Case Study: Analyzing Patient Deterioration and Management Strategies

This report presents a comprehensive analysis of a patient deterioration case, specifically focusing on the death of a 15-year-old girl, Jenny Whyte, due to meningococcal septicaemia. The study examines the recognition and response to patient deterioration, evaluates the case study, and identifies situational factors and points of incorrect care. The report delves into the patient's condition, management recommendations, and the complexities that contributed to the outcome. It highlights the legal and ethical issues missed in the case, such as the principles of beneficence and non-maleficence, and the failure to adhere to relevant standards. The report concludes with recommendations for improvement, including implementing a helicopter view leadership strategy and a track and trigger system, to reduce future errors in patient deterioration. The study emphasizes the importance of early recognition, effective communication, and skilled healthcare practices to ensure patient safety and improve outcomes.

MANAGING COMPLEX PATIENT
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Table of Contents
Introduction........................................................................................................................ 3
Recognition and response to deterioration in complex client...........................3
Case study evaluation...................................................................................................... 4
Understanding patient condition and management recommendations.................4
Identifying situational factors and point time where care was incorrect...............5
Identifying Patient-complexities contributed to outcome..........................................6
Outlining Legal and ethical issues missed in case..........................................................6
Recommendations for improvement in trigger points to reduce future
errors in patient deterioration..................................................................................... 7
Conclusion........................................................................................................................... 9
References......................................................................................................................... 11
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Introduction
Patient deterioration has become a common or casual phenomenon due to
increasing complexity in hospitalized patients as well as lacking professional
expertise in health services. Around 17% of hospitalised patients experience adverse
event in their complete duration of hospital stay (Pocock, 2013). According to Lambe,
Currey & Considine (2016) studies patient deterioration is one of the main reasons for
increased mortality and morbidity as per Australian Commission on Safety and
Quality in Health Care statistics.
This study aims to demonstrate, evaluate and understand one such patient
deterioration care that ended into the death of the patient named Jenny Whyte. The
complete case is critically analysed followed by providing recommendations that can
help to avoid or manage such deterioration event in healthcare practices.
Recognition and response to deterioration in complex client
Recognition and response are two strategic concepts that directly aim to
ensure patient safety avoiding the risk of deterioration (Potter et al. 2016). According
to Odell (2015) studies recognising in healthcare services involves determining the
patient data, assessment of patient health information (primary, secondary health
data), patient education and critical patient observations. Further, recognising process
is completed with measurement and documentation of patient data.
Secondly, responding involves situation awareness, effective communication,
and knowledge transmission, providing support care services, processing patient
information with teamwork and avoiding any kind of risk to the patient (Fayers &
Machin, 2013). According to Barker, Rushton & Smith (2015) studies an effectively
recognised and responded patient case will involve the minimum chance of
emergency admission, long-term hospitalization or patient deterioration. Osborne et
al. (2015) studied about the National Safety and Quality Health Services (NSQHS)
standard 9 that is “Recognising and Responding to clinical deterioration in acute
healthcare”. This standard aims to ensure proper recognition and response to patient
deterioration. The four criteria that hospitals need to follow as per this standard are
installing recognition and response systems, diagnosing clinical deterioration,
escalating care, acting to clinical deterioration and proper communication with
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patients and carers.
The early recognising and responding to patient deterioration using effective
action implants improved patient outcomes, minimises the level of deterioration,
stabilises patient condition, lessen required intervention effort as well as avoid the
condition of death. The process of recognition and responding surely addresses all of
these factors across every area of a healthcare facility (Potter et al. 2016). The present
study helps to understand the importance of early recognition and responding to avoid
the condition of deterioration that occurred in case of the patient, Jenny Whyte.
Case study evaluation
Understanding patient condition and management recommendations
In the provided patient deterioration case Jenny Renne Whyte was a 15-year-
old girl admitted to the emergency department complaining headache, dizziness,
aches in legs and arms. Jenny confronted deterioration condition due to negligence,
malfunction and situational factors in healthcare service. As per condition analysis,
Jenny was suffering from meningococcal septicaemia, which is a serious, and life-
threatening condition caused by infection of Neisseria meningococcal bacteria in
bloodstream. The initial vital signs and symptoms of Jenny clearly indicated about
meningococcal disease. As per Considine & Currey (2015) studies fever, headache,
rapid breathing, severe aches, vomiting and rashes on the body are most simple signs
of meningococcal infection. Jenny was complaining about the similar condition when
admitted to hospital. Further, bacterial infection was already rife in Jenny’s town
indicating a requirement of serious action. The vital signs of Jenny involved a high
pulse rate, increased respiratory rate and low blood pressure. In case of Jenny, these
vital signs and symptoms got worse with time creating patient deterioration. Lastly,
Jenny faced breathing difficulties with no blood pressure readings confronting cardiac
arrest leading to death.
As per the patient condition analysis, the most essential management
recommendation involves assessment of primary and secondary vital signs which is
missed in case. The Jenny’s health condition requires blood culture analysis (blood or
cerebrospinal fluid test) followed by meningococcal PCR analysis (PCR testing)
(Mochizuki et al. 2017). After PCR reports a CSF test should be performed to
determine gram stain (gram negative diplococcic). But, antibiotic treatment should not
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be avoided to obtain CSF results because Trinkle & Flabouris (2011) indicated that
meningococcal bacteria start to disappear within 24 hours if proper antibiotic
treatment is implemented on time. In case of Jenny, the vital signs and symptoms
highlighting bacterial infection were avoided completely leading to deterioration. The
antibiotic treatment (flucloxacillin or ceftriaxone 50mg/kg, max 2g or benzylpensillin
60mg/kg, max 2.4g) and fluid resuscitation would have avoided the severity of
bacterial infection in Jenny’s case. The antibiotic treatment should last minimum 5-7
days (Pocock, 2013).
According to Campbell et al. (2016) studies Meningococcal disease spreads
from person to person through respiratory droplets, therefore, hospital staff needs to
take necessary personal precautions as well as keep patient under isolated conditions.
In case of Jenny, proper isolation and droplet precaution is another mandatory
management condition to avoid deterioration. Further, management requires
implementing respiratory support because Jenny was confronting breathing
difficulties and norepinephrine warm shock to correct hypotension (lower blood
pressure) avoiding cardiac arrest criticalness (Hart et al. 2014). Jenny should be
shifted to ICU followed by a proper blood test to avoid deterioration.
Identifying situational factors and point time where care was incorrect
The arrival of Jenny to the emergency department involved highlighted vital
signs that were not properly monitored and no proper comprehensive assessment was
performed related to these vital signs. Further, ED nurse didn’t even call emergency
and neither added scoring to ADDS chart in the emergency department. Even the
assessment session by the doctor in ED department missed orders or test related to
vital signs clearly identified in the initial admission of Jenny to ED. Hence, Jenny’s
vital signs got worsen with time till evening in the emergency department.
Further, ED nurses provided no clear plans or handover after Jenny’s transfer
in the hospital ward at evening 6 o’clock. There was a missed bedside rounding after
admission to ward at 1800 hr and staff performed no frequent observations. Further,
staff failed to call for help or emergency even after continuous worsening of vital
signs involving low blood pressure, increased respiratory rate a vomiting by Jenny in
the night at 2320hr. The next day at 0242hr, Jenny faced breathing difficulties but no
ventilator was provided to control this emergency condition.
The deterioration in Jenny’s case occurred due to situational factors where the
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emergency department of the hospital was full due to dehydration and electrolyte
imbalance. Further, there was a shortage of staff in the hospital because the town was
facing Gastroenteritis rife creating maximised sick leaves by hospital staff. Most of
the implemented staff was having less than 3 years experience. Therefore, high
workload, mismanagement, staff shortage and exhaustion created deterioration. There
was failing in proper communication, teamwork and proper leadership approach. The
nursing staff fails to perform proper recognition unable to use ADDS score chart,
inadequate nursing skills and lacking experience.
Identifying Patient-complexities contributed to the outcome
Some of the patient complexities that contributed to the deterioration in
Jenny’s case involved inadequate assessment performed by nursing staff followed by
the improper handover of patient information from emergency department to the ward
staff that highlights poor communication and documentation in hospital. Further, there
was no family member of Jenny present all over the hospital admission process to
report or identify the mismanagement in the handling of Jenny’s case. Even at the
time of death, no family member of Jenny was present, the doctor called her mother
after Jenny passed away on 4th August afternoon in the hospital.
Outlining Legal and ethical issues missed in case
The ethical missed In Jenny’s case involved non-maleficence and beneficence.
The ethics of beneficence instruct healthcare professional to benefit the patient in all
possible manner and situation (McKenna et al. 2014). In Jenny’s case, healthcare
professionals in their assessment, diagnosis, management and communication process
missed ethic of beneficence. The professionals avoided various vital disease signs and
symptoms that clearly highlighted the occurrence of the emergency condition. No
oxygen support, ventilator and medications were administrated from Jenny’s complex
conditions like breathing difficulties, low blood pressure, rashes etc.
Further, the ethical principle of non-maleficence is also missed in this case,
which indicates that it is a primary duty of healthcare professional to ensure “no
harm” to the patient. In this case, nursing staff mishandled Jenny (Jenny was allowed
to use mobile), avoided emergency situations to call doctor, careless attitude in the
ward observations etc. clearly highlight a miss in non-maleficence ethics.
Further, legal obligations, in this case, involve miss to Safe Patient Care Act
2015, National standard: 9 by NSQHS “Recognising and Responding to Clinical
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Deterioration in Acute Health Care” and NMBA standard 4 “Comprehensive conducts
assessments” (Pocock, 2013). The hospital and professionals in Jenny’s case have
missed all these legal practices implemented as a duty of conduct in their profession.
They missed providing proper professional care to Jenny, followed by improper
recognition and responding in the care process. Lastly, the patient assessments were
either missed or improperly performed by the nurse in hospital confirming these legal
obligations in Jenny’s case.
Recommendations for improvement in trigger points to reduce future errors in
patient deterioration
As per conditions in the provided case study of Jenny, there is a requirement
of proper management strategies and techniques to overcome issues triggering patient
deterioration. According to Newman, Patterson & Clark (2015) studies, acute care
hospitals in Australia are now confronting complex patient problems that require the
special approach to handling with care. As per one survey, 4.5% patient in hospital
meets clinical deterioration at some point or other. The present case of Jenny is also a
clear case of patient deterioration leading to death. The trigger points leading to this
situation of Jenny are lacking team-work, improper leadership, unskilled staff,
negligence, improper communication and management in the hospital.
The most suitable form leadership strategy for the provided case study is
implementing helicopter view phenomenon in the hospital (Barr & Dowding, 2015).
According to Tume, Sefton & Arrowsmith (2014) studies the helicopter view in
leadership is the most contemporary and advanced form of leadership strategy that
works effectively in companies or structures having a huge human resource like
hospitals, corporates, airlines etc. Newman, Patterson & Clark (2015) opine that with
helicopter view leadership, one can get a view from different angles, aspects,
structures and perspective to implement successful working of the organisation. In the
present case of patient deterioration, there was a missing hold to the condition
variable factors. No person or professional was answerable for the death of Jenny due
to missing helicopter view in leadership. To overcome patient deterioration because of
small issues it is required by the hospital to implement helicopter view leadership
where one professional is responsible for delegating the task to staff members,
implementing team plans, collecting information from staff, cross-checking and
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detecting emergency (Lavoie, Pepin & Alderson, 2016). This recommended
leadership strategy works to address “Governance for safety and Quality in Health
Service Organisations” standard by NSQHS. As per this standard, every organisation
requires a specific management framework to ensure quality of the health service
organisations ensuring safety.
Another recommendation suitable to manage patient deterioration case like
Jenny is implementing “Track and trigger system”. This system is basically an early
warning system constructed to support early clinical deterioration identification
involving periodic vital signs measurement (tracking) and calling response or
emergency help (triggering) when a marked threshold is identified in particular case
(Romero-Brufau et al. 2014). There are four types of track and trigger system
recommended by NICE in 2007 that are single parameter, multiple parameters,
aggregate scoring and combination system. The implementation of the system
depends on the clinical condition of the patient. In the present case, Jenny was having
more than one disturbed vital sign, therefore, the track and trigger system suitable for
this case is “Multiple parameter systems” because this system provides a response for
more than one criterion to be met. The medical emergency team (MET) dealing with
more than one parameter is called for help through this system (Simpson, 2016).
According to Romero-Brufau et al. (2014) studies, the single parameter
system is generally used in the Australian hospitals and an aggregate scoring system
is used in hospitals of the United Kingdom. But, Australian healthcare is working to
upgrade its system to multiple and combination track and trigger system. Through the
multiple and combination system, a core set of parameters like respiratory rate, pulse,
blood pressure, temperature, oxygen saturation and urine output are easy to be
measured at the same time allowing better control over patient deterioration. In the
present case Jenny was facing an issue in more than one vital sign with low blood
pressure, high respiratory rate and no urine output that required emergency call but
due to the missing system the staff was not able to call for emergency help or are
unaware about emergency calling system. Therefore, multiple track and trigger
system can be considered a best recommendation to control patient deterioration.
According to Bunkenborg et al. (2014) studies, this multiple track and trigger system
is a part of NSQHS standard “Recognising and Responding to Clinical Deterioration”
working to establish recognition and response system missing in the acute care
process of Jenny.
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Further, Tobiano et al. (2017) studied the use of communication tools in health
care practices that work to escalate information between team members. One of the
most successful communication tools controlling patient deterioration condition is
RSVP (Reason, Story, Vital signs and Plan). This communication tool is designed for
emergency and involves easy techniques to remember information allowing the
appropriate call for an emergency at the appropriate time. RSVP communication tool
is suitable for acute life-threatening event recognition and treatment (ALERT). The
condition of Jenny can be considered as an ALERT condition because her blood
pressure went very low with 24 hours of duration followed by difficulty breathing and
cardiac arrest. Therefore, RSVP is a vital sign based communication tool that can help
nursing staff to initiate proper communication getting emergency help in Jenny’s
deterioration case.
Lastly, the situation factor of lacking experienced nursing staff that lead to
deterioration of Jenny’s condition in the provided case can be overruled by providing
a stand-alone course to nursing staff that is developed to enhance recognition,
responding, communication and management of adult patients facing critical
conditions (Hargestam et al. 2013). This course was first practised in Portsmouth
Hospital, United Kingdom as a part of short and quick nursing education to staff
handling emergency cases (Potter et al. 2016). In the provided case, the situational
factor of work overload and lacking skilled staff can be overruled by providing this
quick and short education to less experienced nursing staff. This staff education will
help to overcome patient deterioration in case of medical emergency situations like
Jenny’s case. These can be considered as some of the best recommendations to
overcome reasons that developed deterioration situation for Jenny. These
recommendations helicopter view leadership, track and trigger system, RSVP
communication tool and staff education can help to avoid further patient deterioration
in medical premises facing any such case as Jenny’s death.
Conclusion
A proper system of recognition and response is a mandatory requirement to
control the patient deterioration condition allowing a proper system to handle critical
illness, patient observations, and team communication and asking for help. The
provided case about Jenny Renne Whyte is clearly a deterioration case occurred due
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to negligence by staff, improper communication, lacking skilled staff, missing
leadership, recognition and response system within hospital along with various other
situational factors that resulted in patient’s death. These issues in the patient handling
also missed ethical and legal obligations of non-maleficence, beneficence ethics as
well as National standard 9 & 4 provided by NSQHS.
The study involves identification of certain recommendations to get a control
over such deterioration cases. The provided recommendations are as per issues
identified in case of Jenny but these recommendations can be implemented in any
case scenario avoiding the situation of patient deterioration. The recommendations
involve helicopter view leadership, track and trigger system, RSVP communication
tool and staff education to get a control over severe patient deterioration.
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