Failures in care coordination at Boston Children's Hospital MSICU

Medical Practice Case Study

Summary of Consultant's Findings and Recommendations

The tragic case of Matty was the combined result of several major problems in the way that the Children's Hospital of Boston managed its medical intensive care unit (MSICU) that were further exacerbated by errors in judgment and prioritization of emergency and non-emergency medical issues. The comprehensive review of the information suggests that there is a need for the standardization of care and of authority for care in the MSICU. Moreover, it appears that the power dynamics inherent in the respective levels of authority (especially as between nurses and doctors) contributed to the tragedy by virtue of preventing nurses from speaking up in time to address what they believed were inappropriate aspects of treatment.

The record of this case suggests that in addition to emphasizing the appropriate prioritization of clinical issues, the institution must also establish formal protocols for ensuring that authority over patient care is clearly delineated well before patients are put at risk; that all members of the healthcare team must understand the relative authority of all other team members; and that appropriate training and care plans necessary for the welfare of every patient are delivered before any unit is charged with patient care.

Finally, there is evidence of the need to establish protocols to ensure that members of the healthcare team always identify themselves to other members of the team to avoid any misunderstanding in that regard. In principle, the case of Matty illustrates the observation by Groopman (2008) that the failure of the healthcare team to reach a swift and accurate diagnosis of a clinical problem can typically be traced to specific errors in the logical conclusions and corresponding decisions made by physicians.

The Need for Standardization of Care in Medical Intensive Care Units

This case illustrates a lack of diligence on the part of various senior members of the healthcare team as well as of the institutional administration. In principle, diligent medical practice entails, at a minimum, devoting sufficient attention to detail to prevent avoidable medical errors (Gawande. 2008). There were multiple failures of diligence in this case. This patient was admitted to an MSICU unit that was entirely inexperienced caring for neurological patients with implanted grids and strips. Such experience and appropriate training would be a prerequisite for medical diligence with respect to the admission of such patients to any unit.

More specifically, the record shows that the team charged with the care of this patient had received absolutely no such training and were not advised about any aspect of the post-operative care plan. Inclusion of all members of the healthcare team in the post-operative care plan should be required. While the particular of training and post-operative care plans cannot be standardized, the protocol of requiring training in the care of every clinical issue entrusted to the unit and the inclusion of all healthcare team members in the post-operative care plan should certainly be standardized immediately throughout this institution.

Need to Establish Definitive Bases of Authority Long before Crisis Intervention

According to the record, there was no coordination, mutual understanding, or even individual awareness on the part of the most senior members of the healthcare team as to the delineation of authority for this patient. The Neurosurgical team thought that the MISCU staff was in charge. Meanwhile, because the institution generally employs an "open model" of authority and responsibility in which surgical specialties manage the care of patients admitted to the MSICU, the MSICU staff assumed that the neurosurgical team was managing this patient's care while he was being treated in the MSICU. The fact that the MSICU staff was not included in any consultations about post-operative care only reinforced their assumption that medical management of this patient must have been the responsibility of the neurosurgical team in conjunction with the specialists in epilepsy. Ultimately, the non-involvement of the MSICU staff in this regard probably delayed their ability to recognize that a medical emergency was, in fact, being mismanaged by the rest of the healthcare team.

At a minimum, this case illustrates why this institution absolutely requires formal protocols for establishing the respective responsibilities and authority for every case admitted to the MSICU units. Furthermore, to ensure that MSICU staff can fulfill their responsibility to address apparent medical mismanagement by any member of the team, they must be consulted about post-operative care plan of every patient admitted to the unit, irrespective of their actual responsibility for medical management. Finally, in-service training for the care of patients admitted to the unit with specific clinical needs must also be a formal requirement, irrespective of whether or not MSICU staff is principally responsible for the care of specific patients.

Failure to Prioritize Acute Clinical Crisis Management over Long-term Objectives

The record of this case indicates that the neurosurgical resident completely failed to appreciate the need to prioritize a medical emergency over longer-term clinical concerns. Specifically, he indicated that although he recognized that the patient's seizures were not being managed appropriately, he assumed that this was necessitated by the intention to preserve the value of the data generated by the strips and grids in Phase 2 of the patient's long-term treatment plan and to reduce the potential of long-term adverse consequences of surgery. The MSICU staff also indicated that they allowed this assumption to override their concerns about possible mismanagement of the seizures and of the apparent medical emergency unfolding.

This illustrates a fundamental need for institutional protocols to prioritize potential medical emergencies and their management over all other clinical concerns. Whether this series of decisions constitutes reasonable error or indefensible medical error (Bosk, 2003) is a matter of debate because it involves such seemingly obvious issues of patient safety and welfare. At a minimum, the institution must implement protocols detailing the absolute priority of any bona fide potential medical emergency over all other concerns. In this case, appropriate prioritization of the emergency would have emphasized seizures management through less conservative medication dosages, faster orders for a transfusion, and (possibly) immediate return to the operating room to remove the strips and grids. Emergency management always has priority over data collection management and over long-term post-operative complications. Finally, the epilepsy specialist should also have immediately deferred to the exigencies of the medical emergency and to the neurosurgical and MSICU staff upon being consulted. Institutional protocols for specialists should also address that issue.

Need to Establish Protocol for Addressing Concerns and Personnel Identification

Timmermans (2003) details the manner and degree to which the professional hierarchies in modern medicine sometimes contribute to medical errors in the clinical setting. More specifically, the power differential, particularly between physicians and nurses frequently operates as a barrier to the immediate and most timely recognition of possible errors when they are still either preventable or their associated harm to patients capable of being minimized. In this case, for example, all three MSICU nurses recognized that the seizures (and, more generally,) the medical emergency was being handled inappropriately. Nevertheless, they all failed to voice their concerns, as frequently in the case as between nurses and physicians or between nurses and surgeons in the operating room (Timmermans, 2003). In this case, that power dynamic was only exacerbated by the fact that the entire MSICU nursing team had never received training in management of the type of clinical issues presented and by the fact that they were excluded from any consultation in connection with a post-operative management plan.

Therefore, it is recommended that the institution immediately implement a policy of "see something, say something" according to which all members of healthcare teams are encouraged to speak up irrespective of power differentials. Furthermore, that protocol must include a statement of policy insulating any member of a healthcare team who does voice a legitimate concern in good faith from any retaliation or other negative response that could conceivably deter such diligence. Finally, the record of this case also indicates the immediate need for protocols requiring all members of the healthcare team to identify themselves to other members of the team, especially in connection with communications taking place over the telephone or other media besides face-to-face interactions where relative seniority and authority are obviously apparent to all involved.