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Introduction

The paediatric patient assessment and nursing accountability and responsibility are discussed and verified considering the case of Hunter. Patient risks and missed opportunities are identified and how holistic approaches to treat Hunter are unmet under different circumstances. The case elaborates on how misjudgement and mistreatment were carried out throughout the patient’s stay in the regional hospital. Also, the advocacy and effective communication failed to be retained by the medical team. The assessment develops insights on a holistic paediatric assessment and underlying factors necessary to make decisions for care provision for the patient. The information is specific to the case patient; however, put forward a general assessment to avoid similar situations in the future.

Patient risks and missed opportunities

Hunter was 8-year-old boy when he was diagnosed with Autism Spectrum Disorder (ASD) Level 1. He was admitted to the regional hospital after visiting the emergency department for his severe stomach pain. The previously diagnosed disorder has impacted his development and led to a delay in speech recognition and communication. As explained by the Centres for Disease Control and Prevention, CDC, (2023), ASD-affected children are enhanced with developmental delays and therefore, lead to communication issues, speech restriction, and repetitive behaviours. Considering the state and condition of Hunter, the proper assessment of his stomach pain is severely impacted. The initial triage after visiting the ER was carried out with Ondansetron to reduce nausea. Hunter was in continuous distress and felt uncomfortable with an extended period of treatment. Even after mediation and continuous examination, there has been a gap in the proper assessment. On different occasions, immediate and appropriate measures are declined by the paediatric team. For instance, the clinical management report from 15-16th March 2020 shows that the patient was unable to indicate the region of his pain to the doctor, which is a sign of ASD. From a registered nurse perspective, a CT scan and inpatient review were necessary at the moment; however, they were declined by the medical team.

After a day's stay and under different medications, even though the condition was stable along with his vitals, Hunter felt immense stomach pain again, followed by vomiting and loose bowels. Despite the necessary query for bowel obstruction, PHO-2 has marked no likely obstruction considering the X-ray report. In this particular situation, the patient risks have increased with mistreatment and misjudgement. According to the case, PHO-2 has misjudged Hunter’s condition for constipation and viral illness as a credible cause of nausea, pain, and vomiting. Demarest et al. (2023) explained that bowel obstruction (intestinal obstruction) is a complication for gastrointestinal and genitourinary tumours. The symptoms are similar to constipation and viral illness; however, proper diagnosis is required for confirmation. From an RN’s perspective, Jodie has repeatedly explained Hunter’s condition and requested extra medications and a nasogastric tube. However, the misjudgement of the condition led to unmet needs. 

Holistic Paediatric Assessment

In the above assessment, patient risks and missed opportunities are identified at every stage of the treatment. The paediatric team has neglected their responsibilities as required to treat Hunter’s clinical deterioration despite his mother’s concern for necessary treatment options. A holistic approach to clinically assess bowel obstruction in paediatric patients needs distinguished measures, although initial symptoms of this syndrome are confusing and non-specific (Mayo Clinic, 2021). Moreover, the case overview explains that the surgical team lacks effective training to assess autistic patients and henceforth appears to have misjudged both the patient’s condition and the clinical measures to be underpinned. Upon presenting the situation, one of the common holistic assessments for bowel obstruction is bedside ultrasonography (USG) which can allow the pediatric team to initiate appropriate and rapid decision-making (Fukuhara & Yamaguchi, 2019). Turcotte & Faure (2022) explained that intestinal pseudo-obstruction (IPO) is a rare and complicated syndrome that signifies gastrointestinal mortality and has the potential to cause morbidity and mortality among young children. The initial indications of symptoms include bilious and non-bilious vomiting, stomach pain, intestinal occlusion, and nausea. From these specifications, it is understandable that the holistic assessment for Hunter was unmet, considering which effective decisions failed to reach for bowel obstruction by the paediatric team.

Based on the clinical assessment of Hunter, another factor comes into consideration. The Children’s Early Warning Tool (CEWT) has been used to document the paediatric risk and accordingly proceed with medical intervention. Trubey et al. (2019) explained that pediatric health deterioration in hospitals is caused by multifactorial problems which are unrecognized initially. In the concerned case, however, Hunter’s condition shows that the paediatric team has neglected the CEWT score even though it shows a clear sign of health deterioration. Moreover, on the day of Hunter’s death, his vitals show rapid respiratory and heart rate and afebrile condition with a CEWT score of 4. Trubey et al. (2019) further stated that “early warning system” monitoring is multifaceted and therefore requires quick response from the medical team, education, and training to make proper decisions in treating pediatric health complications. Another study conducted by Silva et al. (2023) has mentioned a widely used procedure among pediatric patients named Bishop-Koop Ileotomy that intended to include a significant amount of bowel in intestine transit to manage children with bowel obstruction or intestinal atresia. This method has gained high recognition as an improvement in testing “distal bowel function” among children with bowel motility.

Upon presenting the approach and assessment of holistic pediatric care, it can be explained that Hunter’s case supposedly needed an immediate CT scan and USG to confirm the bowel obstructive syndrome. Moreover, interventions based on CEWT scores were a much-needed approach at the time.

Advocacy, Human Factors, and Effective Team Communication

The case study observation and analysis of missed opportunities served to provide a better understanding of the lack of situational awareness among the medical team. It has been observed that under different circumstances, advocacy, and human factors (physical, cognitive, and emotional) are not recognized with the persistent deterioration of Hunter’s condition (as per CEWT score). It leads to ineffective comprehension of clinical assessment/reassessment with extensive investigations. Although there is a communication identified among the medical team, lack of advocacy to access proper treatment and human factors necessary to intervene in this situation led to a gap in making informed decisions. Hubinette et al. (2017) explained that health advocacy is important to enable individuals to access care, system navigation, and mobilize resources to prevent health inequities.

According to the review of Hunter’s autopsy report, it has been determined that there is a small distal bowel strangulated within band surfaces leading to infarction. The strangulated adhesive recognized the condition of ischemic bowel. In this rare and complicated circulatory condition, bowel-supplying arteries are affected (blocked) thus, reducing the blood flow (British Heart Foundation, 2023). Tong Lingam & Shelat (2020) explained that this condition enhances approximately 12-16% “emergency surgical admissions” and almost 20% surgical manifestation. Henceforth, the need for health advocacy, human factors and paediatric team communication are necessary to be administered.

Human factors (HF) imply certain factors that regulate self-performance during the care and also impact the interaction among teams. Considering the case of Hunter, human factors are necessary to focus to enhance safety and effective communication among the team (both verbally and non-verbally). Brennan & Oeppen (2022) explained that team interactions although essential, it can cause patient safety issue, errors in communications and steep hierarchical gradients leads to potential lacking in situation awareness. Thus, focusing on Hunter’s case, human factors such as situational awareness and communication are considered to enable the team to understand the situation and approach accordingly the holistic intervention already mentioned to treat and manage bowel ischemia.

Innovative strategies implemented to mitigate risks of missed opportunities

When caring for pediatric patients, a registered nurse (RN) must be responsible and account for both treatment approaches and underlying risks with bowel ischemia. In Hunter’s care, several missed opportunities are identified. In this regard, a proper follow-up of strategies with response to “National Safety and Quality in Healthcare Standard (NSQHS) partnered with Consumer Standard are considered. The NSQHS standards are developed to protect general public from any harm and ensure the provision of quality health services (National Safety and Quality Health Service Standards, 2023). The standards are identified under NSQHS and considerable based on the case report of Hunter.

Partnering with consumers standard is identified as the first strategy that involve a patient-cantered system and include patients to share decisions. Accordingly consumers can also be involved (here Hunter’s parents) to develop and design healthcare system that ensure proper care for ASD patients and understand their dilemma in recognizing pain.

Comprehensive care is the next standard to be considered here, that identify a strategy to screen and assess the risk of the disease on time to develop an individualized plan to care, prevent and reduce risks to the patient.

Communication to ensure safety standard identifies a strategy that can promote effective interaction among patients, families and the medical team. To mitigate a similar situation as in the case of Hunter, situation awareness and proper communication among multidisciplinary teams, patients and families are important.

Recognition and Response to Acute Deterioration is another standard that introduced a strategy to respond to the health deterioration of the patient physically, mentally or in cognition. Hunter’s health was rapidly deteriorated yet no proper recognition or response was administered. To avoid similar situation, appropriate and on-time response to acute deterioration of the patient should be administered.

Conclusion

The overall assessment of the clinical report of Hunter provides an understanding of his condition and the clinical journey the patient has taken. Under certain negligence and lack of situational awareness, the fatal consequence of the patient is identified. This assessment, therefore, provides an acknowledgment from an RN’s accountability and responsibility perspective to understand the management and treatment intervention supposedly considered to treat bowel ischemia upon underpinning missed opportunities for Hunter’s condition.

Reference

Brennan, P. A., & Oeppen, R. S. (2022). The role of human factors in improving patient safety.  Trends in Urology & Men's Health ,  13 (3), 30-33. https://wchh.onlinelibrary.wiley.com/doi/full/10.1002/tre.858

British Heart Foundation, (2023). What is bowel ischemia? https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/ask-the-experts/bowel-ischaemia#:~:text=When%20the%20arteries%20supplying%20the,a%20clot%20blocking%20blood%20flow.

Centers for Disease Control and Prevention, (2023). ASD Diagnosis, Treatment and Services. https://www.cdc.gov/ncbddd/autism/facts.html#:~:text=People%20with%20ASD%20often%20have,can%20make%20life%20very%20challenging.

Demarest, K., Lavu, H., Collins, E., & Batra, V. (2023). Comprehensive diagnosis and management of malignant bowel obstruction: A review.  Journal of Pain & Palliative Care Pharmacotherapy ,  37 (1), 91-105.https://www.tandfonline.com/doi/abs/10.1080/15360288.2022.2106012

Fukuhara, S., & Yamaguchi, Y. (2019). Small bowel obstruction and the role of bedside ultrasonography performed by a pediatric emergency physician: a case report.  Journal of Acute Medicine ,  9 (4), 194. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440378/

Hubinette, M., Dobson, S., Scott, I., & Sherbino, J. (2017). Health advocacy.  Medical teacher ,  39 (2), 128-135. https://pubmed.ncbi.nlm.nih.gov/27866451/

Mayo Clinic, (2021). Intestinal Obstruction. https://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/diagnosis-treatment/drc-20351465

National Safety and Quality Health Service Standards, (2023). Australian Commission on Safety and Quality in Healthcare. https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

Silva, M. A. C. P. D., Miranda, M. L., Oliveira-Filho, A. G., & Bustorff-Silva, J. M. (2023). BISHOP-KOOP OSTOMY REVISITED: A “TEST-DRIVE” INTESTINAL DIVERSION FOR CHILDREN WITH SUSPECTED BOWEL DYSMOTILITY.  ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) ,  36 , e1722. http://rajournals.com/index.php/raj/article/view/410

Tong, J. W. V., Lingam, P., & Shelat, V. G. (2020). Adhesive small bowel obstruction–an update.  Acute Medicine & Surgery ,  7 (1), e587. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642618/

Trubey, R., Huang, C., Lugg-Widger, F. V., Hood, K., Allen, D., Edwards, D., & Powell, C. (2019). Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review.  BMJ open ,  9 (5), e022105. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502038/

Turcotte, M. C., & Faure, C. (2022). Pediatric intestinal pseudo-obstruction: progress and challenges.  Frontiers in Pediatrics ,  10 , 837462. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9045367/

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