Root Cause Analysis: Fluid Overload Case Study

Problem

A patient came into the ER with a fluid overload and difficulty urinating. Once given a Foley Catheter and diuretic, the patient still would not urinate. The ER failed to check for renal and heart problems and to stabilize patient or have him transferred to ICU. Decreased blood pressure and low perfusion were caused by renal problems and exacerbated by fluid retention, the wound and sepsis. The patient’s death was inevitable once the medical staff failed to discover kidney dysfunction and elevate his level of care (Pendse, Singh & Zawada, 2008, pp. 14–21; Shapiro, Zimmer & Barkin, 2009; Talan, Moran, & Abrahamian, 2008).

Intended Process Flow

When a patient comes into the ER with fluid overload; the standard protocol calls for him to be checked for kidney failure and heart problems. Before running tests, the patient’s medical history will provide a lot of clues as to the seriousness of his condition. Does he have diabetes? Is he taking medications which cause fluid retention or swelling? Does he drink alcohol? Is there swelling in his face, feet or ankles? Is there a wound with discoloration? Where is it located? Does he have a history of heart problems or hypertension? A creatinine blood test will reveal elevated creatinine levels and kidney dysfunction (Pendse et al., 2008, pp.14–21).

A bladder scan will reveal how much fluid is in the bladder and nurses could then follow up with the doctor to check for kidney failure (kidney problems are the primary cause behind fluid overload) and source of all other abnormality. Having noticed that the patient was still not urinating, nursing staff should check oxygen circulation levels. The heart pumps blood and the blood pushes oxygen through the body. The kidney produces red blood cells which carry oxygen to vital organs like the brain and heart (Pendse et al., 2008, pp.14–21; Nabili, n.d.).

Also important is a urinalysis which can give immediate clues about the patient’s condition. Nurses will answer the following questions: Is the potassium in the urine high? Is there blood in the urine? Nurses should run a BUN and creatinine blood test and, with the help of the patient’s medical history, have grounds to elevate the patient’s level of care to ICU or CCU (Nabili, n.d.; Pellowe, 2007).

After the diuretic intervention fails, the incident should be treated as a major health issue and the patient should be cauterized to expel fluid and improve oxygen circulation. Dialysis is an intervention that is most appropriate for renal patients. Dialysis would expel urine and filter wastes to replicate functions of a normal kidney. The patient can be stabilized with mechanized oxygen which prevents low blood pressure and organ failure. Cardiac protocol and an EKG automatically monitor bioprocesses (Pendse et al., 2008, pp.14–21). Once the patient is semi-stable in ICU / CCU, he should be turned to prevent sacral decubitis which is a serious and untreatable wound condition made worse by low blood pressure, fluid retention and, possibly, diabetes (a condition which promotes wounds when the body is not receiving enough insulin).

Once given diuretics, if the patient does not urinate, nurses should pay attention to his medical history. Protocol calls for nurses to take every step to ensure that fluid overload is monitored to prevent “complications induced by inappropriate therapeutic strategies” (Ronco, Constanzo, Bellomo, & Maisel, 2010, n.p.). If nurses insert the catheter and move the patient from the ER to the unit, cloudy urine should raise an immediate alarm that an infection is present and the doctor should be alerted. In the initial phases the nurse should communicate with ER to find out how long the catheter has been inserted and why (Bernard, Hunter, & Moore, 2012; Randall & Clarke, 2011).

Deviation from Intended Process Flow

ER nurses failed to establish whether patient was having heart or kidney problems by first running a full lab to identify the cause of problems even though they administered diuretic. Patient’s medical history and lab work should determine course of action (Pendse et al., 2008, pp. 14–21). Nurses failed to perform a bladder scan in the ER or to treat the patient’s condition as a serious health issue by e-monitoring heart rate and oxygen and elevating the level of care to ICU / CCU prior to transfer. In failing to expel wastes through the use of a foley and diuretic, nurses again failed to communicate the seriousness of the patient’s current condition to the treatment team. Dobutamine, once administered, did not improve the patient’s worsening condition because the kidney was not functioning and blood was not circulating. Also, the nurse did not monitor patient’s breathing and turning. Nurses failed to monitor oxygen and blood pressure or note the patient’s worsening condition.

Once the patient is cauterized, careful and routine monitoring, centered around removal of the catheter as soon as it ceases to be medically necessary, is essential (Ronco et al., 2010; Kahnen, Flanders, & Magalong, 2011). Moreover, because the primary goal of the nursing staff should be to reduce incidence of CAUTI as much as possible and monitor all efforts to investigate the nature of the patient’s condition are primary. Nurses provide important data to doctors and follow up by monitoring bladder protocol and checking for CAUTI. If these basic protocols were maintained; the infection and kidney issues would have been discovered (Bernard et al., 2012; Dailly, 2011; Helpern et al., 2009; Munford & Suffredini, 2009).

After evaluating the patient’s progress, the nurse is in the first and best position to determine when the foley should come out. The observation should be recorded in an electronic health record and the nurse should make direct contact with the doctor regarding removing the foley right away. Maintaining foley and bladder protocol and removing the foley in a timely manner would prevent all other health complications.

5 WHYS

What human factors were relevant to the outcome?

Failure to follow established policies/procedures and poor communication mechanisms.

What medical equipment and devices worsened the outcome?

The outcome was worsened by the use of a Foley Catheter.

What controllable internal factors affected the outcome?

Poor communication between the ER and unit and non-existent communication between the nurse and doctor. Also, no lab work.

Did staff performance during the event meet expectations?

No. Staff performed outside of the processes.

To what degree was all the necessary information available when needed?

Patient assessments were not completed, shared and accessed by members of the treatment team.

In the future, standard protocol for fluid overload should be immediate lab work in the before diuretics and inserting catheter along with a careful review of patient history and better communication (Ronco et al., 2010; Angus & van Der Poll, 2013).

References

Angus, D.C. and van der Poll, T. (August 29, 2013). Severe Sepsis and Septic Shock. English Journal of Medicine. pp. 369:840-851. DOI: 10.1056/NEJMra1208623.

Bernard, M.S., Hunter, K.F., & Moore, K.N. (2012). A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections. Urologic Nursing, 32(1), 29-37.

Dailly, S. (2011). Prevention of indwelling catheter-associated urinary tract infections. Nursing Older People, 23(2), 14-19.

Helpern, E. H., Killeen, K., Ketchem, A., Wiley, A., Patel, G., & Lateef, O. (2009). Reducing Catheter-Associated Urinary Tract Infections Through The Use Of Sliver-Coated 100% Silicone Indwelling Catheter System. American Journal of Critical care, 18(6), 535-541. Retrieved October 2, 2013, from: http://ajcc.aacnjournals.org/content/18/6/535.long.

Kahnen, D.A., Flanders, S. & Mangalong, T. (November 2011). Catheter-Associated Urinary Tract Infections: Making Them Matter! Academy of Medical-Surgical Nurses, 20(6), pp. 4-7.

Munford, R.S., Suffredini, A.F. (2009). Sepsis, severe sepsis, and septic shock. In Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Churchill Livingstone Elsevier.

Nabili, S.T. (n.d.). "Creatinine Blood Test Levels, Results, Kidney Disease and Symptoms."MedicineNet. Ed. William C. Shiel. MedicineNet, Inc. Retrieved from http://www.medicinenet.com/creatinine_blood_test/patient-comments-376.htm.

Pellowe, C. (2007). Managing and leading the infection prevention initiative. Journal of Nursing Management, 15, 567–573.

Pendse S, Singh A, & Zawada E. (2008). Initiation of Dialysis. In: Handbook of Dialysis (4th ed.). New York, NY.

Randle, J. & Clarke, M. (2011). Infection control nurses' perceptions of the code of hygiene. Journal of Nursing Management, 19, 218–225.

Ronco, C., Costanzo, M.R., Bellomo, R., Maisel, A.S., (eds). (2010). Fluid Overload: Diagnosis and Management. Basel,Switzerland: S. Karger A.G.

Shapiro, N.I., Zimmer, G.D., Barkin, A.Z. (2009). Sepsis syndromes. In Marx, J.A, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier.

Talan, D., Moran, G., & Abrahamian, F. (2008). Severe sepsis and septic shock in the emergency department. Infectious Disease Clinics of North America, 22(1), 1-31.