A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedure for hypoplastic left heart syndrome. The child initially made good progress. He was weaned from inotropic support and tolerated enteral liquids on the first postoperative day. That evening the child developed respiratory distress with acidosis and fever. The resident physician notified the on-call ICU attending, who came in from home to manage the child's respiratory status. The surgeon called from home to check on the child at midnight and spoke with the resident, who indicated that the child had suffered respiratory deterioration and that the ICU attending was at the bedside managing the patient. The surgeon requested an echocardiogram but did not speak directly to the ICU attending, and the cardiology fellow who performed the echocardiogram communicated results to the surgeon, the child's attending of record for this admission.
After stabilizing and monitoring the child's respiratory status, the ICU attending returned home. The resident communicated with the ICU attending by phone and pager through the rest of the night, as the child's status was not improving as expected. The resident assumed the ICU attending was communicating with the surgeon, and did not contact the surgeon or cardiologist. The child suffered a cardiac arrest at 7:00 AM from low cardiac output. The surgeon and cardiologist arrived in the ICU for rounds just minutes before the arrest. Despite aggressive resuscitation efforts, the child suffered massive brain injury and subsequently died.
In post-event debriefings, staff identified several issues in the care of this patient. The attending surgeon and cardiologist were only briefed on the initial respiratory distress and did not have a complete picture of the child's condition; similarly, the ICU attending focused on stabilizing the child's respiratory status and missed his low cardiac output. There was confusion among the resident physicians and nursing staff about who was coordinating the child's care, and a lack of awareness of how to ensure effective team communication when multiple attending physicians are involved in caring for a child. The residents and nurses noted that having the ICU attending physician at the bedside left them with the impression that the surgeon and cardiologist were being updated about the child's continuing deterioration. The nurse observed the resident on the phone frequently discussing the case, and did not realize that no one was communicating with the other physicians involved. The resident and nurse either did not recognize the need to escalate the case beyond the ICU attending, or were not comfortable doing so. The surgeon and cardiologist were under the impression the child's issues were respiratory, not multi-system, and because of this, as well as the belief that the attending ICU physician was in-house throughout the night, neither of them recognized a need to go to the hospital to evaluate the child.
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