical floor.

“You must be George Thomas?”

“I am, and you must be the waitress that I’ve been waiting for. I asked for a two-egg omelette and fried tomatoes and black coffee. Service is so bad here. Even my driver here can’t get a drink.”

“All right then, Mr. Thomas. You are in the hospital, you have a serious infection, and your driver here, Glen, is the hospital porter. I am going to be the nurse caring for you. My name is Greta.”

“Right, right. I remember now. That Dr. Jim was always telling me that. You must think I am a crazy old man.”

“No, Mr. Thomas. Sometimes infections do strange things to our thinking.”

“Greta, can you help me push Mr. Thomas into his room?” Glen asks.

“Sure thing, Glen. Mr. Thomas, hands off the rails. I don’t want to catch your finger on the door frame as we go through.”

Glen and Greta get the stretcher into George’s room, and with a little help, George is able to slide from the stretcher onto the bed.

“Oh, this bed is so much more comfortable. Why was I on that thing?”

Glen leans down and quietly looks around like he is sharing a secret. “That is the Emergency Room stretcher. It’s designed so it’s easy to move and transport, but it’s really made to be uncomfortable so people don’t stay long in the Emergency.”

George nods his head. “Makes sense to me. That’s the way I would have designed it.”

“Had your fun, Glen? Let’s not make Mr. Thomas more confused,” Greta reprimands, hiding a smile. “Mr. Thomas, Glen is pulling your leg.”

“I knew that. Just checking to see if you did.”

Glen moves the stretcher out of the room. “I’ll drop the charting off at the desk.”

“Yes, that would be perfect,” says Greta. “Thank you.” She then turns her attention to the patient. “Mr. Thomas, I’m going to pull the side rails up here to keep you safe. Here is a call button. If you need anything, press it, and I will come and help you. I want you to stay in bed until Physio can help us. I’ll be back in a few minutes to take your blood pressure and complete your admission to this floor.”

“Got it. Stay in bed, push button for help, you’ll be back.” George nods.

Greta smiles and leaves the room.

Time: 13h00

“Mr. Thomas, I have a small lunch tray for you.”

Greta enters the room and sees the bed empty, and a small pool of blood on the sheet with the IV device hanging on the side rail.

“Confound it. Where did he go?” Greta looks down and sees small drops of blood on the floor and notes that the trail leads to the bathroom.

Moving quickly to the bathroom, she opens the door to find George on the floor under the sink to the left of the toilet.

“George, George, are you ok?”

“I think so. Who waxed the floor and made it slippery? This is an accident waiting to happen!”

“Yes, do you hurt anywhere?”

“My hip hurts.”

“Ok, stay right where you are.” Greta leans across George and pulls the nurse assist cord.

“What do you think I have been doing for the last while?”

A few seconds later, Addy comes in and opens the bathroom door wider. “Oh my, you really do need help, Greta.”

“Yes, Mr. Thomas slipped here and says his hip hurts. I wonder if the physiotherapist is around and can help us move him in a manner that won’t further injure his hip.”

“If you’re ok, I will find the physio and another to help,” Addy says.

“Yeah, I believe we’re ok,” responds Greta.

A few minutes later, Addy returns to the bathroom with Dorothy, a physiotherapist.

“Greta, Tim will be joining us shortly to help move him. He’s gone to get one of the stretchers that go almost to the floor, as he thinks if his hip hurts he will be going for X-rays.”

“Good thinking. Are you our new physio?”

“Yes, name is Dorothy. Quite the pickle you have here, eh?”

“That’s one way of describing it. How can we get Mr. Thomas out of the bathroom?”

“Well,” considers Dorothy, “if he can lift his shoulders a bit, we can wrap a lift sheet around his upper body, then pull on the sheet and slide him out from under the sink.”

Addy grabs a lift sheet out of the cupboard just outside of the room and assists Dorothy with lifting Mr. Thomas’s shoulders while Greta wraps the sheet around his upper body.

Dorothy leans down and grabs one end of the sheet and holds onto the sink with the other hand. Greta imitates her and uses the wall for balance.

“Addy, can you just lift Mr. Thomas’s heels off the floor, and we will slide him little by little out the door where it will be easier to look after him,” Dorothy says.

All three work together to slide George out through the bathroom door and into the middle of his private room.

“Ow, my hip really hurts.”

“Addy, can you take his vital signs? Dorothy, can you help me assess his hip?” Greta says.

Addy leaves the room to grab the vital sign machine.

Dorothy kneels down beside George and pulls his legs slightly to straighten them.

“Ok, it looks like his left leg is slightly shortened, and look how it turns out a bit more than the right. He may have fractured his hip or maybe this is the way he has always been. Not sure. Needs an X-ray.”

“Right. Once we have him on the stretcher, I will contact Dr. Pierce who is covering today and let him know,” Greta says.

Addy takes George’s vital signs to find not much of a difference.

Tim finally arrives with the stretcher and lowers it down to about six inches off the floor.

The three nurses, with the physiotherapist coordinating the lift, move George off the floor and onto the stretcher.

“Thought I would get a nice bed. Back to Emergency I go?” asks George.

“No, Mr. Thomas. Just this stretcher until we can X-ray your hip,” Tim says.

“Ok,” Greta says. “Can someone help me bring the stretcher out to the nursing station? I want to keep an eye on him until I contact Dr. Pierce and get the X-ray completed.”

Addy and Tim laugh. “Sure thing,” Tim says.

Greta contacts Dr. Pierce and explains the whole situation. Dr. Pierce agrees that a left hip X-ray is warranted. He also asks Greta to restart the IV.

Time: 14h30

“Greta, X-ray called,” reports Addy.  “They can take Mr. Thomas now. Should I send for a porter?”

“Yes, he is good to go with a porter.”

Time: 15h00

“Gurpreet, this is Mr. George Thomas, from med/surg, fell this morning in the bathroom, suspected hip fracture.”

“Ok, follow me into Room 2 and we can get started.”

“Not sure if you remember me, Mr. Thomas. I was the one that took your chest picture when you were in Emergency.”

“Oh, yeah, I remember you. I asked for a discount on the picture.”

Gurpreet smiles. “Not quite, Mr. Thomas. Not that type of picture. Ok, we are going to help you shuffle over to this X-ray table.”

The porter and Gurpreet get George onto the X-ray table, and they position him for the X-ray. Gurpreet places a cassette under George’s hip, and then positions the camera. Double checking the distance and the aperture settings, she steps back behind the lead shield and presses the button. Gurpreet repeats the process three more times to get views of George’s hip from all directions possible.

At the scanner she reviews the images and makes some adjustments to the brightness of the last image. She thinks to herself, All look good. Don’t see any fractures . Gurpreet then releases the images into George’s health record.

Health Case Studies Copyright © 2017 by BCIT is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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22 Day 1: Medical Ward

Time: 08h00, place: medical ward.

“Good morning, Mrs. Smith. Do you remember me from yesterday. I’m Simone?”

“Yes, Simone, I remember you from yesterday. I see you’re back. This your second day shift?”

“Yes, this is my second. I am doing three days and a night shift this week so we will probably have one more day together. I have your meds here: a beta blocker, ace-inhibitor, and diuretic. But before you take these, I need to check your morning weight and your blood pressure. This is something you’re going to have to do each day on your own.”

“Ok, do you need me to do anything?”

“Nope, just lie back and relax while I take your BP and weight.”

Simone then presses a button on the bed to get Meryl’s weight and then presses the NIBP button on the monitor.

“Your blood pressure is down to 90/55, which is what we expect. Your heart rate is around 65, which is also what we expected. You have lost 1 kg of fluid since we started the diuretic, which is a bit less than we expected. How are you feeling when you stand at the bedside or use the commode?”

“I feel a bit lightheaded but nothing really serious, I don’t think.”

“Your oxygen has been dialed back to 3 LPM, but is not really changed. I would like to listen to your chest, then I will give you your meds and morning tray.”

Meryl adjusts her gown so that Simone can listen to her heart and lungs. Simone methodically moves through a head to toe assessment and records her findings.

“All done, Mrs. Smith. Here are your pills as we discussed and your breakfast.”

“This is it for breakfast? Some cereal, skim milk, and a couple pieces of fruit?”

“Yes, Addy the dietician you met yesterday has ordered for you the  cardiac diet  low in sugar and salt. She will be coming by later this AM to discuss diet with you and hopefully Dorothy. Diet is very important in heart failure and knowing more about how food affects your condition will help keep you out of the hospital.”

“Ok, this will take some getting use to. I really like my sausage and eggs for breakfast.”

“I can honestly say me too, but for you the rare sausage or eggs will be ok, just not every day. But Addy would be best to ask.”

Simone heads out of the room to check on her other patients. Meanwhile, Meryl picks up her spoon and moves the cereal around but really does not eat anything other than the half apple and tea on her tray.

Time: 10h30

“Hello, Mrs. Smith. My name is Addy and I am the dietician for Cardiology. We met yesterday with the rest of the team. You are Dorothy right? Mrs. Smith’s wife?”

Dorothy smiles. “Good memory, yes I am.”

Meryl looks up, “You’re probably here to discuss what I can or cannot eat?”

“That is correct. For you, diet and activity are going to be very important to maintaining good health and keeping you out of the hospital.”

Dorothy looking unhappy and says: “I suppose I’m here to learn as well so that I keep her on the straight and narrow path.”

“Yes, in my experience and in the research: when families are closely involved in the care of a loved one, the care is much more effective. The diet is not all bad, and you and Mrs. Smith will learn how to adapt it to your likes, but there are some things to consider.”

Addy sits at the bedside and hands both Meryl and Dorothy a sheet of  do’s and don’ts for heart failure patients  along with some   sample menus  and some  links to recipes. 

“It is really important that you consider  low sodium foods  and not adding any additional salt when cooking. Adding salt can lead to further water retention, which can stress your heart and make it not pump as well as it should.”

“Look, Meryl, many of the menu items we already eat. I just need to not add salt.”

“That is correct, Dorothy. Many patients find they are already cooking similar diets. I recommend that you not have a salt shaker on the counter or on the table. That way you’re not tempted to add salt. Look for fresh herbs and spices to add that kick of flavor we all desire. Things like garlic, cilantro, or sage can add some additional flavor to something like a broiled chicken breast.”

“Oh Meryl, we have always said we wanted a herb garden. I guess this will be the encouragement we need to start.” Dorothy’s eyes light up a bit more. “I can go shopping for the stuff we need and when you come home we can start planting.”

“Dorothy, this is not an excuse to go shopping. You always get so excited about things. We need to take this slowly. A garden is a good idea, but let’s start buying and cooking first.”

Dorothy’s eyes shine a bit less brightly, but she nods.

“Ok, you both look like you understand what I am asking you to do,” says Addy. “I would like you to look through the information I have given you. If you have any questions, write them on the sheets and I will come back tomorrow to see how you’re doing. The meal trays you get will be example meals that you should consider making at home. Dorothy, I need you not to bring anything extra in from home until Mrs. Smith is stabilized. Do you think you can do that?”

“I was just thinking of picking her up a milkshake, but I guess that’s out of the question?”

“Yes, until we have things more stabilized and the medications working well, that is for the best.”

Both women nod. Addy gets up and waves good bye to both Dorothy and Meryl, and heads out of the room to see the next patient on her list.

 Time: 11h00

Simone stops Addy a couple of doors down from Meryl’s room. “How did your talk go?”

“Pretty well. They are both intelligent and are ready to learn. They seem less overwhelmed than yesterday. Meryl seems to be feeling better, but is still on oxygen. Dorothy was very excited about making a herb garden. All good signs.”

“Awesome, thanks. If they have any questions are you coming back today?”

“No, I think they will need to digest what I gave them. I said I would be back tomorrow to see how they are doing and to answer any questions.”

“Sounds good.”

Time: 11h15

“Mrs. Smith, how are you doing? I am back to do another  ECG  heart tracing on you.”

“Ok, and you are?”

“I’m Denis. I performed the test yesterday. Do you remember?”

“Oh, there was so much happening, I’m so sorry ,I can’t remember everyone’s name that is helping me.”

“That is quite all right. Ok, this test involves me placing some sticky tape on your arms, legs, and chest.”

“That I remember.” Meryl re-adjusts her gown so Denis can place the leads on her chest and arms. Denis pulls the covers up, leaving Meryl’s feet exposed so he can place the leads on each foot. “All done with that. I now need you to stay very still while we do the test.”

Denis pushes the button and the pink coloured paper is slowly pushed out of the machine with the squiggly lines from each of the 10 leads.

“All done.”

“Is there any change?”

“Mrs. Smith, I see lots of patients every day and my apologies. I cannot remember your test from yesterday. All I can say from looking at the ECG is that there is nothing to be done right away and you are not in danger right now.”

“I guess that’s a good thing, thanks.”

Denis prints out a second copy as an interim report for the chart, then removes the leads and stickies from Meryl’s body. “I’ll see you tomorrow.”

Meryl waves him goodbye.

As Denis is exiting the room, Simone pulls him aside. “You have the latest 12 lead?”

“Yes, I was going to place it in the chart.”

“Excellent, let’s do that and compare it to yesterday.”

Both go to the nursing station where Simone pulls up  y esterday’s 12 lead and looks back and forth from today’s ECG to yesterdays.

“Do you see any differences Denis?”

“Nope, although it is quite a bit slower than yesterday’s. Did you start her on something?”

“Yes, we started her on a beta blocker to slow her rate down and to prevent any remodeling.”

“Well, it seems to be working. Heart rate is about 65, but other than that everything looks the same as yesterday.”

“Ok. Thanks Denis. See you tomorrow?”

“Yes, I’ll be here about the same time.” Denis then grabs his ECG cart and heads down the hallway to another patient.

Time: 14h00

“Good afternoon, Mrs. Smith.”

Dorothy looks up to see a slightly stooped women enter the room and pull a chair up to the bedside. “Who are you?” she asks.

“My name is Stella and I am a social worker for the hospital. I come and see all the cardiac patients to make sure things are going well and to see if I can help at all.”

“Oh, not sure what you can offer.”

“Me neither, but lets have a conversation. Then I might have something a bit more definitive.”

Dorothy looks Stella over a bit more. “I guess that’s ok. Meryl has psych coverage as part of the RCMP so not sure what you can help with?”

“That’s good to know. If there’s something that needs to be shared, I can share it with the RCMP. It benefits people to ensure there is good coverage. I have a few set questions to ask, but please feel free to interrupt at any time. I do this to see if there are any gaps and where a social worker can assist you in your new journey to better health.”

Both Meryl and Dorothy nod.

“Ok, how long have you two been together?”

“We have been living together four years, but have dated for about eight years before moving in. I met Dorothy while I was having a coffee break and stretching my legs after being in the patrol car for 10 hours on a stake out. She was sitting in a booth by herself and the restaurant was completely jammed. I asked if she wouldn’t mind sharing her booth and she told me that it was ok and that I looked to be a safe person. We started talking and here we are 10 years later. She was the right person at the right time after my previous relationship dissolved due to him cheating with the teaching assistant.”

“You were previously married?”

“Yes, before Dorothy, I had a traditional family with a male husband. We were together for about six years. I never really felt comfortable in the relationship, but thought that that was what a woman should be when being a wife to a male. Anyway, he started cheating after I had our second child and then I just left.”

“How many kids?”

“Two. A boy, Roger, and a girl Jennie. Very lovely kids, but they’re growing up so quick. Roger is 16 and Jennie is 14. We share custody. Although Matt, my ex-husband, gets weird with me living with Dorothy.”

“Any issues with the coparenting or the kids?”

“No, the kids have adjusted nicely to having two moms and have really bonded with Dorothy.”

“How long have you been with the RCMP?”

“Twenty-four years—looking at retirement in about five or six, I think. Got a promotion three years ago that took me out of the patrol car and more desk duty. Been a little less active since that time, riding a desk.”

“Yes, physical activity is important. I think that is Addy’s day two talk after she gives you the news about your diet.”

All three women laugh.

“Oh, I am still active, just not the same level as when I was in a car. I like to walk, run a little, and really enjoy hiking on some of the trails we have around here when the weather is nice.”

“Sounds lovely. Good way to relieve stress in your type of job.”

“Yes, I guess so.”

“Do you smoke?”

Both women shake their heads no. “We both quit years ago. Never felt the need to take it up again.”

“How about alcohol?”

“Dorothy and I enjoy a glass of wine after work and the occasional martini when we go out, but I don’t think it’s excessive. What do you think, Dot?

Dorothy ponders this and a few seconds later answers. “Not sure we do drink every day, but only a glass, so I don’t feel it’s excessive.”

“Sounds quite normal to me. Ok, thank you for answering my questions. You are very normal people and look like you have the coping skills and support needed to make the adjustment that heart failure requires. I don’t think I need to be involved. With your permission, I would like to send a note to your HR benefits person in the RCMP to give them an update, and maybe they can follow up with any necessary assistance. “

“That would be fine.” Meryl then gives Stella her division number and the contact information for benefits in her division.

“Thank you both. Have a great day.”

Stella heads out of the room and to the nursing station to update her notes.

Simone comes by just as Stella is finishing up. “Anything I need to know?”

Stella looks up and smiles. “No, I think she is doing pretty good. I don’t believe the diagnosis has really hit her or her partner yet. Right now they’re still processing. On the plus side, good supportive family, and she has great support from the RCMP so things are setup well for her to be successful in this transition. The real question is: will she be allowed to continue to work or will the RCMP push for retirement? But that’s not my decision and could add quite a bit of stress to Meryl and Dorothy.”

“Thanks Stella. I have a good feeling about them. Will you check in with them again?”

“No. I’ll see them in the healthy heart clinic, but I don’t think I need to follow up beyond that.”

Simone nods and moves over to complete her charting on the other patients she is caring for.

Time: 16h00

“Hello Mrs. Smith, how are you doing?” Simone asks as she looks over the monitor and does a primary sweep of her patient.

Meryl looks up with reddened eyes, “It’s going ok I guess.”

“Have you been crying, Mrs. Smith?”

“Just a little. I just. Why me?”

“I don’t know why this has happened to you, but I can explain things a bit more to you if you would like?”

“That might help. I think it’s suddenly hitting me that my body is changing and not for the better and I may have to retire and make so many changes. I, oh gawd. I just don’t know what to do.”

“This is perfectly normal. Let me pull up a chair and I can explain what is happening in your heart ,and what the plan is for you. Does that sound ok?”

“Yes, thank you.”

Simone sits down beside Meryl’s bed and explains how heart failure develops when a valve is not working, how valves become diseased, and the various treatments. She also carefully discusses some of the complications that can develop if Meryl does not follow doctor’s orders.

“Oh, thank you. I think I understand a bit better now. It looks like I’m not going to die.”

“Yes, Mrs. Smith, with the correct treatment, and you watching your diet and exercise you can live a very enjoyable life—maybe not the one you envisioned, but still quite enjoyable.”

“Yes, I think it’s all the changes I am facing that is overwhelming me. “

“Could very well be. Often facing one’s mortality can be a bit daunting. You need to give yourself time to grieve and recognize that this has happened to you and that it is not a punishment, but something that you need to deal with. Remember, there are many people here to help you and Dorothy make the best of this situation and diagnosis. You need to allow us to help you.”

“Thank you again. Yes, I will be asking for help now. What is the plan for tomorrow?”

“Much the same as today. You will have another chest X-ray, ECG, and lab work. I hope that I’ll be able to take you off oxygen, and then, if that happens we can introduce you to the heart failure clinic, which will begin an exercise routine with you to help strengthen your heart and your coping skills.”

“It would be nice to begin moving around again.”

“Let’s plan to do that tomorrow, shall we? I can hear the dinner trays being moved about in the hallway, so I’m going to get your meds and check on my other patients.”

Meryl smiles and pats Simone’s hand.

Simone moves the chair back to the corner and heads off to gather meds and check her other patients.

Health Case Studies Copyright © 2017 by BCIT is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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Simulation for ward processes of surgical care.

Pucher PH, Darzi A, Aggarwal R. Simulation for ward processes of surgical care. Am J Surg. 2013;206(1):96-102. doi:10.1016/j.amjsurg.2012.08.013.

This commentary describes one hospital's development of a simulation ward and its experience designing scenarios , involving multidisciplinary teams, and calculating the associated costs.

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Simulation to enhance patient safety: why aren't we there yet? October 19, 2011

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Impact of the introduction of electronic prescribing on staff perceptions of patient safety and organizational culture. June 28, 2017

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Five reasons for optimism on World Patient Safety Day. October 23, 2019

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Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study. December 17, 2014

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International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process. February 1, 2017

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The WHO surgical safety checklist: survey of patients' views. August 6, 2014

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Surgical technology and operating-room safety failures: a systematic review of quantitative studies. August 7, 2013

Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies. February 1, 2012

Interventions to improve employee health and well-being within health care organizations: a systematic review. June 20, 2018

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature. February 14, 2018

Patient safety in inpatient mental health settings: a systematic review. February 5, 2020

International evaluation of an AI system for breast cancer screening. January 29, 2020

Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis. December 18, 2019

Learning from complaints in healthcare: a realist review of academic literature, policy evidence and front-line insights. February 26, 2020

Patient safety education 20 years after the Institute of Medicine report: results from a cross-sectional national survey. May 20, 2020

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The problem of engaging hospital doctors in promoting safety and quality in clinical care. March 21, 2007

Teamwork in the operating theatre: cohesion or confusion? March 29, 2006

Reliability of a revised NOTECHS scale for use in surgical teams. July 16, 2008

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Surgical skill is predicted by the ability to detect errors. May 25, 2005

Systems approaches to surgical quality and safety: from concept to measurement. March 6, 2005

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The disclosure dilemma—large-scale adverse events. September 8, 2010

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Provider and patient perceptions of an external medication history function. August 5, 2015

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Validity of Agency for Healthcare Research and Quality Patient Safety Indicators at an academic medical center. August 21, 2013

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Monitoring for medication errors in outpatient settings. January 28, 2009

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Systematic review: effects of resident work hours on patient safety. September 28, 2005

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Practical challenges of introducing WHO surgical checklist: UK pilot experience. January 27, 2010

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State policies for prescription drug monitoring programs and adverse opioid-related hospital events. September 9, 2020

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Patient Safety/Quality Improvement Primer. July 27, 2023

Patient Safety Authority Annual Reports. May 1, 2023

Crisis scenarios for simulation-based nontechnical skills training for cardiac surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists, and cardiac operating room nurses. April 12, 2023

Implementation of simulation training during the COVID-19 pandemic: a New York hospital experience. February 24, 2021

COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought. August 19, 2020

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes. July 10, 2019

Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience. July 10, 2019

Understanding the clinical implications of resident involvement in uncommon operations. May 1, 2019

Simulation-based clinical rehearsals as a method for improving patient safety. October 31, 2018

Imitating incidents: how simulation can improve safety investigation and learning from adverse events. June 27, 2018

Using simulation to improve systems-based practices. August 16, 2017

Operative team communication during simulated emergencies: too busy to respond? December 21, 2016

Improving the communication between teams managing boarded patients on a surgical specialty ward. August 31, 2016

Improving Weekend Out Of Hours Surgical Handover (WOOSH). May 25, 2016

Nontechnical skills in pediatric surgery: factors influencing operative performance. April 13, 2016

Simulation-based Surgical Education. November 25, 2015

Nurse interrupted: development of a realistic medication administration simulation for undergraduate nurses. August 26, 2015

Simulation in Surgical Training and Practice. August 19, 2015

Innovative teaching in situational awareness. June 24, 2015

Training safer surgeons: how do patients view the role of simulation in orthopaedic training? May 13, 2015

Simulation in Anaesthesia and Surgery. May 13, 2015

Teaching a 'good' ward round. April 22, 2015

Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills. March 18, 2015

What about doctors? The impact of medical errors. January 14, 2015

Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students. December 10, 2014

Standardise, Educate, Harmonise: Commissioning the Conditions for Safer Surgery. April 23, 2014

Graded autonomy in medical education—managing things that go bump in the night. March 26, 2014

A just culture after Mid Staffordshire. March 26, 2014

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Maben J, Griffiths P, Penfold C, et al. Evaluating a major innovation in hospital design: workforce implications and impact on patient and staff experiences of all single room hospital accommodation. Southampton (UK): NIHR Journals Library; 2015 Feb. (Health Services and Delivery Research, No. 3.3.)

Evaluating a major innovation in hospital design: workforce implications and impact on patient and staff experiences of all single room hospital accommodation.

Appendix 23 cross-case analysis of the four case study wards.

Here, we consider how the four case study wards fared in the move to the new hospital. Findings are brought together to explore similarities and differences between the wards and possible reasons for the findings. The focus is particularly on the context and characteristics of the wards; initiatives taken by staff to adapt to the new environment; and outcomes for patients and staff.

• Context and characteristics

All the wards relocated to single room accommodation in the new hospital, but they varied substantially in the nature and extent of other changes they had to cope with. ‘Ward’ is also a proxy for patient groups with particular characteristics and needs; distinct groups of staff with a variety of assets and priorities; and a particular place in the organisation. Key stakeholders and staff identified a range of contextual factors and characteristics which they felt compounded or buffered the challenges inherent in moving to the new hospital. Our summary of the nature and scale of these changes and challenges is displayed visually below ( Table 77 ). A challenge in the physical environment of the wards identified by the research team has also been added, namely whether the design supported decentralised nursing teams relating to clusters of 10 rooms or was different from this ‘standard’ plan for general wards. Two wards (older people’s and surgery) conformed to the standard plan and two (AAU and postnatal) deviated from it. The AAU had a unique layout that staff found difficult to adapt to; the postnatal ward layout supported midwives’ established practice, but its design integrity was compromised by a section being assigned to another specialty.

Context of the case study wards: nature and extent of the challenges

Other challenges at ward level included an increased number of beds on the ward (for the AAU and the postnatal ward, the number doubled); patient characteristics; discontinuities in the staff team; and staffing issues such as turnover and mix of experience. Finally, two wards were affected by system or policy changes that signalled both opportunities and challenges. Service reconfiguration gave the AAU a more prominent role in the new acute hospital, where maintaining the flow of emergency admissions through the system was paramount, putting additional pressures on staff in the unit. The merger of maternity services, which increased the size of the postnatal ward, was also associated with discontinuities in staffing and leadership and the introduction of new policies and procedures, including allowing fathers to stay overnight. These contextual changes determined the extent and type of change staff had to cope with and influenced the character and culture of the wards. The AAU appears to have faced the most challenges, with changes in size of the ward, increased acuity of patients and a decreased level of staffing coupled with a legacy of staffing difficulties that remained unresolved. The older people’s ward faced challenges of monitoring dependent and confused patients in single rooms, with a newly formed team and leadership. The surgical ward appears to have the most favourable context for the move, with fewest concurrent changes.

The issues identified here as ‘contextual’ can be seen as dynamic and inter-related, changing over time and having the potential to interact with each other in unpredictable ways to create new opportunities or constraints. For example, discontinuities in leadership or staff are not inherently negative; they can bring new blood, skills and ideas to a ward. Some issues may amplify disadvantage; for example a decrease in staffing level for a ward with pre-existing staffing difficulties may exacerbate recruitment and retention problems, which in turn almost certainly affect the development of nursing teams. Contextualising the case study wards also allows us to consider the interplay between context and the processes adopted and adapted by staff after the move to the new hospital.

• The process of adapting to the single room environment

The all single room wards in the new hospital had important benefits for patients and staff, but they also posed particular challenges for nurses, who had to use their ingenuity to adapt their work patterns and processes to deliver safe and effective care, as discussed in Chapter 6 . All the wards responded to the challenges of establishing decentralised nursing teams, monitoring patients, managing the risk of falls, and reducing patient isolation by selecting from a repertoire of conventional methods and, in some cases, developing novel approaches tailored to the particular requirements of patients, staff and ward. A summary of where the wards focused their efforts is provided in Table 78 . The differences between wards are due to the salience of the various challenges and how wards used the resources available to them. The priority for the AAU was initially finding a configuration of decentralised nursing teams that enabled staff to work effectively in the ‘non-standard’ ward layout, a protracted process that was described by staff as disruptive and stressful (see Chapter 6 ). The older people’s ward took a concerted ‘belt and braces’ approach to its biggest challenge, preventing falls, employing all available methods. The surgical ward focused on supporting the ward team, with its established leadership and team work, to deliver good care overall rather than prioritising one particular challenge of single room working. For the postnatal ward, isolation of patients was seen as the most significant challenge, and multiple methods were used to try to increase interaction among patients. None of the wards focused on time management and prioritisation of care, highlighted by nursing staff as a significant issue in the new environment, and largely left to individuals to resolve. Further exploration of this aspect of nursing practice to identify strategies that would help nurses and nursing teams allocate and manage resources (their time, skills and knowledge) appropriately in the single room environment could help to improve patient experience and staff job satisfaction.

Extent to which case study wards used different approaches in response to challenges presented by single room wards

• Achievements and outcomes

The wards adapted to the new hospital environment at different rates but all were functioning satisfactorily a year after the move. The patient outcomes measured in the study and the achievements identified by staff on the wards are linked with summaries of the contextual issues and staff initiatives to adapt work patterns (discussed earlier in this appendix) in Table 79 . This cross-case comparison of patterns of context, processes and outcomes enables possible explanations for similarities or differences in outcome to be explored.

Summary of the study findings for the case study wards

• Patient outcomes

In terms of patient outcomes, coinciding with the move there were significant increases in the rates of falls and medication errors on the AAU and significant increases in the rate of falls and pressure ulcers on the older people’s ward. On the older people’s ward the rates remained high and are consistent with the changed case mix of the ward (see Chapter 8 ). On the AAU the rates fell back to pre-move levels after 6–9 months, suggesting that they were associated with adaptation to the new environment. Interestingly, the timing of the return of outcome measures to pre-move levels coincides with staff reports of settling into the new pattern of decentralised working when, to quote the ward manager, ‘suddenly it all clicked’ and staff ‘started to manage things that little bit better’ (see Chapter 6 ). However, in a complex environment, attributing an outcome to be a single factor is probably too simplistic. For example, the fall rate may also have been influenced by hospital-wide initiatives (provision of equipment, reinforcement of policies and procedures). Other interventions that we have not considered may be implicated. However, it is intriguing that the AAU’s rate of falls and of medication errors stabilised at around the same time, a pattern not found on the other case study wards. This example flags up the importance of the ward layout supporting a configuration of nursing teams that staff can make workable in practice. It also seems likely that pre-existing staffing difficulties on the AAU and the post-move reduced investment in staffing (not experienced by any other case study ward) may have played a part in the difficulties of adapting to the new environment.

• Staff experience and well-being

When interviews with staff were carried out, the rate of falls on the AAU had returned to the pre-move level and the rate on the older people’s ward was consistently higher. However, AAU staff were less confident about their ability to prevent falls than staff on the older people’s ward and this was reflected in staff morale. No adaptive effect was detected in outcome measures for the older people’s ward, despite its newly formed ward team. However, what distinguished this ward was the ward manager’s leadership in caring for people with dementia and the ‘belt and braces’ approach to safeguarding patients at risk of falls. Staff were emotionally engaged with the concerted effort to prevent falls, which may have been more effective in bringing them together as a team than an initiative to build teams per se.

Longstanding leadership and an established team were important assets that the surgical ward brought to the new environment and used to good effect. This ward had no significant post-move increase in rates of adverse outcomes. The ward manager introduced various initiatives to support good communication and maintain whole ward teamwork. Staff morale remained high but nurses found that decentralised teams had a divisive effect that was difficult to overcome. Difficulties of finding acceptable alternatives to preferred face-to-face communication with colleagues and the erosion of teamwork and trust, despite efforts to sustain them, are important negative findings in relation to single room wards that merit further investigation, since they have longer-term implications for the development of nursing teams.

• Leadership and co-ordination

Nurse managers considered that selecting the right ward sisters to provide leadership was important for securing successful transition to single room working in the new hospital. Our findings provide some support for that view, but the AAU experience suggests that that effective leadership, like any other factor in isolation, is necessary but not sufficient to enable rapid adaptation to the single room environment. The shift co-ordinator role was also an important innovation on the older people’s and surgical wards (the AAU had this role previously) that appears to have been vitally important for maintaining situation awareness across the whole ward. Some less experienced staff interviewed found the demands of this role challenging, which raises questions about preparing staff to take on this and similar co-ordinating and supportive roles.

• Patient experience

The surgical ward and the postnatal ward made efforts to encourage mobile patients to leave their rooms to exercise and interact with other patients. Both wards were limited by the inadequate and unattractive social spaces provided for patients and it was not clear how successful their efforts were. Since isolation was one of the main disadvantages of single rooms identified by patients and staff, and staff felt considerable discomfort because they had no time to talk to patients who were simply lonely, it seems important for both patient and staff to find effective ways of enabling social interaction among patients that do not make too many additional demands on staff.

The postnatal ward was different from the general acute wards in many respects. Although midwifery staff considered a high proportion of single rooms an appropriate design for a postnatal ward, not least because patients wanted them, they experienced challenges in delivering care that required adaptations at least as significant as those on the acute wards. Midwives particularly noted the ‘isolating’ effect of single rooms on postnatal women; this had consequences for their practice, restricting them to mainly individual interaction, with few opportunities to work informally with groups of women, as they had done on multibedded wards. The change in policy allowing fathers to stay overnight also altered the ward social environment in ways that some midwives were finding difficult to adapt to. The study suggests that single room working combined with other significant policy changes intended to make care more ‘patient centred’ created tensions for professionals that raised questions about their role and the nature of the service they were providing.

Bringing together the evaluation findings for the four case study wards we found that:

• The AAU had to cope with multiple contextual challenges and experienced difficulties adapting to single room working, which were reflected in outcomes, with rates of falls and medication errors initially increasing and then falling back to pre-move levels. Staff morale on the ward was low.
• The older people’s ward, despite a disrupted nursing team and a patient group that was particularly challenging to care for in the single room environment, found ways of adapting rapidly and managed to keep falls at a rate consistent with the ward case mix. A comprehensive and coherent approach to preventing falls was in place and staff morale was good.
• The surgical ward had fewer contextual challenges to cope with and continuity of nursing team and leadership were assets that may have helped rapid adaptation to the new environment, with minimal impact on outcomes. Staff were confident and morale was good.
• The postnatal ward had some significant contextual challenges, including fathers staying overnight, which had implications for midwifery practice. Staff had adapted to the new environment, but for some tensions remained, and raised questions about midwives’ role and the nature of the service they were providing.

Included under terms of UK Non-commercial Government License .

• Cite this Page Maben J, Griffiths P, Penfold C, et al. Evaluating a major innovation in hospital design: workforce implications and impact on patient and staff experiences of all single room hospital accommodation. Southampton (UK): NIHR Journals Library; 2015 Feb. (Health Services and Delivery Research, No. 3.3.) Appendix 23, Cross-case analysis of the four case study wards.
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Exploring a rare case of juvenile psammomatoid ossifying fibroma in the ethmoid: a case study and review

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Taha Yassine Aaboudech, Hafsa El Ouazzani, Habiba Kadiri, Leila Essakalli, Ayoub Bouteyine, Hanae Benadbdenbi, Naji Rguieg, Nadia Cherradi, Exploring a rare case of juvenile psammomatoid ossifying fibroma in the ethmoid: a case study and review, Journal of Surgical Case Reports , Volume 2024, Issue 4, April 2024, rjae242, https://doi.org/10.1093/jscr/rjae242

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Juvenile ossifying fibroma (JOF) and its variants, including juvenile psammomatoid ossifying fibroma (JPOF), represent rare yet clinically significant benign fibro-osseous lesions that primarily occur in children and young adolescents. They can be found in diverse anatomical sites such as the jaw, nasal cavity, paranasal sinuses, and orbit. JOF exhibits an aggressive nature, necessitating early radiological detection and surgical intervention. Similarly, JPOF, with a locally malignant potential, requires surgical removal, typically conducted through endoscopic approaches. We report a case of a 5-year-old girl with JPOF arising in the ethmoid, revealed by recurrent epistaxis and proptosis. The text emphasizes the importance of early diagnosis through histopathology as a diagnostic tool and underscores the need for appropriate management.

Juvenile ossifying fibroma (JOF) is a rare condition primarily observed in children and adolescents. This benign fibro-osseous tumor commonly occurs within the sinonasal region. Its distinctions from the conventional ossifying fibroma lie in the age of onset, anatomical site, locally aggressive behavior, and a notable propensity for recurrence. Clinical manifestations vary based on the tumor’s location, potentially presenting as nasal obstruction, facial swelling, or proptosis. The World Health Organization (WHO) classifies JOF into two main subtypes: juvenile trabecular ossifying fibroma and juvenile psammomatoid ossifying fibroma (JPOF) [ 1 ]. The psammomatoid subtype is a rare, benign tumor found in the head and neck region, often affecting children and young adults. It tends to develop in areas such as the nasal cavity, paranasal sinuses, or the orbit. Although typically non-cancerous, it may display locally aggressive behavior, potentially damaging nearby structures. Surgical removal is the preferred treatment, with either endoscopic or external approaches being considered, with a preference for the latter. Due to the risk of significant bleeding during surgery, precautions to secure blood products beforehand are essential [ 2 ].

This article outlines a case of JPOF diagnosed in a child.

A 5-year-old girl presented with progressive right eye proptosis and recurrent epistaxis over the past 6 months, along with a history of nasal obstruction persisting for several months. During the examination, non-axial proptosis was observed, and both extraocular movements and visual acuity were found to be intact.

Flexible nasofibroscopy revealed a protrusion filling the right nasal fossa, closely approaching the nasal septum. Computed tomography (CT) and magnetic resonance imaging scans indicated a well-defined osteolytic lesion with a peripheral sclerotic rind, measuring 4.1 × 3.8 × 3.7 cm and originating from the right ethmoid, expanding into the ipsilateral nasal cavity, orbit, and maxillary sinus ( Fig. 1 ).

CT showing an expansible, well-demarcated, osteolytic lesion with a peripheral sclerotic rind on the right side of the ethmoid bone, expanding into the ipsilateral nasal cavity, orbit, and maxillary sinus; (A) coronal CT scan; (B) axial CT scan.

Upon admission to the Ear, Nose, and Throat department, the patient underwent an initial Frozen Section procedure. The sample was promptly sent to the pathology laboratory for histological analysis. The findings indicated the presence of a benign mesenchymal tumor accompanied by roughly round-shaped calcifications. Given the potential for further complications, total tumor removal was deemed necessary to both prevent complications and establish a definitive histological diagnosis.

The pathology laboratory received a white to reddish fragmented tumor with an elastic to hard consistency. Histological examination disclosed a proliferation of spindle-shaped or ovoid cells with vesicular nuclei and rare mitotic figures. Cells were arranged in sheets, with numerous rounded purplish formations corresponding to psammomatous body-type calcifications. A few giant cells were also observed. The stroma of the tumor was fibrous and collagenous. No necrosis was found ( Fig. 2 ).

H&E staining of the pathological specimen at different magnifications shows a benign fibro-osseous proliferation characterized by a large number of spherical basophilic calcified entities with no osteoblastic rimming resembling psammoma bodies (arrowheads), within a fibroblastic stroma of uniform stellate or spindle-shaped cells; (A and B) low power magnifications; (C) x20 power magnification; (D) high power (x40) magnification.

Immunohistochemical studies were conducted, revealing that the tumor cells did not express Cytokeratin, CD34, S100, smooth and striatal muscle markers, MDM2, progesterone receptor (PR), or epithelial membrane antigen (EMA). Vimentin was diffusely expressed, with a very low ki67 proliferation index estimated at 4% ( Fig. 3 ).

Immunostaining reveals that the tumor tissue is (A) diffusely positive for Vimentin in the stromal component; (B) low Ki-67 proliferation index; (C and D) negative staining for EMA and CD34.

This case illustrates a typical clinical history, radiographic appearance, and classic histological findings of JPOF presented in the ethmoid.

JPOF predominantly affects younger individuals, with reported average ages ranging from 16 to 33 years. However, Malek’s review of 86 JPOF cases revealed an age range from 3 to 49 years, with a mean age of 17.7 years and a slight male predominance (1.2:1) [ 3–5 ]. This tumor is typically found in the nasal cavity, paranasal sinuses, orbits, or the fronto-ethmoid complex, with an exceedingly rare occurrence in the base or vault of the skull [ 6 ]. The primary clinical presentation often involves bony expansion, which is frequently observed. This expansion can manifest through a range of symptoms including proptosis, nasal obstruction, headaches, facial swelling, pain, and recurring sinus infections [ 7 ]. Additionally, it may exhibit an aggressive clinical course [ 8 ].

Radiologically, ossifying fibroma typically appears as a mass with a distinct border, unlike fibrous dysplasia. Moreover, ossifying fibroma lacks ground-glass opacity and instead exhibits a mixed density resembling both compact bone and fibrous tissue [ 9 ].While the appearance of the lesion on imaging might offer diagnostic insights, distinguishing it can be challenging due to its resemblances to other osteo-fibroid lesions within the facial skeleton [ 10 ].

Histologically, JPOF is characterized by a large number of spherical calcified entities with no osteoblastic rimming. Some of these calcifications have psammoma-like concentric lamellae with basophilic cores and an eosinophilic osteoid rim. The surrounding fibrous stroma is composed of loosely to densely collagenized tissue that contains a dense proliferation of fibroblast-like, spindle-shaped cells with hyperchromatic nuclei [ 11 ].

JPOF must be distinguished from other fibro-osseous lesions such as fibrous dysplasia, osteoblastoma, low-grade central osteosarcoma, and primary aneurysmal bone cyst. Additionally, it is important to consider intraosseous cavernous hemangioma and eosinophilic granuloma due to their similarities in radiological and histological features [ 6 , 12 ]. Misdiagnosis may occur with extracranial meningioma featuring psammoma bodies, which typically tests positive for EMA, unlike JPOF [ 7 ]. JPOF typically does not express S100 and CD34 [ 7 ].

Despite its benign and slow growth, this subtype exhibits local malignancy with a tendency to infiltrate surrounding structures. Therefore, accurate diagnosis is crucial, and treatment should involve complete tumor removal. Incomplete or partial resection is associated with a heightened recurrence risk [ 2 ].

Our report underscores the rarity of JPOF, focusing on its clinical, radiological, and primarily histological aspects. Despite its uncommon occurrence, JPOF poses diagnostic and management challenges due to its potential aggressiveness and recurrence. Histopathological examination remains pivotal for confirming the diagnosis, highlighting the importance of thorough evaluation and appropriate management guided by histological findings.

None declared.

No external funding sources were obtained for this submission.

No new data were generated or analyzed in support of this research.

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient.

El-Naggar AK , Chan JKC , Grandis JR , et al.  World Health Organization Classification of Tumours , 4th edn. Lyon, France : International Agency for Research on Cancer, 2017 , 251 – 2 .

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