HospitalInspections.org

Based on observation, document review, and interview, the staff failed to ensure that Anesthesia Services were provided in a well organized manner consistent with recognized standards of anesthesia care. Specifically, the facility failed to:
(a) Follow protocol for initiating cardio-respiratory arrest code.
(b) Report, communicate, and escalate changes in patients' vital
signs.
(c) Provide consistent documentation of patients' vital signs on the Cardiac Monitoring Strips and Anesthesia Records.
(d) Ensure patient vital signs are stable prior to start of anesthesia induction.
(e) Develop and implement a policy that address patients who are unstable
for surgery.


These failures place all patients at risk for potential harm.


Findings include:

See Tag A1002

Based on document review and interview, in two (2) of 22 medical records reviewed, (a) the facility did not ensure that patients' vital signs were stable prior to start of the anesthesia induction, (b) failed to report, communicate, and escalate change in patients' vital signs, and (c) failed to initiate resuscitative measures for patients with cardiopulmonary emergencies.
(Patient #1 and #2)


Findings include:

Review of Medical Record (MR) for Patient #1 identified a 65 year old female admitted electively on 10/5/16 for a cataract extraction of right eye.

The Pre-surgical History and Physical Exam Form dated 9/13/16 documented vital signs as Blood Pressure (B/P) 100/56, Pulse 63, and Respiration 18.

The Nursing Pre-Procedure Assessment dated 10/5/16 at 8:20 AM documented vital signs as Blood Pressure (B/P) 135/84, (Normal range: 90/60 to 120/80); Pulse 53 (Normal range: 60 to 100); Respiration 18 (Normal range: 12 to 18).
There was no documentation that the nurse communicated patient's low pulse to the physician/surgical team.


The Pre-Anesthesia Assessment dated 10/5/16 at 9:00 AM documented vital signs: B/P 168/75, Pulse 50, and Respiration 16. The patient's Anesthesia Risk Assessment was Category II (A patient with mild to moderate systemic disturbances that may or may not be related to the reason for the procedure).
There was no documentation that the anesthesiologist communicated the abnormal vital signs to the physician/surgical team, and that the patient was reevaluated for the low pulse rate prior to surgery/induction.


Documentation in Surgical Safety Checklist dated 10/5/16 lacked evidence that the low pulse was addressed prior to procedure.


The facility failed to ensure that the patient's low pulse was communicated, and patient was reevaluated by the surgical team.


On 10/28/16 at 9:10 AM, during interview with Staff A, Eye surgeon, this staff member stated that the patient had a planned cataract extraction of the right eye. She acknowledged being aware of the low pulse rate but stated, "I was not concerned because some patients run a pulse rate in the 50's."


The Operating Room Record documentation for Patient #1, dated 10/5/16, showed anesthesia started at 8:50 AM and ended at 10:14 AM.

The Cardiac Monitoring Strips documentation dated 10/5/16, showed that the patient remained with a low heart rate through out the procedure.
For example:
At 9:00 AM - Heart Rate 49
At 9:02 AM - Heart Rate 51
At 9:04 AM - Operation started
At 9:05 AM - Heart Rate 46
At 9:08 AM - Heart Rate 57
At 9:10 AM - Heart Rate 56. No Blood Pressure recorded.
At 9:15 AM -Heart Rate 0. No Blood Pressure recorded. No initiation of resuscitative measures documented.
At 9:16 AM - Operation ended.

No heart rate or blood pressure was recorded at 9:20 AM and 9:25 AM. No rescue measures were noted.

At 9:30 AM, Cardio-Pulmonary Resuscitation (CPR) was initiated by responding anesthesiologists, Assistant Director, and another anesthesiologist.
This represent a delay of approximately 30 minutes from 9:00 AM when heart rate began to decline, until 9:30 AM when assistance arrived. There was no documented evidence that a Rapid Response or Code Blue (Cardiorespiratory Arrest Code for assistance) was called.


Review of the Anesthesia Record dated 10/5/16 indicated that patient received Narcan, Flumazenil, Epinephrine, and Atropine. The times that these drugs were given, and the call for assistance were not documented.

During interview with Staff A, Eye Surgeon, on 10/28/16 at approximately 9:10 AM, staff stated, "I was never informed that there were any problems during the procedure, nor did I hear any alarms go off. I left the room and I went onto the next case. I was never informed by the CRNA (Certified Registered Nurse Anesthetist) that there was a significant change in the patient's vital signs. As the Surgeon, I was focused on the eye." She acknowledged being aware of the low pulse rate but stated, "I was not concerned because some patients run a pulse rate in the 50's."

Interview with Staff H, Supervising Anesthesiologist, was conducted on 10/27/16 at 10:10 AM. Staff acknowledged that he was aware of the patient's low heart rate. When asked if this patient usually has a low heart rate, he could not recall. He could not recall if he was in the room at the start of the case. Staff stated that he did not receive a call from the CRNA during or after the procedure. He did not hear a Rapid Response Code nor did he hear a Code Blue (Cardiopulmonary Arrest Code) called at any time.

On 10/28/16 at 10:45 AM, Staff F, responding Anesthesiologist (Assistant Director), was interviewed. He stated that the staff called him to OR #17 for assistance. He stated that when he entered the Operating Room, the patient was unresponsive and a dusky or purplish color. He noticed that the patient was not attached to any monitoring devices at the time. He immediately started CPR since he realized that the patient had no pulse. There was only one EKG complex. He called for additional assistance and the anesthesiologist who intubated the patient without difficulty. When asked why a code wasn't called he replied, "We are the code team."

The facility staff was unable to provide information when the patient was removed from the monitors, and by whom.


The facility failed to ensure that patients were appropriately monitored, changes in cardiopulmonary status identified and communicated to the surgical team, and that resuscitative measures were initiated timely.



2. Review of Medical Record (MR) for Patient #2 identified a 67 year old female admitted for right hand third digit trigger finger release on 8/30/16.

The Pre-surgical History and Physical Exam, dated 8/23/16, documented vital signs as: Blood Pressure 108/72, Pulse 68, and Respiration 16.


The Anesthesia Record documentation showed Patient #2's anesthesia induction started at 8:14 AM and ended 9:23 AM.

The Cardiac Monitoring Strips documented the patient's vital signs during this period as follows:

At 8:25 AM - Heart Rate 80, Blood Pressure (BP) 87/53 (Normal range: 90/60 to 120/80). There was no documentation that the low blood pressure was identified and communicated to the surgical team.

At 8:30 AM - Heart Rate 37 (Normal range: 60 to 100), No B/P was recorded.
There was no documentation that the patient was identified as having a cardiopulmonary emergency. No resuscitative measures were implemented.

Documentation did not indicate that the anesthesiologist communicated the patient's physiologic status to the surgical team and surgery proceeded.

At 8:31 AM - Operation started. Heart Rate 47.

At 8:35 AM - Heart Rate 43. Anesthesia Record documentation indicated glycopyrrolate (arrhythmia preventing agent) was given at approximately 8:35 AM. No B/P was recorded. Surgery ongoing.

At 8:40 AM - Heart Rate - below 30. No B/P was recorded.
Atropine (to increase heart rate) was given. There was no indication that a Cardiopulmonary arrest Code (Code Blue) was called at this time. Surgery was ongoing.

At 8:41 AM - Resuscitative drugs were administered.
At 8:44 AM - Operation ended; Code was called.

There was a fourteen (14) minute delay from 8:30 AM, when documentation indicated that the patient had a cardiopulmonary emergency, to 8:44 AM when code was called and team responded.


During interview with Staff B, Hand Surgeon, on 10/27/16 at approximately 2:53 PM, when asked if he was aware of his patient's cardiac changes and if he heard any alarms, he stated, "I was not aware, I was concentrating on the hand." He further stated that the anesthesiologist did not inform him of his patient's cardiac changes, and he was not aware of the Code, as he was not in the room when it happened.


During interview with Staff C, Anesthesiologist, on 10/27/16 at 3:45 PM, she stated the patient was given an arrhythmia preventing agent (glycopyrollate, 0.4 milligrams) post MAC-anesthesia, however, she was unable to recall the time. She stated that she wanted to bring up patient's heart rate during the procedure. She had no recollection of notifying the surgical team of the patient's heart rate and calling for assistance.