26 September 2014

The College is issuing a safety alert following an inquest into the death of a patient after a chest drain was inserted into the wrong side. A number of factors specific to the ED were shown to have contributed to this never event; failure to identify an incorrectly labelled chest x-ray, a failure to examine the patient prior to the procedure, a failure to review all chest x-rays and misinterpretation of the chest x-ray reviewed.

Senior teams within EDs are asked to reflect on the possibility of such an event occurring in their own department and ensure they have done all that is possible to reduce the risks associated with this procedure. The safer care committee has previously prepared guidance regarding never events but also refer you to the NRLS Rapid Response Report of May 2008 which addresses the risks associated with chest drain insertion. 

Would you consider ingestion of a button battery if a child were to present with a haematemesis?

The modern family home is likely to be littered with multiple devices and toys using button batteries. These are liable to be swallowed by small children and can present in a variety of ways including haematemesis.

Following a recent adverse event a Coroner has issued a regulation 28 notice which highlights the need for staff to be aware of the need to exclude ingestion of a button battery as a cause for upper GI bleeding in young children. This should occur even in the absence of a history of ingestion. Being aware of this presentation and undertaking the appropriate imaging is critical in ensuring the right management of such patients. 

Further information is available at the Toxbase website (for health professionals only). 

Would you recognise the signs of a patient suffering from an Addisonian crisis?

Fatal but avoidable Addisonian crisis is the second most common cause of death in patients with known Addison’s disease, accounting for 15% of deaths in patients with this disease.

It has recently been highlighted to NHS England that Patients continue to die because of a failure to recognise this condition and ensure patients receive appropriate steroids.

All staff working in the ED need to be aware of the how to avoid precipitating an adrenal crisis. See more here. 

What is the risk of intracranial heamorrhage in patients on warfarin who sustain head injury?

Although not a formal risk factor in NICE guidelines – there is clearly an increased risk which requires additional thought in the management of these patients. A recent “adverse event” review in Northern Ireland confirms the need to prioritise these cases within the ED; and any delay in assessment; investigation; and treatment of these patients should be avoided. Early CT scanning of all head injured patients on warfarin (irrespective of INR and GCS) appears to be clinically appropriate, with early reversal of INR to be considered in the balance of risk/benefit for the individual patient. Prothrombin complex concentrate should be rapidly available in the ED and be administered promptly when indicated.

With a normal initial evaluation normal initial CT and INR<3, the risk of delayed haemorrhage is <1%. A period of clinical observation in hospital for these patients may not be required but patients must have clear instructions to return. Prudence is advised in the management of head-injured patients on clopidogrel or novel anticoagulants. Insufficient evidence exists at present to provide robust specific clinical advice for these patients.
 
NICE guidance (updated Jan 2014) reflects the clinical justification for liberal use of CT in patients on warfarin. 

Recent BestBETs articles also succinctly summarise the issues:

• Coagulopathy as a risk factor in warfarinised head injury patients
• Observation is unnecessary following a normal CT brain in warfarinised head injuries: an update 

Summary of Reports to Prevent Future Deaths (formerly Rule 43 Reports)

The first report from the Chief Coroner on Reports to Prevent Future Deaths (PFD) covering the period from 1 April to 30 September 2013 has been published.

Under Schedule 5 paragraph 7 the coroner has a statutory duty to issue a report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths. Responsibility for the Reports transferred from the Ministry of Justice to the Chief Coroner on 1 April 2013. During this period, Rule 43 Reports were replaced by PFD reports on the implementation of the Coroners and Justice Act 2009 (the 009 Act), which came into force on 25 July 2013.

These PFD reports provide an opportunity to improve safety across all Emergency Departments as it is likely the events described will or could have occurred elsewhere. Senior teams should use this information to prospectively review local processes in order to reduce the risk of a similar incident occurring in their department.

In total 244 reports were issued in this period; 42 appear to be related to Emergency Medicine or the Emergency Departments. The key themes were:

• Training of staff
• Processes and practice related to admission, handover or referral
• Processes and practice related to discharge to community
• Clinical care
• Measurement and interpretation of vital signs
• Staffing levels
• Access to radiology
• Availability of medical records

More detail regarding individual circumstances can be obtained here.

Have you done all you could do to reduce the risk of a never event occurring in your ED?

Senior teams need to ensure they have done all that is possible to understand the possible risks in their ED and take steps to mitigate that risk. The occurrence of a never events is one risk where simple changes are likely to help reduce the opportunity for this to happen. A recent publication from NHS England focused on the surgical never events; many of their recommendations are applicable to the ED. This can be found here.

The Safer Care Team has previously prepared a guide which highlights the Never Events that could occur within your Emergency Department. This guide identifies events that should never happen but if they do should always be reported and fully investigated to identify learning.

This can be found here.

2 July 2014

Does your ED have all the necessary equipment to resuscitate a neonate?

All EDs need to stock readily identifiable and available equipment for the resuscitation of babies down to the size of 1.5kg. This must include standard airway, breathing and circulation equipment of the appropriate size, umbilical catheters, and a heat source.

The following links can assist you in accessing guidance:

• Resuscitation Council - please access ‘The Newborn Life Support Equipment list’
• Advanced Life Support Group - please access the ‘Advanced Paediatric Life Support: The Practical Approach (APLS) course book.’

Do you have an idea about how to make care safer in your ED?

Last month the Secretary of State launched a new campaign to make the NHS the safest healthcare system in the world.  Read more about the campaign at www.signuptosafety.nhs.uk

There are five pledges for safety: