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Clinical networking (09HDC01207)

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(09HDC01207, 20 December 2010)

Public hospital ~ District health board ~ Hemicolectomy ~ Clinical networking between hospitals ~ Patient safety ~ Referrals between provincial and regional centres ~ No breach

A man complained about the management of complications when his mother had a right hemicolectomy[1] in a provincial hospital, and developed symptoms postoperatively. The surgical team at the hospital decided to take a conservative approach to treatment, and did not re-operate straight away. The woman's condition did not improve. The surgical team decided that she should be fed intravenously, to rest her bowel. However, she developed an infection, and it was decided to stop the intravenous feeding and resume an oral diet.

The surgeons then decided to re-operate. During the operation, they discovered that there was a leak in the colon where it appeared that a staple had fallen out. Postoperatively, the woman seemed to recover. However, five days after the surgery, she suddenly became unwell, vomited and had a cardiac arrest. Despite attempts to resuscitate her, she died.

Professor Bryan Parry, a general surgeon, provided expert advice. He noted that although he would have managed the care differently, the treatment was of a satisfactory standard overall:

"In my Institution's Morbidity and Mortality Meeting there would have been a robust professional discussion about her management along the lines above. Although disagreement would have been expressed, it is unlikely that the surgeon would have been censured due to the acceptable divergence of opinion in the management of anastomotic leak in general, and the undoubted complexities of [this patient's] case. There is no reason to suppose that [the surgeon's] management was negligent in any way."

As a general statement for how similar cases should be managed in the future, Professor Parry noted:

"…as these are infrequent cases, consideration of referral to a larger regional centre should have been considered. In mitigation there is no 'Intestinal Failure Unit' formally established or funded in NZ, although Auckland Hospital has traditionally tended to function in that capacity by default."

In light of the expert advice, it was held that there was no breach of the Code.

It is important that clinicians in smaller, provincial areas are able to have access to advice from, and/or referral to, larger regional centres. Although the DHB advised that there were no barriers to clinicians accessing advice from the regional centre, the Commissioner asked the DHB to review its current guidelines for referral, and to consider whether it provides sufficient encouragement for clinicians to seek the input of other providers beyond the local facility.

The lessons from this case are not unique. In particular, the importance of clinical networking in the interests of promoting patient safety has been noted previously. For example:

1.      In a case involving the failure of an orthopaedic surgeon in a small hospital on the West Coast to refer to a larger centre, HDC recommendations included:[2]

"I recommend that the Ministry of Health, all district health boards and the Royal Australasian College of Surgeons (RACS) work together to develop and implement a plan to address the issue of credentialling surgical services provided by district health boards (especially in remote areas or smaller centres) and the surgeons who work in such services. This process should include consideration of:

  • what support services are needed before surgical procedures can safely be undertaken in remote areas and smaller centres in New Zealand;
  • the need for a regional perspective on service planning and collaboration between neighbouring district health boards."

2.      One of the key messages from the report of the Whanganui DHB/Dr Hasil inquiry was that:[3]

"Public Hospitals face major pressures related to workforce and training, distribution of skills and skill mix, and financial resources. They are particularly acute in smaller centres. Isolation is the 'kiss of death' for a clinician, a department and a DHB. Regional and national service planning, and increased coordination and collaboration across DHBs, is essential to maintain safe, good quality services in the face of these pressures."

In that case, it was apparent that for the women of Whanganui, a safe and sustainable obstetric and gynaecology service may need to be on a regional basis.

3.      In a case involving a general surgeon undertaking rectal cancer surgery, the Commissioner noted:[4]

"I accept that an appropriately trained general surgeon practising in provincial New Zealand can maintain high standards of care if adequately supported. Provincial centres must have strong relationships with larger centres as they inevitably face limitations in terms of support."

These cases involve different DHBs, and different areas of practice of medicine. However, all highlight the need for DHBs and doctors to work collaboratively in the interests of improved patient safety.

 


[1] Surgery to remove part of her colon.

[2] Opinion 06HDC09552 (31 January 2008) page 38.

[3] Opinion 07HDC03504 (February 2008) pages 5-6.

[4] Opinion 07HDC17438 (21 April 2009) page 9.

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