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See also: Medical, Legal Nurse Consultants, Clinical Nursing Case of the Week, Clinical Charting and Documentation, Nurses Notes, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety: Each week a case will be reviewed and supplemented with clinical and legal resources from the web. Attorneys, Legal Nurse Consultants and nursing professionals are welcome to submit relevant articles. Please contact us if you'd like to reproduce our material. For a free subscription to our publication: Please send a blank e-mail to: clinicalnursingcases-subscribe@topica.com Summary:  Patient noncompliance can present serious challenges to nurses  and physicians providing care.  If aware of the proper measures to be taken, what happens when the patient does not agree or comply with the course of treatment?  In this case, a patient after having a coronary artery bypass grafting developed a sternal infection. When advised by a nurse to return for treatment, the patient refused. The patient was known to have Insulin-Dependent Diabetes Mellitus. She would seek medical attention with a history of Angina (chest pain).  Following the episode, she was referred for a diagnostic cardiac catheterization. "According to latest statistics from the American Heart Association, roughly 323,000 cardiac catheterizations were performed in the United States in 1994. The procedure provides doctors with information about the heart's structure and its ability to function. Doctors may also use catheterization to perform procedures on the heart, such as balloon angioplasty. To perform a cardiac catheterization, a thin catheter is inserted through a small puncture wound in a blood vessel -- usually the femoral artery in the leg. Using X-rays for guidance, doctors feed the catheter through the circulatory system until it reaches the heart."2 Following the catheterization, an emergent multiple bypass surgery was recommended by the Cardiologist. "What is coronary artery bypass surgery? A coronary artery bypass graft operation is a type of heart surgery. It is sometimes referred to as CABG or "cabbage." The surgery is done to reroute, or "bypass," blood around clogged arteries and improve the supply of blood and oxygen to the heart. These arteries are often clogged by the buildup over time of fat, cholesterol and other substances. The narrowing of these arteries is called atherosclerosis. It slows or stops the flow of blood through the heart's blood vessels and can lead to a heart attack."3 The patient would refuse and left the hospital Against Medical Advice (AMA). Three days later the patient would return to the hospital and provide an Informed Consent to the operation.  It was performed by the Facility's Cardiac Surgery  Director assisted by a fourth year resident. ""Revascularization with coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) is well accepted as a method of relieving anginal pain and thus improving quality of life. In addition, CABG has been shown to improve survival in certain subgroups of patients with coronary disease, which has led to the widespread use of this procedure in revascularization. In 1991 407 000 bypasses and 303 000 PTCA procedures were performed.1 Currently, coronary atherectomy, various laser techniques, and coronary stents are being evaluated as additional approaches to revascularization."4 Following the coronary artery bypass grafting, the patient would remain in the hospital for ten days. The patient would return for a follow-up visit just under two weeks later with the surgeon.  Assisted by a cardiac nurse, the midsternal incision was examined, staples were removed.  A portion was found to be purulent, draining and healing poorly. Cultures were obtained and sent, the patient would be scheduled for another follow up visit a month later. Four days later, the patient spiked a temperature.  She called the medical center and spoke to the nurse who had assisted the surgeon. After listening to the patient's complaints, the nurse instructed her to return to the medical center for treatment.  She informed the patient that her test results had come back and multiple infections had been discovered from the midsternal wound in her chest. "Approximately 2% to 20% of CABGs are complicated by a surgical- site infection (SSI).4,5 Much of the literature on SSI following cardiothoracic surgical procedures focus on deep chest infections, which, although not frequent (complicating 0.5% to 5% of cardiac procedures4,5), are important because of the high morbidity, mortality, and immense costs they add to the healthcare system."5 The patient refused.  She stated that it was almost an hour's drive to go to the medical facility.   In her "condition" she didn't feel she could "make" the trip. She asked the nurse if antibiotics could be "prescribed over the phone" and started without her being evaluated.  The nurse informed her this was not an option. The nurse informed the patient that it would be best for her to return to the facility where the operation had been performed.  If she returned her condition could be evaluated and treatment initiated.  The patient still refused. Alternatively the nurse stated that the patient should seek immediate medical assistance and contact her local physician. The patient was unable to contact a local physician and did not go to the Emergency Room immediately.  In fact, the patient was not examined by her physician until almost ten days later. At that time, ten days after the known Insulin Dependent Diabetic patient had been informed by the nurse that she had a potentially life threatening multiple organism infection in her chest, she was readmitted to a local hospital. "Surgical-site infection of the sternal wound includes superficial SSI, deep sternal SSI, sternal osteomyelitis, mediastinitis, and endocarditis. These often have been pooled together in the analysis of risk factors. Host intrinsic risk factors that have been linked specifically to SSI of the sternal wound include obesity,4,9-11 diabetes mellitus,4,9-13 current cigarette smoking,9 and steroid therapy,13 the former two risk factors being the most frequently reported (Table 1). Kluytmans and colleagues further demonstrated that the risk of developing SSI was higher in the diabetic patient using insulin therapy than in the diabetic patient treated with oral agents.12"5 A sternal infection was verified.  The patient would require readmission and surgery to debride the wound and bring the infection under control.  Part of her sternum would be removed in the process. At the patient's request, the course of events was examined by the Physician Medical Review Board.  She alleged that standards of care had not been maintained.  She stated that negligence on the part of the surgeon and the nurse had led to her infection and subsequent surgery. The board dismissed the complaint.  They stated there was no clear evidence of wrongdoing or negligence on the part of the nurse or physician. The patient filed a lawsuit regardless against the physician, facility and the nurse accusing negligence.  The case was dismissed. The patient appealed. Questions to be answered: 1. Did the nurse fail to observe the applicable standards of care in her conversation with the patient? 2. Was the nurse giving the patient "medical advice" when she advised her to return for treatment? 3. Did the nurse mislead the patient or make any statements that could have contributed to the patient's complications? The physicians and the court when reviewing the nurse's performance agreed it was appropriate.  The nurse was dealing with a known septic patient with a history of noncompliance.  She instructed and emphasized to the patient that an infection was present and required treatment. The nurse advised the patient of where the best treatment could be obtained.  The patient was notified that if she could not return immediately, that treatment should be sought elsewhere on an emergent basis. The nurse was giving medical advice.  In this case, the nurse was telling the patient exactly what a competent surgeon would have told her as well. This is a special situation involving a nurse with advanced skills and experience in a nursing specialty.  Nurses with specialized training are recognized as competent to advise patients on pre-defined situations according to their level of expertise. A midsternal infection is a known complication of coronary artery bypass grafting.  The nurse being aware of this was appropriate in her counseling of the patient to seek immediate care. The nurse in the eyes of the law would be and was held to the same standards as a physician in the advice that was given.  The nurse did in fact, maintain the standards of care expected in the situation. Her responsibility or "duty" to the patient was to advise her of the medical condition present (a septic infection), make recommendations for treatment (return to the hospital), inform her of consequences of not being treated and present alternatives. This duty was fulfilled and recognized repeatedly by the medical review panel and the courts.  It is unfortunate that the noncompliant patient decided to pursue litigation regardless. It demonstrates clearly how vulnerable even the most prudent nurses are to being sued.  Often it is the case that nothing has been done wrong, nor is there negligence likely.  It's a constitutional right for an individual to initiate a lawsuit for real or perceived losses. Makes an excellent case for carrying a malpractice insurance policy. For the cost of a typical day's pay, you can have protection against lawsuits without having to depend on an employer's policy being adequate to protect you. Related Link Sections: Cardiac Arrhythmias Links on: The Nurse Friendly http://www.nursefriendly.com/nursing/directpatientcare/symptoms/cardiac.arrhythmias.htm Cardiac Catheterization (Diagnostic) Links on: The Nurse Friendly http://www.nursefriendly.com/nursing/directpatientcare/tests/cardiac.catheterization.diagnostic.htm Cardiac Links, Direct Patient Care on: The Nurse Friendly http://www.nursefriendly.com/nursing/directpatientcare/cardiac.htm Clinical Charting and Documentation, Nurses Notes: http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm Coronary Artery Bypass Grafting (CABG) Links on: The Nurse Friendly http://www.nursefriendly.com/nursing/directpatientcare/cardiac/coronary.artery.bypass.grafting.cabg.htm Direct Patient Care Links on: The Nurse Friendly http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm Emergency Department Nurses on the Nurse Friendly: http://www.nursefriendly.com/nursing/directory/spec/ed.html Ethics: http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm Head Injuries: http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htm Informed Consent: http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/informed.consent.medical.legal.htm Mechanical & Physical Restraints: http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.restraints.htm Medical Legal Consulting Nurse Entrepreneurs: http://www.nursefriendly.com/nursing/ymedlegal.htm Operating Room (Surgical) Links on: The Nurse Friendly http://www.nursefriendly.com/nursing/directory/spec/operatingroom.htm Sources: 1. 40 RRNL 1 (June 1999). 2. WTVC NewsChannel 9.  1999.  Cardiac Catheterization: http://www.newschannel9.com/healthwatch/hw594.html 3. The American Heart Association.  1999.  Bypass Surgery, Coronary Artery:  Retrieved July 4, 1999 from the World Wide Web:  http://www.amhrt.org/Heart_and_Stroke_A_Z_Guide/bypass.html 4. American Heart Association.  1994.  Optimal Risk Factor Management in the Patient After Coronary Revascularization.  Retrieved July 4, 1999 from the World Wide Web: http://www.amhrt.org/Scientific/statements/1994/129401.html 5. Infection Control & hospital Epidemiology.  April 1988.  Surgical-Site Infections After Coronary Artery Bypass Graft Surgery: Discriminating Site-Specific Risk Factors to Improve Prevention Efforts. Retrieved July 4, 1999 from the World Wide Web: http://www.slackinc.com/general/iche/stor0498/edit.htm   See also:Comparison Shopping Children and Infants, Clothing and Fashion Accessories, Credit, Financial and Lending, Health & Beauty Aids, Travel, Hobby & Leisure, Housewares, Home and Garden The Uniform Resource Locator (URL) or Internet Street Address of this page is http://www.nursefriendly.com/nursing/clinical.cases/070499.htm Send comments and mail to Andrew Lopez, RN Created on July 4, 1999 Last updated by Andrew Lopez, RN on Monday, January 25, 2010

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