An attorney may come to you as an LNC with a concern about a healthcare-acquired infection, which you can identify in the patient’s medical record.
A legal nurse consultant should look in the medical record for the presence or absence of rapid diagnostic tests, potential therapeutic failure of antibiotics, or death due to failure to diagnose and treat an infection. Patients at high risk for pneumonia are those who are immunocompromised, have chronic diseases, undergo general anesthesia, or are critically ill and intubated in the intensive care unit.
With so much focus now on infections by antibiotic-resistant organisms, the correct prevention and treatment of infections is crucial.
A Case Study
Alberto Bello, a 58-year-old father of three, is admitted for coronary artery bypass surgery. He comes in on the day of surgery. His surgery is successful; the surgeons bypassed two arteries.
Alberto recovers in the cardio-thoracic intensive care unit overnight before transferring to the cardiac step-down unit, right in line with the expected plan of care.
On day three of hospitalization, Alberto is progressing with his ambulation and nutritional intake. Discharge plans are for day four. On day four, he wakes up with a fever and drainage from his sternal wound.
Staff take cultures of his wound, blood, sputum, and urine. His blood and sternal wound grew methicillin-resistant Staphylococcus aureus (MRSA), even though his swabs for MRSA from his groin and nares were negative on admission.
Next, Alberto starts to complain of severe pain in his chest, and he develops an unstable sternum, likely indicating that the bones were not fusing well. He returns to the OR, where they find his bone is infected with oxacillin-resistant Staphylococcus aureus and needs to be removed.
He returns to the cardiothoracic intensive care unit with an open chest wound.
Alberto faces months of IV antibiotics for the infection related to his surgery, and he will require additional surgery to close his chest.
When Alberto is well enough, he seeks a plaintiff attorney and asks, “How did I get this infection?” He states, “ All this treatment is ruining my life. I can’t do anything. I’m so weak; my wife has to take on more of my responsibilities at home, and I can’t go back to work because of these IV treatments. I was supposed to be in and out of the hospital without problems.”
Causative Organisms
Pathogens responsible for hospital-acquired infections include bacteria, fungi, and viruses. Which microorganism favors which healthcare infection depends on the location of the infection. The prevalence of healthcare-acquired infections varies depending on the location, type of healthcare facility, setting, and patient population served.
Types of Healthcare-Acquired Infections
- Bloodstream infections
- Pneumonia
- Urinary tract infections
- Surgical site infections
Surgical Site Infections
The patient’s organisms cause many surgical wound infections. However, direct contact, improper sterilization, or airborne transmission of organisms can contaminate an open wound and seed the infection during the surgery.
Some surgical site infections may be preventable if the correct strategies are implemented before and during the procedure. Strategies include:
- Avoiding hair removal at the surgical site,
- Appropriate skin preparation with chlorhexidine gluconate with alcohol or povidone-iodine with alcohol,
- Correct antibiotic prophylaxis was given with the correct timing,
- Decolonization of the nares with anti-staphylococcal agents and anti-staphylococcal skin antiseptics for high-risk procedures,
- Maintaining normothermia during the procedure,
- Perioperative glycemic control and,
- As appropriate, use of negative pressure wound therapy (Seidelman, J.L., Mantyd, C.R., and Anderson, D.J. 2023).
Surgical site infections affect up to 3% of patients who undergo surgery (Hou, Y. Collinsworth, A., Hasa, F., Griffin, 2023).
A Misconception That the OR is Sterile
The OR is not sterile, and the patient’s skin is not sterile, even after surgical prep. Co-morbid conditions such as smoking and diabetes complicate the prevention of surgical site infections.
Surgical site infections are complex and devastating. They are a major cause of morbidity and mortality and contribute to longer hospital stays, loss of function, disability, increased cost of care both in-hospital and after, increased readmission rates, and financial stress.
The attorney turns to you for help.
Factors for the LNC to consider include:
- possible contamination of the surgical site during the procedure
- contaminated equipment, or personnel
- presence of foreign material in the surgical site
- improper hair removal
- insufficient application of skin prep
- direct injury to another organ during surgery
- excessive tissue trauma
- inadequate hemostasis
- leaving excessive dead space
- tissue devascularization
- unintended spillage of bowel contents
- failure to remove dead or dying tissue, and
- direct organ or tissue injury
The Patient’s Story
Mr. Bello experienced severe adverse events after surgical procedures. His infection is considered deep.
Sternal wound infections are a serious complication after cardiac surgery and can evolve into life-threatening complications for some patients.
Mr. Bello will likely require bone allographs to reconstruct his sternum, which may be fixed to the costal stumps with titanium plates and skin grafts to close the wound in his chest. He will be left with a large scar, provided he survives his treatment.
An LNC reviewing Mr. Bello’s chart noticed that the antibiotic, which should have been given before the procedure to allow peak concentration at the time of skin incision, hadn’t been started until 15 minutes after the operation began.
Checking that the antibiotic had been administered should be part of a time-out done by the surgeon at the beginning of the procedure. It is the responsibility of anesthesia personnel to give the antibiotic.
Without antibiotics, any skin cells left on his skin after the prep or any bacteria from the operating room personnel that gain entry to the wound immediately start to reproduce.
We cannot know where Mr. Bello’s MRSA came from unless we were able to culture the skin and nares of all of his OR team, but what we can tell is the standard of care was not met to administer the prophylactic antibiotic before the surgery to prevent surgical site infection.
Read the Rest
This is a small section from Chapter 4, from the book: Iyer, P. (Ed.) ‘Medical Record Analysis A Guide for Attorneys by Expert LNCs Volume 3.’
Chapter 4 is contributed by Gwen Rogers, DBA, MSB, BSN, RN, FAPIC, CIC, HACP-IC, CLNC.
Get your copy here.
Pat Iyer is president of The Pat Iyer Group, which develops resources to assist LNCs in obtaining more clients, making more money, and achieving their business goals and dreams.
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