Caitlin is a 22 yo female who has presented on a Friday evening after a 2 hr history of sudden onset, severe abdominal pain. On arrival she is very distressed rating her pain at 8 out of 10.
During her assessment and treatment she has an PIVC (peripheral intra venous cannula) placed in her right arm, bloods drawn, fluids commenced, and narcotic analgesia is administered with good effect.
An hour and a half later, at 8PM, it becomes apparent that Caitlin has left the department before treatment has been completed, or as we somewhat self-righteously refer to it… absconded.
After a quick check around the unit one of the nurses reports to you that she cannot be found …and she left with an 18fr cannula still in her arm. The nurse has rung Caitlin’s mobile phone repeatedly, but it appears to be turned off.
As team leader for the shift, what will your response to this situation be?
Each year there are many patients that are discharged with cannulas insitu.
In the UK such events are considered serious enough to fall under the department of health ‘never events’ policy.
Never events are: “serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers.”
So, in the UK at least, cannulas left insitu have resulted in nurses being disciplined and even suspended.
Whilst looking around for some more information on this, I was referred to a 2010 article from the Irish Times in which an 83yo man. Dr George Kelly, presented to hospital with back pain which he attributed to sleeping in an uncomfortable hotel bed.
He was discharged that afternoon, but soon developed increasing swelling and decreased range of movement in his right wrist. An IV cannula was discovered in situ by his daughter a week later and he represented to hospital.
The wound was thoroughly washed out to clear the infection in his wrist but the presence of the hospital bug MRSA was detected.
Dr Kelly initially responded well to treatment, but his condition deteriorated and he died five weeks after being discharged with the tube in his wrist.
Pathologist Dr Margaret Bolster attributed his death to a series of health complications arising out of the MRSA infection in his wrist.
Members of the Kelly family said they did not hold any one individual responsible for the death of their father, but voiced concerns over the discharge process and wished to see guidelines in place to prevent a similar tragedy.
:: Irish Times ::
How to avoid accidental discharge with cannula insitu:
There are several strategies for avoiding patient discharge with cannula in-situ, including:
- A discharge checklist that includes a check for cannulas.
- Developing the habit as you insert the cannula of informing the patient (and family members) that it must be removed on discharge.
And advising them to flag with a staff member if this has not occurred.
If you are working in an emergency department or primary care setting, beware the patient that enthusiastically re-dresses themselves prior to discharge.
It is easy for long sleeved shirts etc to obscure that visual cue of the cannula dressing.
From my own experience, this is a frequent contributing factor in failure to remove the cannula.
Again, the best solution to this problem is a clear discharge checklist and a culture of staff always checking for cannulas when the patient is discharged.
But what about when the patient just walks out?
So. Back to our scenario.
This is not a case of staff forgetting to remove a cannula, this is a patient who has abruptly and intentionally left the unit, of their own volition, against medical wishes, and without informing the staff.
How would you manage this situation?
Do we still have a duty of care to this patient, or as adults, should they accept responsibility for their actions?
Does your own hospital have a policy to cover such an event?
There was some talk amongst the staff that they suspected that Caitlin would use the cannula for personal IV drug use. This is often a concern amongst medical staff when this sort of thing occurs, although I have never actually seen any evidence to support this (and it would raise the question of why IV drug users don’t steal and use cannulas more often to make their habit easier).
In all likelihood Caitlin had other things on her mind and was totally oblivious to the fact she still had the cannula in when she left.
In cases were patient are accidentally discharged or self-discharge I believe we have a duty of care to make every reasonable effort to contact them and facilitate a safe removal of the cannula.
- This might involve contacting the person and asking them to return to the hospital to have it taken out.
- Or arranging for them to go to another medical facility to have this done.
- In some cases it may involve contacting the police to attempt to locate the person (the police will likely be none too impressed with this).
- In worse case scenarios where there were no other options I have talked patients (or their family) through the steps to remove the cannula at home.
These scenarios are always inconvenient & annoying for the patient, time consuming for the staff and reflect poorly on the quality of care we are trying to deliver.
Again, this can all be avoided by developing the habit of routinely performing a full body scan for cannulas at the time of discharge.