Progress & Changes

We are currently going through a few growing pains, so please excuse our current progress. Our primary phone number has now changed. Our phone number is now 1-877-347-6557. We now have three locations to better serve our clients across the country. Our office locations are now in California, Alabama & Florida. Our business operations will resume on Monday, January 2, 2012, and we look forward to a new year with our clients. We wish everyone a happy and safe new year.

The Role of Cytotec in Obstetrics

As a legal nurse consultant who has also been a labor & delivery nurse for more years than I care to count, I review many medical malpractice cases where the underlying issue is Cytotec. For those of you who do not work in labor & delivery, Cytotec is also known as Misoprostol and was FDA approved for gastric ulcers many years ago. It is also an effective drug when used properly for the induction or augmentation of labor which is also known as "off-label use".

The problem with Cytotec often occurs when obstetrical caregivers become complacent with its use. First, they seem to forget that Cytotec's use in obstetrics is not FDA approved for that purpose. This creates controversy surrounding the use of the drug and liability issues when careful scrutiny is not taken to ensure the indication for its use in obstetrical practice is consistent with current standards of care. Nurses must realize they will have to answer serious questions at deposition regarding the indication and monitoring of patients who have received Cytotec for induction or augmentation purposes.

Next, Cytotec is widely used in obstetrics primarily for its ability to produce rapid labor progression. It is often referred to in obstetrical circles as "Cytoblast" which offers an indication of how the drug can effect labor progression. Nurses should always be aware of the role this drug plays in uterine contractions and the response of the fetus to it. Close monitoring of the fetal heart tracing as well as contraction pattern should be maintained after administration of Cytotec.

Third, Cytotec should never be used for induction or augmentation on pregnant women who have had a previous cesarean section. The risks of uterine rupture creating significant liability issues are far too great. Nurses should also question physicians who order Cytotec with an admitting dignosis of a "non-reassuring fetal heart rate". This could also create liability issues down the road if the outcome is not good. For any other questions or concerns regarding the use of Cytotec in labor, you may contact us at 1-877-347-6557 or email at mcook@cook-legalnursing.com.

IV Infiltration Injuries in Infants

An IV infiltration or extravasation injury to an infant or child while hospitalized can be devastating. You trust every precaution will be taken to ensure your child's safety when you place your child in the care of medical professionals.

When it comes to IV therapy, hospitals and medical professionals have a duty to follow certain standards of care to protect patients, especially infants, from IV infiltration and extravasation injuries. These standards of care include:

•  Following proper procedures for IV placement and insertion
•  Routine and frequent monitoring and assessment of IV site
•  Applying transparent dressing over IV site
•  Properly securing the IV catheter to extremity
•  Diligence in checking the IV site for coolness, swelling, or color changes.
•  Ensuring proper function (infusion or flow) of IV fluids
•  Checking for signs of infiltration

The following are terms and definitions that may help you better understand the types of injuries associated with IV infiltration:

IV Infiltration

When an IV slips out of the vein and the fluid escapes into the surrounding tissue. This may cause injuries from a small amount of edema (swelling) in the affected area or severe, causing tissue death.

Extravasation

Occurs at the IV site and surrounding tissue when there are actual changes in appearance or temperature. There may be edema along with blanching, coolness, blistering, discoloration and tightness to the area. The severity depends on the type of fluids and/or medications that have infiltrated the area as well as the length of time before the infiltration was discovered.

Compartment Syndrome

When the compartments around the affected site become filled with fluid restricting the muscles, nerves, and vessels within the compartments. This can result in severe pain and tissue death.
Fasciotomy
Surgical Procedure done to relieve tension or pressure as a result of compartment syndrome and treat the resulting loss of circulation to the area of tissue or muscle.

IV infiltration and extravasation injuries to children can be more severe and harder to detect than injuries to adults. Children cannot express pain or irritation the same as an adult. Often they cry because the IV hurts but the medical staff attributes their crying to something else and fails to check the IV site. As a result, IV infiltration or extravasation can go undetected for a longer period of time. If timely assessment of the IV site is not performed, harmful fluids and medications infiltrate into the tissues surrounding the IV site rather than the bloodstream. The longer the infiltration goes undetected, the worse the injury becomes.

Without medical training or experience, it is difficult to assess the care surrounding an IV infiltration injury and determine if a breach of the standard of care occurred. A review of the medical documentation must be done by someone trained to evaluate the medical evidence. This is usually done after you have consulted with an attorney. A legal nurse consultant will usually review the records to determine whether you have a cause of action against a negligent doctor, nurse, or hospital. The attorney will then advise you of your rights and provide straightforward information about how to proceed.

If you have any questions regarding IV infiltration, you may contact us at mcook@cook-legalnursing.com or call us at 1-877-347-6557.

Monday Med Mania

Handwashing Reviewed

It's not that I like bringing up old topics that seem to be worn into the ground, but every so often I find it necessary to emphasize the importance of handwashing. Unwashed or improperly washed hands are a very common way of spreading nasty critters that cause disease such as colds, flu, ear infections, strept infections, staph infections, diarrhea, vomit viruses and other intestinal problems.

It is the routine things we do every day without even thinking about it that pass along these germs and viruses such as handling food, touching doorknobs, shaking hands, and even talking on the phone. However, the single most important thing we can do to keep these uninvited guests from invading our lives is proper handwashing.

First, frequent handwashing is extremely important expecially when the following is involved:
Before handling food or eating

• After using the bathroom
• After sneezing, coughing or blowing your nose
• After taking out the trash
• After handling money
• After changing a diaper
• After handling uncooked meat
• After playing with a pet
• Before touching your face, eyes, mouth or ears

Proper handwashing includes:

• Using hot or warm running water
• Lathering hands with soap
• Rubbing hands togethor for at least ten seconds
• Washing the back of the hands, between fingers and under fingernails
• Rinsing with warm water
• Patting hands dry
• Turning off the water using a paper towel

According to the U.S. Centers for Disease Control and Prevention (CDC), handwashing is the most avilable "low-tech" prevention of illnesses. Developing a routine habit of frequent handwashing will help transfer that habit to others and prevent illnesses and infections in households as well as pofressional offices, restaurants, medical facilities and clinics.

Monday Med Mania

Time Out Procedure

I consulted on a case that rested solely on the "Time Out" procedure used in the operating room. All the documentation was neatly in order, yet somehow the patient ended up having the wrong part removed. Finally, inconsistent stories emerged as each inidividual member of the surgical team was deposed. The deviations in standards of care surrounding the "Time Out" procedure were clearly identified:

• The operating was noisy during the "Time Out"
• The attending physician was not even present when the "Time Out" took place
• A right-left distinction was never identified during the "Time Out"

Surgical team members must remeber that the "Time Out" procedure was put in place for a reason. We don't do "Time Out" just to satisfy Joint Commission requirements - We do it to protect the patient. The attending physician has to be present, and the "Time Out" must take place just prior to the surgery in a quiet room. A right-left distinction must be clearly identified, and if the surgery requires more than one procedure, a new "Time Out" must be done before each individual procedure. This process eliminates the risk of wrong site, wrong procedure or wrong person surgery.

I came across one facility's Universal Protocol on the internet for "Time Out" procedure which identifies the process that must be followed: Universal Protocol - Time Out. This may help those that need clarification with the process. There are also some helpful videos on YouTube that actually simulate the process as well. For more information on "Time Out" Procedures or other Universal Protocols you may email us at mcook@cook-legalnursing.com.

Monday Med Mania

Pain Assessment Doesn't End with Pain Scale

As a legal nurse consultant I review massive amounts of medical records. Part of that review includes pain assessments of which I can say without hesitation hardly ever provide a sufficient description of patient pain. I'm sure all nurses understand that pain scale was integrated into nursing documentation to help standardize an important part of pain assessment; however, many nurses still do not grasp the concept that pain assessment does not end with pain scale.

I review many medical records that will note a pain scale above zero describing pain intensity and/or severity which then leaves me hanging with many questions regarding a more descriptive evaluation of pain:

• Where is the pain?


• When did the pain start?


• Is this pain the same as previous pain or something new?


• Is the pain constant or intermittent?


• How long does the pain last?


• How long is the absence of pain?


• What type of pain is it? Burning, Stabbing, Dull, Cramping, Pulling, Tearing, Throbbing, Tingling, Aching, etc.?


• Is the pain deep or superficial?


• Can the patient describe if the pain feels like it originates from bone, muscle, organs or skin?


• Does the pain radiate or is it isolated to one specific area?


• What relieves the pain?


• What exacerbates the pain?


• Is the pain associated with anything specific? Food, Activity, Exposure, etc.?


• Are there any associated symptoms with the pain?


• What are the nonverbal signs? Facial Expressions, Crying, Body Movements, Guarding, Position, etc.?


• What are the paitient's current vital signs?

If all these questions can be answered within a pain assessment then there is sufficient documentation regarding patient pain. Even when patients are admitted for pain, a nurse must never assume the paitient's complaint of pain is derived from the same origin as the presenting complaint. An adequate pain assessment is required routinely to determine if the pain is the same or something new, and that can not be determined with a pain scale alone.

Monday Med Mania

Coordination of Response to Obstetrical Emergencies

Since my area of specialty is high risk obstetrics, I spend a lot of time reviewing and analyzing medical records relative to obstetrical malpractice cases. As an obstetrical nurse for almost twenty years it really gives me a lot of grief when I review medical records to realize coordination of response to obstetrical emergencies has been mismanged to the point of malpractice. This seems to be a constant within almost every malpractice case I review.

The major elements that fall within this issue include:

• Failure to anticipate and prepare
• Failure to commuicate
• Failure to fully understand responsbilities

Obstetrical nurses must understand that the possibility of obstetrical emergencies can occur at any time, especially when high risk patients and/or use of induction agents are involved. A poorly coordinated response results in panic and chaos ultimately creating a situation that places both mother and baby in danger. A poor outcome is then directly contributed to events that were both avoidable and incompetent.

The use of emergency simulation drills on obstetrical units does help to better prepare for obstetrical emergencies; however, all staff including physicians must be on board to effectively coordinate the response. On the other hand, if the obstetrical staff fails to acknowledge the reality of a high risk situation, then simulation drills are rendered useless.

For coordination of response in obstetrical emergencies to be effective there are four seperate and distinct factors that must take place:

• Anticipation
• Preparation
• Communication
• Delegation

These are the four factors I identify within medical records of an obstetrical malpractice case. I really hate to say it, but most of the cases I am asked to consult for will reveal a breakdown in one or more of these four areas. With the number of obstetrical law suits escalating, it is imperative that obstetrical nursing supervisors properly educate their staff the significance of obstetrical emergency response.

For more information on this subject matter and obstetrical staff education, contact Marinna Cook, RN, CLNC at mcook@cook-legalnursing.com or call (661) 368-2290.