Case 29 A difficult transfer
Sophie, a 3-year-old girl, attends ED in the evening with a high fever and a history of insect bites. At triage she has a temperature of 40°C, a heart rate of 185/min, CRT of 3 seconds centrally and 4 seconds peripherally, a respiratory rate of 28/min and a SaO2 of 97% in air. She is confused, not recognizing her parents.
Sophie is taken to the resuscitation bay and the paediatric team are asked to come immediately to see her.
The paediatric registrar manages to establish iv access and collects blood for baseline tests, including blood culture and venous gas. The registrar confirms that Sophie is clinically shocked and gives 20 ml/kg of 0.9% saline.
The venous gas shows a pH of 7.19 (normal 7.35–7.45), pCO2 of 3.5 kPa (4.0–6.5 kPa), BE -7 mmol/L (+2.5 to -2.5 mmol/L) and a lactate of 5 mmol/l (<2 mmol/L). The registrar also fully examines Sophie and finds that the left thigh has an area of firm induration surrounding an insect bite with tracking cellulitis and inguinal lymphadenopathy. He asks the ST1 to prescribe iv ceftriaxone (for sepsis) and iv flucloxacillin (for possible Staphylococcal infection).
On reassessment Sophie’s heart rate has fallen to 150/min, while the CRT has improved to 2 seconds centrally and 3 seconds peripherally. The registrar gives a second 20 ml/kg bolus and following this Sophie’s observations all normalize and she calms down and responds appropriately to her parents.
A plan is made to admit her to the ward with a diagnosis of early sepsis secondary to cellulitis for iv antibiotics and monitoring.
Is this a reasonable course of action?
Approximately 45 minutes after Sophie was last seen by the paediatric team, the ED nurses prepare her for transfer. The cannula inserted by the registrar stops working during the last third of the second antibiotic infusion. This information is communicated to the ward nurses prior to Sophie’s transfer to the ward.
During the transfer from the ED to the ward the nurse accompanying Sophie notices that Sophie is becoming confused again. She attempts to take a repeat set of observations, but Sophie is too distressed and routine observations cannot be properly done.
They arrive on the ward just before handover. The ED nurse informs the ward nurse that Sophie is becoming increasingly confused and that the cannula has stopped working. The ED nurse asks the ward nurse to inform the registrar of this. Sophie’s mother, informs the nurses that she is going to the canteen to get some food, before it closes.
The ward nurse finds the registrar in the ward office as handover is about to start. She tells the registrar that the cannula has stopped working. The registrar confirms that Sophie has received the majority of the antibiotics before the cannula stopped working. The registrar tells the nurse that the night doctors will site a new cannula after handover.
Should further information have been provided by the nurse?
The doctors finish handover, which takes approximately 40 minutes. After handover the night ST3 goes to site a new cannula.
On entering Sophie’s cubicle, he finds that she is apparently asleep. However, when he starts to examine her, he realizes that Sophie is unresponsive. He pulls the crash bell and the night registrar and nursing staff enter the cubicle.
Sophie is found to have a heart rate of 180/min, a CRT of 4 seconds peripherally and centrally, and a respiratory rate of 35/min with a SaO2 of 94% in air. IV access is secured using an intra-osseous needle and she is given a further 20 ml/kg bolus of 0.9% saline, with no improvement. A full paediatric arrest call is put out this time and a further 20 ml/kg bolus is given.
She continues to deteriorate clinically, despite aggressive fluid resuscitation and inotropes and requires intubation and retrieval to the local PICU. However, Sophie goes on to recover and returns to the ward one week later.
The ED nurse subsequently learns what happened to Sophie and fills in an incident form, as the ward nurse failed to act on her concerns that the child was deteriorating on arrival to the ward. The mother goes on to complain that poor monitoring and care of her daughter led to her deterioration and the need for intensive care and that all this could have been avoided with good ‘proper’ care.
Expert opinion
The importance of communication errors in critical incidents has been long understood. Early work on this topic was carried out by the aviation industry with the development of Crew Resource Management (CRM) training, which focused on the non-technical skills needed to avoid critical incidents.
This training technique was later adapted by anaesthetists as Anaesthesia Crisis Resource Management (ACRM) and one of the main learning points was the importance of effective communication.
Within paediatrics, research has shown that communication errors are a common component of critical incidents, especially in PICU and during the transfer of critically ill children. There is an increasing use of simulation training to teach ACRM non-technical skills in paediatrics.
In this case, although the initial management of Sophie was entirely appropriate, there was a critical failure of communication. Firstly, between the two nurses and then between the ward nurse and the doctors. While it is impossible to say if there would have been a different outcome had this not happened, it is likely that Sophie would have been dealt with in a calmer fashion with a better outcome for all involved.
Legal comment
The cannula stopped working during the last third of the second antibiotic infusion. As a result of communication errors, nothing was done about it for an hour or more. Sophie then collapsed and required aggressive treatment in PICU for a week before she made a complete recovery. If the collapse was due to the cannula problem, which seems likely, then the hospital is liable for any unnecessary pain and suffering caused by the failure to deal promptly with that problem. Sophie’s collapse was dramatic, but she covered quickly and well. The damages will not be high. This case highlights a system error, and reinforces the importance of our mantra: communication, communication, communication!
