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News: Due to injuries suffered from a car accident, hospital staff inserted a tracheostomy tube to aid the breathing of a 17-year-old male. While still in the hospital one month after the tracheostomy, hospital staff removed the tracheostomy (trach) tube in anticipation of the patient's transfer to a rehabilitation hospital. However, upon removal the patient began experiencing difficulty breathing and tachycardia, and the tube was subsequently reinserted. Despite difficulty breathing without the trach tube, the patient was transferred to a rehabilitation hospital, where the tube once again was removed. Shortly thereafter, the patient went into respiratory distress and ultimately suffered anoxic brain injury. The boy's parents brought suit against the rehabilitation hospital and family practice physician who oversaw the removal of the trach tube, and they alleged negligence. The jury returned a verdict in favor of the plaintiff for $15.26 million after a month-long trial.
Background: Following a serious car accident, the 17-year-old male was admitted to a local hospital where a tracheostomy was performed. A tracheostomy is a surgical procedure in which a physician creates an airway by making an incision in the trachea. A tube is then inserted as an airway and to allow easy removal of secretions from the lungs.
Over the next few weeks of stabilization in the hospital, the boy's condition improved. The trach tube subsequently was removed. However, the boy experienced extreme difficulty breathing without the tube, so the tube was inserted again. Shortly thereafter, medical tests indicated that there was swelling in the patient's airway, but no treatment was provided to reduce the swelling. Capping off of a trach tube is standard practice before a patient's trach tube is removed. Generally, capping off trials are done to determine if a patient is able to tolerate the removal of the trach tube. If the patient does not respond well, the trach tube should not be removed at that time.
Eventually the patient was transferred to the rehabilitation hospital with direct orders that he return in two weeks to the hospital's surgical clinic for a checkup and to evaluate plans to downsize and cap off the trach tube. However, the appointment was not kept, and the boy was not evaluated by the hospital for removal of the trach tube. Instead, the rehabilitation personnel took initiative and starting capping off of the trach tube without advice or consent of the hospital's surgeon.
In this case, the boy experienced tachycardia and labored breathing after capping off of the trach tube. Despite this inability to tolerate the capping off trials, the family practice physician at the rehabilitation hospital decided to remove the trach tube. The boy continued to complain of difficulty breathing after removal of the trach tube, but the tube was not reinserted. The following morning, the boy complained that he felt as though something was stuck in his throat. No further tests were conducted. That same day the family practice physician administered a benzodiazepine to relax the patient and to allow for rest. Unfortunately, several hours later the patient went into respiratory distress. After waiting more than 20 minutes to call an ambulance, the patient was taken to the hospital; however, anoxic brain injury already had been sustained.
Additional testing showed that the boy had suffered subglottic stenosis. Subglottic stenosis occurs when there is a narrowing below the vocal chords and above the trachea. The underlying cause of the narrowing must be addressed to prevent any further complications. In this case, despite the boy's complaints that he felt like something was stuck in his throat, the rehabilitation facility made no attempts to treat or discover the cause of this feeling. Thus, it went untreated, which resulted in decreased ability to breathe.
The parents of the boy brought suit and alleged that the rehabilitation hospital and the family practice physician failed to replace the trach tube or otherwise act before it was too late to prevent the anoxic brain injury. On July 3, 2013, after five weeks of testimony and 3-4 hours of deliberation, the jury found the physician and the rehab hospital negligent and awarded $15.26 million in damages.
What this means to you: This case highlights the need for communication. Had the staff members at the rehabilitation facility and the family practice physician maintained proper communication with each other, they might have been able to address the patient's concerns, specifically the patient's inability to tolerate the removal of the trach tube and narrowing of his airway.
A young person who has been breathing with the assistance of a tracheostomy tube should be able to be weaned off the tube fairly easily if there has been no local injury to the neck area. In this case, the fact that the patient developed respiratory distress following the first attempt at removal was significant. The noted swelling below the vocal chords might have been a reason to delay the transfer to the rehabilitation facility. However, if it was not treatable in the acute hospital, but a condition that would resolve itself in time, it should have been an indication to the receiving facility that the tracheostomy tube be left in place until the swelling had been assessed as resolved.
Before a patient from an acute hospital is transferred to a rehabilitation setting, typically a pre-admission assessment is done by staff in the receiving facility. This assessment includes a complete review of the patient's medical record and interviews with the patient and the patient's attending medical and nursing staff. The purpose is to ensure that the patient meets the qualifying requirements of the facility and can tolerate the rehabilitation program. Had this assessment been done as described, the receiving facility staff would have been aware of the patient's need to continue to breathe via the tube. Despite multiple complaints by the patient that he "felt something was wrong," the rehabilitation facility staff and the physician did not investigate further to find out if something was indeed wrong. Furthermore, because the rehabilitation facility staff and the physician were not communicating adequately with each other, they both failed to recognize changes in the boy's condition, namely the fact that he had been experiencing increased difficulty breathing during removal of the trach tube.
Another important point to be noted is that there must be adequate consultation with specialists anytime the patient's care requires knowledge outside of the physicians' scope of expertise and treatment capabilities. In this case, the rehabilitation facility failed to seek the assistance of additional specialists who would determine if there were any complications with the airway of the boy. Nor did the family practice physician ensure that the patient kept the appointment with the surgeon, as ordered to do so.
This tragic oversight could have been prevented had there been adequate communication by all medical staff. Here, the family care physician contended that she was not required to consult with a specialist prior to making the decision to remove the trach tube. The standard of care, however, is based on what a prudent medical professional would do under the circumstances. Physicians should request referrals and consultations from experts prior to making significant decisions related to a patient's care when the issues involved are not squarely within their areas of expertise. It is necessary to make it very clear that there is a professional medical standard of care that must be adhered to, and if current protocol does not appear to require it, perhaps that protocol should be reconsidered.
Lastly, and most importantly, it is crucial for orders from one medical facility to another be followed and implemented as ordered. In this case, orders from the hospital surgeon were not followed once the patient was transported to the rehabilitation facility. The orders were for the boy to attend a checkup two weeks after being transferred to the rehabilitation facility. Instead, the family practice physician made the decision to remove the trach tube without checking with the hospital's surgeon. The jury's verdict shows this decision fell below the required standard of care.
More generally, after transfer, admission orders usually are written by the receiving facility's physician based on the orders the patient had while in the acute hospital. What sometimes occurs is that the receiving nurse will transcribe orders from the medical records he or she receives from the sending hospital onto the order sheet used at the receiving facility. The new physician signs those orders as his or her own without a careful review of their relevance to the care of the patient. These orders seldom reflect the medical plan of care usually found in the physician's progress notes, which might or might not have even been sent with the transferring paperwork. This practice is not uncommon and is one that should be seriously reconsidered if happening in your facility.
When there are orders issued from one facility to another, a continuing and open line of communication also must be maintained to ensure that orders are followed exactly. Where there are differences in opinion as to those orders, medical facilities must ensure that physicians are required to consult and defer judgment to the appropriate specialist for that particular matter. Here, had the rehabilitation facility ensured that the hospital surgeon's orders were followed, costly mistakes would not have occurred without supervision by the appropriate specialist.