practice partner
determined that the patient had a total large
bowel obstruction from the distal colon to the
sigmoid. Megacolon from childhood was also
considered, but no evidence in the medical
history pointed to this. The physician then
ordered dimenhydrinate and morphine.
A call was made immediately to a surgeon
in Hospital B at 1459h and connected at
1504h where it was suggested that they contact Hospital C, as Hospital B was not able to
manage the patient appropriately due to the
degree of his obesity. A call was made to Hospital C at 1509h which was returned “fairly
quickly” (no time was provided) but there
were no beds available there either. A call was
then placed to CritiCall at 1601h in order to
identify a receiving facility.
During this time, blood work results were
received which included a white count of
14.4 with neutrophilis up at 13.2. Hemoglobin was 121, platelets were 550, sodium was
136, potassium 3.8, chloride 104, creatinine
57, urea 9.8, random glucose 8, total protein
66, albumin 31, AG ratio 0.9, conjugated
bilirubin less than 2, total bilirubin 4, amylase 13, AST 11, ALT 15, GGT 28, alkaline
phosphatase was 105.
Over the next hour, CritiCall contacted
four hospitals which had no beds. Physician
A documented that CritiCall found a bed at
Hospital D and the patient was accepted for
transfer at 1740h. Staff were asked to prepare
for transport. Physician A completed his shift
and left the ED at 19:00 without handing
over the patient as transfer arrangements were
made and the patient was to be transferred to
general medicine.
At approximately 1915h the patient came
up to the nursing station, reporting severe
pain and shortness of breath. He pulled out
his nasogastric tube and intravenous, and told
his mother he could not breathe. At 1925h
his pulse was noted to be weak and his lower
legs appeared mottled. Morphine 4mg was
given for pain. At 1945h Physician A (who
had now left the hospital) was called and
directed that the patient be transferred Code
4 to Hospital D. Physician B (the emergency
physician now on-duty at Hospital A) called
CritiCall at 2018h to give an update on the
deteriorating condition of the patient and
at this point CritiCall began to search for a
intensive care unit (ICU) bed. Over the next
30 minutes, CritiCall contacted three hospitals
in an effort to find an ICU bed; however, a bed
was not immediately identified.
The patient continued to deteriorate and
resuscitation measures were instituted. He became asystolic at 2139h and was pronounced
dead at 2145h.
The PSRC noted that the initial trans“CritiCall
fer acceptance was received at 1740h but
it was unclear as to why the patient still
should review
had not been transferred to Hospital D
their process
before his condition started to deteriorate
for accessing
at 1915h. The transfer was upgraded to a
Code 4 when the individual’s condition
specialized
worsened; however, when Physician B
beds for
informed CritiCall at 2034 of the degree
of deterioration, there were no appropriate surgical care of
ICU beds available at any of the locations obese patients”
contacted.
Timely access to ICU beds must be
ensured for patients with life-threatening
conditions, PSRC’s review stated. CritiCall
was not able to secure an ICU bed for this
critically-ill and unstable patient. While this
may be improved through the recent implementation of the Provincial Life or Limb
Policy, close attention needs to be paid to this
issue in order to ensure that timely access has,
in fact, been achieved. Ongoing evaluation
and adjustments to this process will be critical
to ensuring its success.
The purpose of the Patient Safety Review Committee (PSRC)
is to assist the Office of the Chief Coroner in the investigation, review and development of recommendations towards
the prevention of future similar deaths relating to healthcarerelated cases where systems-based errors appear to be a major
factor and to assist coroners in improving the investigation
of deaths within, or arising from, the health-care system in
which system-based errors appear to have occurred.
Issue 3, 2015 Dialogue
45