Patient Re-admitted, 2nd Surgery Required, Stay Extended

This example examines an actual case of hospital re-admittance which included a second surgery.  While recovering from the second surgery, the patient contracted a clostridium difficile infection which extended his stay for an extra two days.  The re-admittance was complicated by the fact that the patient had to be transported by air (Lear jet) due to the fact that he lives 150 miles away from the hospital.

This is an interesting case because it involves a highly experienced surgeon and well-respected hospital facility.  The surgical team participated in this RCA by providing very detailed information regarding the information available to them, how they processed it, and what decisions resulted from that process.  They were actively involved and interested in learning from the experience.

It should be noted that all turned out okay – the patient is now well on the pathway to recovery.

 

On 8/30/2016 a male in his mid-seventies went to the hospital to have what was initially thought to be a dime-sized hernia repaired.  Given the fact that this patient treats kidney failure with peritoneal dialysis, a process that involves filling and subsequently draining the abdomen with fluid, the surgical team decided to place the hernia repair mesh between the inner abdominal lining and the layer of abdominal muscles.  This would keep the mesh from coming in contact with the dialysis fluid, thereby lessoning the risk of infection or other complications.

Once the operation was begun, the damaged area turned out to be much larger.  The plan did not change – however the area of the repair was much larger.  The surgical team thought this to be the best possible plan.  And there have been no past complications.

The operation was a success.  The patient was sent to post-op, and then admitted for overnight observation.  The next day, after receiving hemodialysis, the patient was released.  The patient was strongly advocating for release.  And there is systemic pressure on hospitals from insurance companies to limit stays.  A family member then drove the patient 150 miles back to his home.

Over the next two days, it was determined that the patient was not recovering as expected.  He had no appetite, felt nauseous, was bloated/distended, and had not moved his bowels since before surgery.  The following morning, he was feeling extremely ill and asked to be taken to the emergency room of the local hospital (different from where the surgery was performed).  The local hospital examined him and ordered an X-ray.  The X-ray was inconclusive, so they ordered a CT scan.  The CT scan revealed a suspected blockage in the bowel.  They were in contact with the surgeon who performed the hernia operation, who recommended that he be admitted and treated until the blockage resolved – a process they estimated would take a few days. 

After further examination of the CT film, it was determined that the patient’s initial hernia operation had failed.  The stitches inside the abdomen had pulled out due to the integrity of the abdominal tissue.  This patient’s abdomen was compromised by the process of peritoneal dialysis.  Additional stresses were present because the patient is also obese and he has had numerous past surgeries.  A portion of his small bowel had become occluded (trapped) inside the area where the stiches had torn out.  This small bowel occlusion was causing the distressing symptoms.

The local healthcare team decided that they could not repair the hernia locally.  So they decided to send him back to the surgeon that conducted the original surgery.  This required an air ambulance (Lear jet). 

The patient was immediately sent to the OR upon arrival.  The hernia was again repaired, but this time using a much larger piece of mesh that covered most of the abdominal wall.  The patient was then admitted to the hospital.

After a few days, the patient developed diarrhea.  The surgical team thought that this was due to the quantity of stool softeners prescribed.  But when it did not clear up after a few days, a family member requested a test for clostridium difficile.  The family member requested this test because his mother died from hospital-acquired clostridium difficile in 2007. 

The test confirmed that the patient had contracted clostridium difficile.  Therefore, his stay was extended by two days.

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