As we mourn the death of Joan Rivers after a "minor" throat surgery and subsequent respiratory/cardiac arrest, I am reminded of the phrase I used to preach to my staff early on in this ambulatory movement. I remember working in the hospital recovery room managing 13 recovering outpatients a day mixed in with the inpatients. On this particular day one of the outpatients scrunched into the preop "holding" room was an 18 year old female coming in for a local D & C. I recall hearing the OR staff refer to her as "just a local." At that time the hairs on the back of my neck stood straight up, as subconsciously I registered that there couldn't possibly be "no such thing" as "just a local." Sure enough a few hours later, the doors from the OR corridor burst open and anesthesia propelled a bed on which lay this same young woman being bagged with an ambu bag. During the hand-off communication, the anesthesia resident advised me that she had experienced an apparent allergy to the local — lidocaine. It was touch-and-go for a while, but ultimately the allergic reaction abated.
When interviewing this patient in preparation for her discharge, I queried her regarding any previous such reactions. She confided in me that she had undergone some recent dental work during which she had experienced problems with her mouth swelling, etc. She allowed as how she had not told the physician or the anesthesia provider because she didn't think it was important — BUT, neither had they ASKED!!! We clearly could have lost this patient just from the lack of a detailed preoperative history.
The collecting of a thorough preoperative history as part of the preop assessment is a challenge always, whether the patient is an inpatient OR an outpatient. However, it becomes even more crucial in the outpatient setting where the amount of time allocated for the collection of data can be minimal in the face of busy, busy schedules, short staff, and the effort, and time, required to reach patients over the phone vs. visiting them in their hospital room. Nevertheless, such information is crucial in assuring patient safety and a safe outcome.
We do not know what the issue was with Joan Rivers. Was it a drug reaction?...a drug overdose?...some underlying, previously undetected condition? I recall the incident of a few years ago regarding an eight-year-old patient in one of the surgery centers. The child came in for PE tubes and an adenoidectomy. The patient had a history of Transposition of the Great Vessels which had been repaired during infancy. He was under the care of a cardiology, was active in school playing flag football, was symptom free of any lingering health problems.
A medical clearance was obtained from his cardiologist. The decision was made to do the tubes first followed by the adenoids using an LMA device to protect the airway. Bottom line, once the surgeon inserted the electrosurgery pencil (he made no incision), the patient bled out in a bit over one and ½ minutes. Even the post did not reveal what happened. The point is that we, who work in ambulatory surgery, must NEVER be complacent. We must NEVER assume that the procedure being performed is "just another PE tube, etc." We must NEVER assume that anything is routine. We must NEVER assume nothing will ever happen.
We must, rather be ever vigilant through all established processes. We must never assume that a detailed patient history/assessment isn't required. I hear so often that certain practices reserved for general anesthesia patients are not implemented for "just a local." At one time in the ambulatory industry, local patients did not have a comprehensive H&P performed. Rather, a "procedure specific H&P" was considered adequate. CMS put the kebash on that practice with the new regulations of 2009. Too often "just a local" can turn into a major disaster!
What can be done to decrease the possibility of a catastrophe occurring in the surgery center? I would suggest:
• Perform a comprehensive preoperative assessment on ALL patients. Demand that the patient's H&P have been performed within the last 30 days and that it adequately documents the patient's health status. I recently had an EGD performed at a corporate/physician owned "chain" center. No member of the ASC staff contacted me preoperatively to conduct a preop assessment, and during my preop visit with my physician (whom I adore and respect immensely), he spent most of the time at the desk across the room with his back to me filling out forms on the EMR. As a knowledgeable HCP I KNOW my health status, but I should have screamed, "Hey, LOOK AT ME! This visit was followed by my annual healthy patient visit. The same thing happened. This physician, who has been my FP for many years, listened to my heart in one spot on my chest, did not auscultate my lungs any further than what he might have heard while listening to my heart, did not palpate my ankles, my glands, my belly, didn't look in my ears,…but he sure did get that EMR filled out, and the lab requisitions! Is this happening to your patients?
As nurses, it is our responsibility to make sure that our patients are safe. It is our job to read that H&P. It is our job to collect a thorough patient assessment and to alert the physician/anesthesia provider to special conditions, or conditions not heretofore disclosed. Talk to the patient about previous medication issues from anesthesia to pain medications, to locals….all of it.
CMS says that the physician must update the H&P on the day of the procedure. Initiate a policy whereby the patient is not taken back to the OR unless the physician has been at the patient's bedside as required by CMS.
• Be alert regarding the drugs patients are being given. The nurse in the operating room is ultimately responsible for patient safety. Confirm with the anesthesia provider the drug and dosage. Observe the patient. Watch the monitors. We are getting reports that not only is the anesthesia provider playing on the Notepad, but the circulating nurses are also joining in this fun. Who is watching the patient?
Nurses complain about anesthesia not being vigilant during procedures. They complain about those games, the stockbroker calls, but what do they do about it?
Complete an incident report and forward it to your manager EVERYTIME you see inattention being given to the patient.
• Use those alarms! The Joint Commission and CMS continue to beat us over the head for failure to use the alarms in the centers. Use an alarm log. Walk through with your staff and identify every alarm in the center. Activate it such that all persons working in the center will recognize what the alarm sounding is …and where it is. Check those alarms to make sure they work. In the ORs, and PACU, make sure they are never turned down or off….and they continue to be turned off throughout the country. Perhaps the status of the alarms needs to be added to the Surgery Flow Sheet? Perhaps it is going to take a requirement for such documentation for it to be taken seriously.
• Check the equipment. Are you familiar with the equipment, its state of readiness for patient procedures, and its maintenance history? ADA receives numerous incident reports on an ongoing basis regarding malfunctioning equipment during a surgical procedure. Who in your organization is responsible for determining the equipment is in good working order PRIOR to its being used on a patient — PRIOR to the start of the case? Does your organization demand that an Equipment Assessment be performed on any and all pieces of equipment that either could cause injury to a patient during a procedure, or whose absence due to a breakdown, could cause harm to a patient? If so, how often is this information updated? Who reviews it?
Is it shared with staff members? Too often, we see it done just to meet a standard prior to a survey.
Finally, beware of ROTE! Beware of performing while on auto-pilot. This condition occurs where staff perform the same type of procedure over and over and over. The advantage is that they become experts in that procedure. The danger is that they can do the procedure "in their sleep"….kinda like driving home, pulling into your driveway and wondering how you got there 'cause you have no recollection of the drive home. This goes with being alert, but even more so.
In conclusion, remember nothing more than this: The patient is someone's child, mother, father, husband, wife, brother, sister, etc. His life is in your hands. You are his advocate, his Patient Safety Officer.
