PRACTICE PARTNER
department (ED) at Hospital A. He was
re-admitted with acute renal failure and
thrombocytopenia. Between July 28 and
July 29, his condition worsened, with in-
creased epistaxis and hypertension.
On July 29, he was found unresponsive
and a CT scan of his head revealed exten-
sive left-sided subarachnoid hemorrhage
with midline shift and cerebral edema. He
was transferred to the intensive care unit
(ICU). Later that day, he was transferred
to Hospital B where he was seen by neuro-
surgery and determined that he was not a
candidate for surgery. He was treated with
platelet transfusion and IV steroids and
then started on dialysis. On July 30, his
neurological condition continued to dete-
riorate and life support was withdrawn. He
was pronounced dead later that day.
The medical cause of death was deter-
mined to be intracerebral hemorrhage
secondary to thrombocytopenia complicat-
ing vancomycin therapy for the treatment
of diabetic foot ulceration.
The PSRC’s report focused its review on
issues associated with the discharge from
Hospital A, in particular the transition
process from hospital to home and manage-
ment of vancomycin administration and
monitoring in the community.
“There was no clear plan for vancomycin
monitoring and dosing adjustment after dis-
charge from Hospital A, including defined
roles and responsibilities for the various care
providers in the community (e.g., both van-
comycin and serum creatinine levels should
have been checked),” stated the report.
After discharge from Hospital A, CCAC
was involved in coordinating care for the
patient. Attempts were made to arrange for
a vancomycin trough level to be done on
Friday, July 26. This did not happen due to
administrative issues, including an incor-
rect fax number to obtain the correct signed
requisition from the ordering physician.
In records reviewed from Hospi-
tal A, there was no clear identifica-
tion of a requirement for moni-
toring of vancomycin levels and
plans for dosing adjustments on
Care in the
discharge. In hospitals, monitoring
of vancomycin levels is typically
community is
looked after by pharmacists. In this
complex and
case, it appears that the CCAC and
requires clear
the pharmacy service provider did
not have a standardized protocol
communication
for the monitoring of vancomycin.
protocols
This case highlights a number of
potential vulnerabilities associated
with providing medication manage-
ment services in the community,
stated the committee. “It is highly
relevant as Ontario moves to increase both
the number of patients cared for in their
own homes and the complexity of the care
provided in the home setting. Hospitals,
CCACs, primary care providers and phar-
macy service providers must work together
to develop reliable systems to ensure that
patients being discharged can be appropri-
ately and safely cared for in the home setting
and that rapid intervention is available if
their clinical condition deteriorates,” the
report stated.
ISSUE 4, 2018 DIALOGUE
41