Medical-setting deaths and the coroner: laws, penalties and guidelines.

We examine the law governing the reporting of medical-setting deaths to the Coroner throughout the Australian states and territories. We use a hypothetical case report to explore the different legal requirements for reporting a medical-setting death and the varying penalties that apply for failing to report a reportable death. It is important for health practitioners to understand the law that applies in the state or territory in which they practice. Knowing when to report a medical-setting death requires not only medical knowledge but also legal analysis. On this basis, we recommend the development of coroners' guidelines in all jurisdictions to assist health practitioners in complying with their coronial reporting obligations.

Why don't hospital staff activate the rapid response system (RRS)? How frequently is it needed and can the process be improved?

BACKGROUND: The rapid response system (RRS) is a process of accessing help for health professionals when a patient under their care becomes severely ill. Recent studies and meta-analyses show a reduction in cardiac arrests by a one-third in hospitals that have introduced a rapid response team, although the effect on overall hospital mortality is less clear. It has been suggested that the difficulty in establishing the benefit of the RRS has been due to implementation difficulties and a reluctance of clinical staff to call for additional help. This assertion is supported by the observation that patients continue to have poor outcomes in our institution despite an established RRS being available. In many of these cases, the patient is often unstable for many hours or days without help being sought. These poor outcomes are often discovered in an ad hoc fashion, and the real numbers of patients who may benefit from the RRS is currently unknown. This study has been designed to answer three key questions to improve the RRS: estimate the scope of the problem in terms of numbers of patients requiring activation of the RRS; determine cognitive and socio-cultural barriers to calling the Rapid Response Team; and design and implement solutions to address the effectiveness of the RRS. METHODS: The extent of the problem will be addressed by establishing the incidence of patients who meet abnormal physiological criteria, as determined from a point prevalence investigation conducted across four hospitals. Follow-up review will determine if these patients subsequently require intensive care unit or critical care intervention. This study will be grounded in both cognitive and socio-cultural theoretical frameworks. The cognitive model of situation awareness will be used to determine psychological barriers to RRS activation, and socio-cultural models of interprofessional practice will be triangulated to inform further investigation. A multi-modal approach will be taken using reviews of clinical notes, structured interviews, and focus groups. Interventions will be designed using a human factors analysis approach. Ongoing surveillance of adverse outcomes and surveys of the safety climate in the clinical areas piloting the interventions will occur before and after implementation.

Rapid response systems: a mandatory system of care or an optional extra for bedside clinical staff.

Two articles in this issue describe different approaches to implementing a rapid response system--one approach involving a wide-ranging marketing plan, the other entailing a policy change to make activation mandatory.

How I nearly MET my maker: a story of clinical futile cycles and survival.

In this series, the articles have highlighted a variety of implementation methods and uses of rapid response systems (RRSs). They have described how RRSs have been uniquely tailored to the organizations' culture and clinical environments, with largely positive results following implementation. In this article, Dr. Buist tells a somewhat different story, a highly personal one, which focuses on his own critical decompensation after surgery at his own hospital. The RRS (in this case, a medical emergency team was the efferent arm) at first successfully intervened, only to make a near-tragic error. Yet, as Dr. Buist, one of the leading proponents of RRSs worldwide, argues, the RRS-like any system-has the potential to err. He reminds us that even safety nets can require safety nets. So this story is also a cautionary tale: Just because your hospital has implemented an RRS, it does not mean (1) that the system is perfect or (2) that all preventable deaths are averted. To meet the goal of eliminating all preventable deaths in hospitals, an RRS requires continuous surveillance and adjustment. Furthermore, it must be implemented and operated in the context of the hospital's organizational culture. Although the administrative and quality improvement arms of the RRS are often underemphasized, this story exemplifies their importance--not just for RRSs but indeed for all hospital systems. The author, one of the leading proponents of rapid response systems worldwide, recounts his own close-call experience, in which he found himself in what he terms a clinical futile cycle.

Interventions to circumvent intensive care access block: a retrospective 2-year study across metropolitan Melbourne.

OBJECTIVES: To measure the prevalence of interventions used to circumvent intensive care access block and to estimate the attributable mortality and additional hospital bed-days associated with them. DESIGN AND SETTING: Retrospective observational study of 11 adult public hospital intensive care units (ICUs) in Melbourne, Victoria, July 2004 - June 2006. MAIN OUTCOME MEASURES: Prevalence of five interventions in response to access block; attributable fatalities and/or increased length of stay associated with each. RESULTS: 21 896 ICU admissions and 3039 inhospital deaths (13.9%) were screened. All hospitals reported ICU access block. There were 6787 interventions for access block (mean, 9.3/day) -- 4070 (18.6% of admissions) instances of after-hours step-down from an ICU to a low-acuity ward; 1115 (5.1%) delays in an emergency department > 8 hours; 895 (4.1%) postponed major surgeries; 487 (2.2%) interhospital transfers; and 220 (1.0%) instances of premature cessation of intensive care. Based on published risk estimates, these interventions may have resulted in 91.1 (95% CI, 34.7-147.2) attributable deaths and 4368 (95% CI, 333-10 050) additional hospital bed-days each year. CONCLUSIONS: Intensive care access block is frequent, and measures to circumvent it increase mortality and length of stay. Further study of the health and financial implications of access block are warranted.

Sperm removal and dead or dying patients: a dilemma for emergency departments and intensive care units.

An unexpected consequence of the increase in the use of fertility treatment is that emergency department and intensive care doctors are receiving requests from wives (actual or de facto) of dying or recently deceased men for sperm removal. Legislation in all states and territories regulates removal of sperm from a dying man and, provided that lawful consent is obtained, a doctor can harvest sperm. In several states, including Victoria, harvested sperm cannot be used in a fertilisation procedure without the man's consent, and debate surrounds the issue of consent and how it can be proved. Recent Victorian Law Reform Commission recommendations attempt to streamline the law to make a man's consent the cornerstone of decision making for both harvesting and subsequent use of sperm.

Documentation of clinical review and vital signs after major surgery.

OBJECTIVE: To describe the quality of postoperative documentation of vital signs and of medical and nursing review and to identify the patient and hospital factors associated with incomplete documentation. DESIGN, SETTING AND PARTICIPANTS: Retrospective audit of medical records of 211 adult patients following major surgery in five Australian hospitals, August 2003--July 2005. MAIN OUTCOME MEASURES: Proportion of patients with complete documentation of medical review (each day) and nursing review and vital signs (heart rate, blood pressure, respiratory rate, temperature and oxygen saturation) (each nursing shift), and the proportion of available opportunities for medical and nursing review where documentation was incomplete. Univariate and multivariate odds ratios for the association between incomplete documentation and hospital and patient factors. RESULTS: During the first 3 postoperative ward days, 17% of medical records had complete documentation of vital signs and medical and nursing review. During the first 7 postoperative ward days, nursing review was undocumented for 5.6% of available shifts and medical review for 14.9% of available days. Respiratory rate was the most commonly undocumented observation (15.4% undocumented). Certain hospitals were significantly associated with incomplete documentation. Vital signs were more commonly undocumented in patients without epidural or patient-controlled (PC) analgesia, during evening nursing shifts, and during successive postoperative ward days. Nursing review was more commonly undocumented in the evening and for patients without epidural or PC analgesia. Medical review was more commonly undocumented on weekends. CONCLUSION: Hospital and patient factors are associated with incomplete documentation of clinical review and vital signs after major surgery.

A sustained reduction in the transmission of methicillin resistant Staphylococcus aureus in an intensive care unit.

INTRODUCTION: In 2001, screening for methicillin-resistant Staphylococcus aureus (MRSA) was initiated in the intensive care unit at Dandenong Hospital, Melbourne, Australia. This followed the identification of a clinical isolate of vancomycin intermediate-resistant S. aureus (VISA). Contact precautions for patients colonised or infected with MRSA or VISA were utilised, together with the promotion of hand hygiene and additional environmental cleaning. In 2004, poor compliance with hand-hygiene requirements was recognised as potentially contributing to the inability to control MRSA transmission. METHODS: A renewed campaign was introduced in 2004, aimed at improving hand hygiene in the ICU. This involved the introduction of an alcoholic chlorhexidine handrub station on a trolley at the door of the ICU. Use of alcoholic chlorhexidine handrub was mandated for existing and visiting staff to the ICU, and its use was actively promoted by all ICU staff. RESULTS: From 2001 to 2004, the average monthly acquisition of MRSA in the unit was 15.2 patients per 1000 occupied bed days (OBD). Following the implementation of the campaign aimed at visiting staff, the average acquisition of MRSA dropped to 3.2 patients per 1000 OBD. CONCLUSIONS: Ownership of hand-hygiene responsibility for patients' protection appeared to contribute to the success of this initiative. The ability to sustain the excellent result was enhanced by the unit leadership and the empowerment of the nurse at the bedside to be the patient's advocate. Nurses, who are at the patient bedside 24 hours per day, 7 days per week, are well positioned to reinforce appropriate hand hygiene.

The rights and interests of doctors and patients: does the new Victorian Health Professions Registration Act 2005 strike a fair balance?

From July 2007, the Health Professions Registration Act 2005 (Vic) will significantly alter the medical disciplinary process in Victoria. For practitioners: Formal hearings for allegations of serious unprofessional conduct will be heard by the Victorian Civil and Administrative Tribunal (VCAT); There will be no right of appeal from a VCAT decision other than on a point of law; The maximum fine for serious unprofessional conduct will increase from $2000 to $50 000; Performance standards panels (PSPs) will be established to conduct informal hearings, with a power to impose conditions on registration; and Costs of the new system will cause an increase in annual registration fees. For complainants: There are new avenues for conciliation; There is a right to seek a review of certain Medical Practitioners Board of Victoria decisions; and Reasons for a PSP decision will be provided. Despite government argument that these changes will make the health complaints handling system fairer, the new Act has the potential to diminish the rights and interests of doctors.

Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.

BACKGROUND: Cardiac arrest outside the hospital is common and has a poor outcome. Studies in laboratory animals suggest that hypothermia induced shortly after the restoration of spontaneous circulation may improve neurologic outcome, but there have been no conclusive studies in humans. In a randomized, controlled trial, we compared the effects of moderate hypothermia and normothermia in patients who remained unconscious after resuscitation from out-of-hospital cardiac arrest. METHODS: The study subjects were 77 patients who were randomly assigned to treatment with hypothermia (with the core body temperature reduced to 33 degrees C within 2 hours after the return of spontaneous circulation and maintained at that temperature for 12 hours) or normothermia. The primary outcome measure was survival to hospital discharge with sufficiently good neurologic function to be discharged to home or to a rehabilitation facility. RESULTS: The demographic characteristics of the patients were similar in the hypothermia and normothermia groups. Twenty-one of the 43 patients treated with hypothermia (49 percent) survived and had a good outcome--that is, they were discharged home or to a rehabilitation facility--as compared with 9 of the 34 treated with normothermia (26 percent, P=0.046). After adjustment for base-line differences in age and time from collapse to the return of spontaneous circulation, the odds ratio for a good outcome with hypothermia as compared with normothermia was 5.25 (95 percent confidence interval, 1.47 to 18.76; P=0.011). Hypothermia was associated with a lower cardiac index, higher systemic vascular resistance, and hyperglycemia. There was no difference in the frequency of adverse events. CONCLUSIONS: Our preliminary observations suggest that treatment with moderate hypothermia appears to improve outcomes in patients with coma after resuscitation from out-of-hospital cardiac arrest.

Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study.

OBJECTIVES: To determine whether earlier clinical intervention by a medical emergency team prompted by clinical instability in a patient could reduce the incidence of and mortality from unexpected cardiac arrest in hospital. DESIGN: A non-randomised, population based study before (1996) and after (1999) introduction of the medical emergency team. SETTING: 300 bed tertiary referral teaching hospital. PARTICIPANTS: All patients admitted to the hospital in 1996 (n=19 317) and 1999 (n=22 847). INTERVENTIONS: Medical emergency team (two doctors and one senior intensive care nurse) attended clinically unstable patients immediately with resuscitation drugs, fluid, and equipment. Response activated by the bedside nurse or doctor according to predefined criteria. MAIN OUTCOME MEASURES: Incidence and outcome of unexpected cardiac arrest. RESULTS: The incidence of unexpected cardiac arrest was 3.77 per 1000 hospital admissions (73 cases) in 1996 (before intervention) and 2.05 per 1000 admissions (47 cases) in 1999 (after intervention), with mortality being 77% (56 patients) and 55% (26 patients), respectively. After adjustment for case mix the intervention was associated with a 50% reduction in the incidence of unexpected cardiac arrest (odds ratio 0.50, 95% confidence interval 0.35 to 0.73). CONCLUSIONS: In clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital.