Breach of Protocol

Coroners reports are interesting.  I think there are many reasons for Doctors to read reports from the Coroner, although am sometimes frustrated that such reports

  • are a legal opinion, operating with total hindsight
  • usually fail to acknowledge the impact of system issues or outside influences (classically the impact of a busy shift, difficult diagnosis etc)
  • is an inevitable result of a death…just think how many more ‘near misses’ there are out there which do NOT attract a Coroner’s investigation but for which important lessons could be learned

This week the SA Coroner ruled on the untimely death of a young woman with a coronary artery dissection.  The full report can be read here.  It is certainly not my intention to criticise the clinicians involved….nor the Coroner – but the case does raise some issues.  The Coroner’s recommendations were :

The iCCnet protocol is an excellent document and the system where remotely situated doctors can avail themselves of the advice of an on-duty cardiologist is excellent if it is duly implemented. I see no need to make any recommendations in this matter.”

That is a little disappointing as I think there ARE some other issues that could be explored in such cases.

Integrated Cardiovascular Clinical Network

I’ve written about this before, but for those of you unfamiliar, iCCNet is the brainchild of Dr Phil Tideman and team (follow Dr T on twitter @heartphilt).

Recognising the difficulty of ECG interpretation for unsupported rural doc, the iCCNet team offer a true ‘one stop shop’ for all matters cardiac.  A single phone line puts the rural doctor in touch with a consultant cardiologist 24/7. who can both advise on immediate management OR (sometimes more useful) smooth the referral pathway for timely investigation.

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The system is supported by point-of-care testing for Troponin T levels in rural EDs, with networked results for both this and other POC tests (as lab tests may take 12-24 hr turnaround in rural Oz). It goes without saying that ECGs are also shared electronically, meaning the cardiologist can report an ECG even if local doctor cannot.

In the old days (and indeed, interstate), the rural doctor has to ring a cardiology registrar and discuss the case…all well and good, although there is considerable heterogeneity in the quality of referrals and responses. The iCCnet system mitigates against this.

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It’s great that we have such a system for cardiology – my dream would be to see a similar setup for trauma radiology in country EDs, perhaps utilising the 24/7 services of the radiology or trauma service in the new Royal Adelaide Hospital…

The value of point-of-care testing is also relevant in this case – the troponin was elevated, yet in this sad case the clinician decided to ignore this and consider an alternative diagnosis.  POC tests are useful – but only if the clinician considers them, or has good reason to ignore.

Why then was there a breach of chest pain protocol in this case? I don’t know – I was not there. But perhaps we should consider two more issues.

Supervision of Juniors

Firstly the potential problems with relatively junior doctors working unsupervised in rural EDs – we wouldn’t allow a PGY3 doctor see such patients in a tertiary ED see such patients without immediate onsite supervision )Ed reg consultant, labs, imaging, specialist services). Is it reasonable to expect junior MOs to work unsupervised in rural EDs? Is this fair on patients?  But in the face of a workforce shortage, what else can we do? Unhelpful rules (no payment for supervisor attending) also work against safety in such matters, a fact which the Coroner did not explore in his report

Second, the fact that this breach of protocol (chest pain, raised troponin – a slam dunk for the iCCNet pathway) happened is puzzling.  Whilst the attending doctor is ultimately responsible for the patient, it seems in this case that experienced nursing staff may have had concerns.

Authority Gradients & Graded Assertiveness

What I think is fascinating is that there is little discussion of the influence of human factors or resus room management in Country Health SA.

Doctors and nurses rarely train together. There is no routine in situ sim of common presentations (ACS, sepsis, confusion, psych etc), nor is there explicit training on topics such as graded assertiveness and flattening authority gradients.

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C.U.S.S. your Clinician

So…the Coroner’s report – interesting reading and of course the feeling of yet another individual failing causing harm….

If we are SERIOUS about patient safety, we’d address some system issues

  • take a leaf from iCCNet and establish similar services – trauma radiology is ‘low hanging’ fruit
  • reassess the supervision requirements of junior MOs working in rural EDs and ensure there are adequate systems to provide support (mindful of rostering, workforce, fatigue and of course remuneration)
  • look more closely at the impact of human factors in preventing mishap. In this case, would a graded assertiveness approach (eg CUSS) have helped the nurse engage the clinician and seek a second opinion? I think regular in situ simulation involving all members of the healthcare team, covering common ED presentations, has the potential to raise the bar significantly

In short – think of how can mitigate system failures, not individual.  Plenty more work to be done in Country I think….









2 thoughts on “Breach of Protocol”

  1. Pingback: Breach of protocol  | Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds

  2. Great Blog as always Tim. Human factors “stuff” is always a great conversation piece. We teach PACE in our clinical education packages here regarding graded assertiveness (Probe, Alert, Concern, Emergency). It’s always a lively debate topic in a mixed discipline group of clinicians. Thanks for sharing.

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