Clinical Handover and Discharge: A Case Study

This case study examines the factors involved in clinical handover and discharge, focusing on the assessment and response to a critically injured patient. It proposes a holistic approach for a registered nurse during the discharge process.

Running head: CASE STUDY 1
Case Study
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CASE STUDY
Case Study
Introduction
Today, clinical handover has become an integral tool in healthcare operations.
Patients’ safety and treatment rely majorly on the finer details that are passed over from one
clinical professional to the other. Therefore, any communication breakdown between the
emergency staff and the paramedics can be detrimental to the safety and well being of the
admitted patient. It is, therefore, necessary for a registered nurse to make use of the
information handed over by paramedics to effectively assess the state of the injured patient.
However, this process should be conducted based on the stipulated clinical standards. This
involves scrutinizing the ECG records, pocket contents and the general information
captured in IMST AMBO during handover. This paper will seek to examine all the factors
involved during handover and discharge. This will involve evaluating Corey’s case through
the A-E nursing algorithm and the relevant case responses. Also, the paper will propose a
holistic approach that can be adopted by a registered during Corey’s discharge.
Primary Survey
At the outset, the primary survey on a critically injured patient is usually governed
by similar principles. The need to stabilize a patient irrespective of the inflicted injuries is a
priority for every nurse working in the emergency department (Shah, Alinier & Pillay,
2016). It is with this reasoning that the A-E algorithm was introduced in the primary survey
of patients (Bjurman, Mangafic & Holzmann, 2018). This protocol aims to ensure that a
registered nurse resolves all life-threatening risks before a patient undergoes other stages of
assessment.
Airway
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The main objective of this assessment criterion is to ensure that a critically injured
patient does not suffer from air blockage or any other constraints in the respiratory system.
In the case of Corey Knight, a registered nurse should prioritize assessing for any signs of
airway obstruction on the patient. This may include checking for paradoxical chest
movements, breath sounds, tracheal fractures, and the presence of different obstacles in the
patient’s respiratory system.
The handover information from paramedics is crucial for the success of the airway
clearance procedure. Usually, this process requires little time since the life of an injured
patient is at stake (Kalyani, Fereidouni, Sarvestani, Shirazi & Taghinezhad, 2017).
Therefore, IMST AMBO serves as a guide through which a registered nurse uses to
accurately determine the leading cause of airway blockage in a patient. As mentioned by
Shah et al. (2016), the IMST AMBO captures the injuries, history, medications, allergies,
signs and symptoms, among other characteristics that identify the patient. Hence, a
registered nurse will carefully look for thigh or leg deformities, bruises on the skin, and
associate the sustained injuries to airway obstruction tendencies.
Adverse Femur injuries are usually associated with excessive blood loss and pain,
which can result in depressed consciousness. In such an event, a registered nurse should
prioritize categorizing the airway obstruction as a medical emergency where high-
concentration oxygen amounts are administered to the patient via a self-inflating bag.
Moreover, the clinical officer in charge has to make use of the patient’s history to determine
if Corey is fit for surgery or non-surgical treatment. Since the paramedics did not have any
historical data regarding Corey’s health condition, surgery is the only viable cause of action.
Breathing
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The main objective of this assessment criterion is to ensure that a critically injured
patient adequately exchanges gases without restrictions. Airway clearance on its own does
not guarantee adequate ventilation. Usually, a regular gaseous exchange is associated with
the proper functioning of the lungs, diaphragm and the chest wall (Silverthorn, 2015). In the
case of Corey, a registered nurse should prioritize examining for central cyanosis, excessive
sweating, and the overall breath sound produced by the patient (Hough, 2013). However,
this process should be guided by the information captured by paramedics during handover.
It is through the historical data obtained in IMST AMBO that serves as a guide in
determining if a patient has ever suffered from pulmonary oedema, asthma, massive
haemothorax or tension pneumothorax.
Since paramedics did not have adequate information about Corey’s health history, a
registered nurse needs to examine for the presence of respiratory system related illnesses
that Corey may harbour. In this case, a registered nurse should recommend for oxygen to be
administered to Corey for stable ventilation. Also, considering that Corey sustained a
broken femur, administration of oxygen serves as a means of restoring energy required for
the next stages of injury assessment.
Circulation
Control of hemorrhage and cardiac output are the main priorities in this clinical
assessment criterion. Corey is considered to suffer from a broken femur; hence, an adverse
hemorrhage is likely to occur. Mostly, bleeding can both be internal or external, depending
on the damage caused by the tissues surrounding the broken bone (Tinubu & Scalea, 2015).
If the blood loss is excessive, a patient is likely to suffer from hypovolemia which
consequently leads to death.
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In the case of Corey, a registered nurse needs to make use of the handover
information to examine for any hemorrhagic tendencies on the patient. Since IMST AMBO
usually contains information regarding the injuries sustained by the patients, a clinical
professional has to evaluate for the accuracy of the provided information. This may include
measuring the patient’s body temperature, assessing the skin colour, pulse rate and blood
pressure (Tinubu & Scalea, 2015). Moreover, the ECG records provided during handover
serves as a guide in determining if Corey may have experienced a hemorrhage. The ECG
usually uncovers abnormalities in heart rhythms, blood supply and tendencies of heart
attack experienced in the past (Seena & Yomas, 2014). Therefore, the information provided
during handover only serves as a platform through which nurses can make quick and
informed decisions regarding the critically ill patient.
Based on the mechanism of injury sustained by Corey, precise control of external
hemorrhage is the best response. This may include fastening the wounds with pads and
crepe bandages. Since the handover information reveals that Corey suffered from a broken
femur, arterial tourniquets should be applied until surgery on the affected area is a success.
However, tourniquets should only be used at extreme cases since they cause distal ischemia
and the crushing of body tissues (Liu, Graham, Gillies & Gillies, 2014). Also, a registered
nurse can make use of pneumatic splinting tools to control external bleeding that Corey
may experience during handover.
The medication adopted in Corey's case depends on the adversity of sustained
injury. After handover from paramedics is done, and all the necessary life-threatening risks
are eradicated, Corey can be presented for surgery. A surgeon can either decide to apply
external fixation or intramedullary nailing based on other injuries that Corey may have
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sustained. Since the handover information only reveal that Corey suffered from a broken
femur, intramedullary nailing is an alternative medical response that can be considered. In
this form of treatment, a broken femur is supported by a designed metal rod inserted in the
bone canal (Aslani, Tabrizi, Sadighi & Mirblok, 2013). A set of screws are then used to
reinforce the femur at its ends. However, external fixation should be preferred in this case
since it provides the medical team with time to assess whether Corey is fit for extra surgery.
Disability
Assessment of the patient's levels of consciousness is the top priority in this form of
survey. A registered nurse needs to check for the patient’s reactivity and pupil size during
handover to accurately determine the exhibited levels of disability. In the case of Corey, it is
the responsibility of a registered nurse to conduct a Glasgow coma scale to assess his motor
response, verbalization and eye-opening abilities during the handover from paramedics
(Reith, Van den Brande, Synnot, Gruen & Maas, 2016). This process is crucial since it
corroborates the information captured in IMST AMBO.
The patient’s medical history is of importance in this assessment criterion since the
exhibited disability levels could be triggered by other biological factors. Even though the
injury sustained by Corey could be responsible for his unconscious tendencies, other
illnesses such as cerebral hypoperfusion, hypoxia or hypercapnia could be involved. It is,
therefore, crucial for a registered nurse in charge to prioritize evaluating Corey's blood
glucose levels, response to stimuli and reviews the background information provided in
IMST AMBO during handover. Since little information regarding Corey, was captured by
paramedics, a clinical officer in charge should consider incorporating other professionals in
the field for an adequate review of the patient.
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Based on the mechanism of the injury sustained by Corey, AVPU is the appropriate
form of response to any unconscious tendencies that he may exhibit. In AVPU, a scale is
used to measure the patient’s levels of pain, unresponsiveness, verbalism, and alertness
(Jacob & Paul, 2017). Therefore, the AVPU results serve as a guide through which a nurse
can make final assessments of Corey’s disability state and response to stimuli.
Exposure
In this segment of the primary survey, a nurse prioritizes on limiting environmental
risks that may jeopardize the recovery of the patient. However, special consideration must
be observed regarding the patient’s culture, age and gender when regulating the immediate
environmental conditions. Moreover, it is crucial for a nurse in charge to carry out the
exposure sequentially. For instance, a nurse can examine the affected body parts one at a
time before controlling body temperatures within the acceptable limits.
Based on the mechanism of the injury sustained by Corey, the appropriate case
response under this assessment criterion is to expose him to a warm environment after all
stages of the primary survey are complete. This may include covering him with a warm
blanket. Furthermore, a nurse can ensure that all the intravenous fluids administered to
Corey are warm enough to limit incidences of mild hypothermia.
Discharge Planning
Today, the rate of readmission in hospitals is alarming and challenging for most
healthcare facilities. The concern has served to highlight the importance of effective
discharge frameworks in hospitals. The aim of proper discharge planning is to ensure that
the care accorded to the patient is not disrupted despite the adjustments made in the
immediate clinical surroundings (Everink, van Haastregt, van Hoof, Schols & Kempen,
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2016). However, the decisions made by the nurse should be guided by a set of factors
ranging from sociocultural to environmental domain.
Biological Factors
The timely discharge of the patient may be influenced by a set of biological factors.
Nevertheless, it is the responsibility of the nurse to anticipate any delays that may be
encountered during discharge (Yam, Wong, Cheung, Chan, Wong & Yeoh, 2012). As
mentioned by Mutisi (2015), a biological factor like bone malunion can be detrimental to
the discharge plans. It is, therefore, crucial for a nurse to asses if Corey harbours any form
of bone malunion on his femur before being discharged. Moreover, bone malunion hinder
the patient from achieving full mobility which can consequently lead to readmission and
corrective surgery (Hashimoto, Matsuzaki, Kawahara, Matsuda, Nishimura, Hatae & Arai,
2014). Therefore, it is crucial to evaluate and anticipate all the necessary biological factors
before discharging a patient.
Psychological Factors
Corey may find it difficult to accept that he can no longer carry out certain activities
in the environment due to the injury sustained. In the process, he may end up being
traumatized. Today, trauma is responsible for high cases of readmission in health facilities
(Nordmark, Zingmark & Lindberg, 2016). Therefore, the need to educate patients on the
necessary precautions is of high importance. In Corey’s case, a registered nurse can make
use of counselling sessions to ensure that the patient’s attitude is right before discharge.
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Sociocultural Factors
The societal values have an impact on the decisions made in the healthcare facility.
As mentioned by Lenzi et al. (2014), a nurse must understand the social roles, transport and
work activities that may impact a patient’s holistic recovery. According to Mutisi (2015),
the societal roles reserved to different people may, at times disregard their health conditions
hence impacting their overall wellbeing. Therefore, once a nurse understands Corey’s
cultural needs, he or she should consider informing his family of the appropriate form of
transport required for discharge.
Environmental Factors
Environmental factors such as road safety and household arrangement have a
significant role to play in the decisions made by nurses during discharge. For instance, the
mode of transport recommended for Corey may vary depending on the road terrain, and the
distance. Since Corey is on crutches, a nurse should decide on a mode of transportation that
may not endanger his ultimate recovery.
Politico-economic Factors
Politico-economic factors have a significant role to play in the discharge approaches
adopted by nurses. In Corey’s case, the nurse needs to ensure that the patient has access to
the relevant facilities for exercises. Lack of such facilities implies that Corey may not have
a chance to recover fully. Moreover, a nurse needs to assess Corey's financial ability to
afford some guided exercises before making final recommendations in the discharge
checklist. In the event that Corey fails to get access to the relevant fitness facilities in his
residence, a nurse can recommend for his discharge to be delayed. However, it the duty of a
registered nurse in charge to anticipate for such situations from the time the patient is
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admitted in the hospital. Observation of such finer politico-economic details only serves to
reduce discharge delays and readmission tendencies.
A registered nurse can incorporate an orthopedic doctor in the decisions made
towards the patient during discharge. In Corey’s case, an orthopedic doctor knows precisely
what is required for the patient to recover from the thigh injury. Also, an orthopedic doctor
can help the nurse in charge to recommend the activities and precautions that Corey should
adhere to for a holistic recovery. According to Nancarrow, Booth, Ariss, Smith, Enderby
and Roots (2013), the interdisciplinary team member chosen should only serve to provide
professional guidance where needed. Moreover, a registered nurse can incorporate a
pharmacist in planning of Corey’s discharge. With this consideration, a registered nurse has
a wide range of interdisciplinary members he or she can choose from depending on the
challenges that may be encountered in handling Corey’s case.
Conclusion
Clinical handover and discharge are two processes that are crucial for the wellbeing
of patients. Communication between the paramedics, the staff in the emergency department
and other interdisciplinary team members is vital for the safety of the critically injured
patients. Any communication breakdown in handover or discharge can have detrimental
repercussions on the medical team and the patients. However, the decisions taken by the
concerned clinical officers should be guided by the stipulated principles. For instance, the
information captured in IMST AMBO should not be evaluated in isolation without
corroborating its authentication. Since the patient’s safety is of high priority in the
emergency department, clinical officers are mandated to evaluate all factors that may
underscore their performance as caregivers.
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