Chapter 4B: Valhalla Inpatient Experience

Chapter 4b: Valhalla Inpatient Experience

After evaluation in the ED she was admitted. to the general surgery service. There was continued concern about possible inadequate arterial blood flow in the involved left leg. A non-invasive Doppler ultrasound was performed but was inconclusive. This was followed by a contrast arteriogram which identified partial, but physiologically significant, occlusive lesions involving the major left leg (iliac and femoral) arteries, and the presence of the prosthetic knee appliance. Disease was also noted in her right leg arterial system.

The decision was made to recommend and perform aorto-femoral and femoral-popliteal bypass grafts. For a variety of reasons related to staff rotations and patient selection policies, this combination of major graft procedures had not been done in the facility in the past two years. This level of case had been referred to the academic medical center hospital in the city during this period. The operating vascular surgeon, new to the facility, had performed multiple bypass procedures during his recent assignment to a Level 1 trauma facility through the Sustainment of Trauma and Resuscitation Skills Program, but had not done this specific surgical combination in the last 18 months. The other staff vascular surgeon had not performed these procedures in the past 24 months. In preparation for these urgent bypass procedures, the patient was evaluated by cardiology, pulmonary, and nephrology services which provided recommendations and discussed the degree of increased operative risk associated with her underlying co-morbid conditions. Consent was obtained from the son.

The patient was taken to the operating room and a truncated “time out” was performed, with a number of items from the required surgical checklist omitted. The subsequent operative procedure was prolonged due to a combination of events related to the procedure itself and difficulty maintaining a stable blood pressure. After five hours in surgery, with no apparent improvement in blood flow to the foot, she suffered a cardiac arrest. She was successfully resuscitated and post operatively it was determined that she had suffered an intra-operative myocardial infarction.

QUESTIONS

1) What principals of a High Reliability Organization would be applicable in making the decision to perform the surgical procedures on site?

2) What issues regarding quality are applicable to the decision to perform the surgical procedures on site?

3) What is the basis for the use of a “safe surgical checklist”? What effect does omission of aspects of the checklist have on surgical outcomes?

4) Within the context of this case, what are potential relationships between the inadequate/inaccurate medication reconciliation at the time of admission and the events in the operating room?