Critical incidentCritical incident

Presented byPresented bySteph Moule 22 November Steph Moule 22 November

20072007

IntroductionIntroduction

IncidentIncident PathophysiologyPathophysiology MedicationMedication Evidence based practiceEvidence based practice Nursing prioritiesNursing priorities Issues arisingIssues arising RecommendationsRecommendations ConclusionConclusion

IncidentIncident

Advocacy on behalf of adolescent Advocacy on behalf of adolescent patient with cystic fibrosispatient with cystic fibrosis (CF) (CF) by by

paediatric outreach nurse.paediatric outreach nurse.

AdvocacyAdvocacy

To plead on behalf of another To plead on behalf of another (Hawkins,1984).(Hawkins,1984).

Having a concern for a client’s rights Having a concern for a client’s rights and actively protecting those rights, and actively protecting those rights, even if this may cause conflict with even if this may cause conflict with other members of the health care teamother members of the health care team

(McMillan and Townsend, 1994)(McMillan and Townsend, 1994)

Advocacy nurseAdvocacy nurse

The role of nurses and midwives in The role of nurses and midwives in advocacy is to mobilise all interested advocacy is to mobilise all interested

parties around an issue which evidence parties around an issue which evidence shows will impact positively on health shows will impact positively on health

system performance system performance

(www.joannabriggs.edu.au)(www.joannabriggs.edu.au)

Advocacy paediatricianAdvocacy paediatrician

Young paediatricians Young paediatricians are reluctant to are reluctant to advocate.advocate.

Paediatric training Paediatric training programmes need to programmes need to improve training in improve training in this area this area (Berman, 1998).(Berman, 1998).

PharmacistPharmacist

Pharmacist has to work within Pharmacist has to work within legal constraints and hospital legal constraints and hospital policy.policy.

Responsible under code of rights.Responsible under code of rights.

NDHB policy states that ‘patients NDHB policy states that ‘patients being discharged will obtain their being discharged will obtain their medications from a community medications from a community pharmacy’.pharmacy’.

(NDHB, 2005). (NDHB, 2005).

PathophysiologyPathophysiology

Genetic conditionGenetic conditionAutosomal recessive diseaseAutosomal recessive diseaseAbnormal gene CF transmembraneAbnormal gene CF transmembraneConductance regulator (CFTR)Conductance regulator (CFTR)

FunctionFunctionTransfer of Cl ions through Cl channelsTransfer of Cl ions through Cl channelsAffects exocrine glandular systemAffects exocrine glandular system

Viscous secretionsViscous secretions impairs respirationimpairs respiration affects digestionaffects digestion increased risk of respiratory infectionsincreased risk of respiratory infections

Shortened life spanShortened life span ( average 28 years)( average 28 years)Death usually from CORD or Cor PulmonaeDeath usually from CORD or Cor Pulmonae

(Dinwiddie, 1997)(Dinwiddie, 1997)

Pathophysiology Pathophysiology

DiagnosisDiagnosis levels of Na & Cl in sweat measuredlevels of Na & Cl in sweat measured

Raised Cl above Na indicates possible CFRaised Cl above Na indicates possible CF

Also may test pancreatic functionAlso may test pancreatic function

SymptomsSymptomsFailure to thrive, despite good appetiteFailure to thrive, despite good appetite

Recurrent respiratory infectionsRecurrent respiratory infections

Salty sweatSalty sweat

Finger clubbingFinger clubbing

Delayed pubertyDelayed puberty

Male sterilityMale sterility(Dinwiddie, 1997)(Dinwiddie, 1997)

PathophysiologyPathophysiology

MedicationMedication

Pulmozyme (Dornase Alfa) nebuliserPulmozyme (Dornase Alfa) nebuliser Special authority number required.Special authority number required. Cost $294.30 for 6 ampoules (3 days Cost $294.30 for 6 ampoules (3 days

supply) supply) Action, decreases viscosity of sputum in Action, decreases viscosity of sputum in

patients with CF.patients with CF. Clinically best used in patients whose FEVClinically best used in patients whose FEV1 1

is less than 70% but greater than 40% is less than 70% but greater than 40% predicted for height & weght.predicted for height & weght.

(www.pharmac.govt.nz)(www.pharmac.govt.nz)

Evidence based practiceEvidence based practice

In a 12 week study carried out in the In a 12 week study carried out in the USA, Dornase Alfa was found to be USA, Dornase Alfa was found to be

safe, well tolerated and significantly safe, well tolerated and significantly improved pulmonary function in improved pulmonary function in

patients with previously untreated patients with previously untreated cystic fibrosis and advanced lung cystic fibrosis and advanced lung

disease. disease.

(Hamilton, Johnson & McCoy, 1996) )

Nursing PrioritiesNursing Priorities

Promote effective airway Promote effective airway clearance and prevent clearance and prevent infectioninfection

Maximize patient quality Maximize patient quality of lifeof life

Support patient and Support patient and familyfamily (Adams, McQuellin & Nagy, 1996)(Adams, McQuellin & Nagy, 1996)

Issues arisingIssues arising

Stress for patient and familyStress for patient and family Guilt/worry for parents due to genetic transmission.Guilt/worry for parents due to genetic transmission.

Financial burden on family.Financial burden on family. Patient denial, reluctance to accept treatment.Patient denial, reluctance to accept treatment. Delayed puberty, low self esteem due to poor body image.Delayed puberty, low self esteem due to poor body image. Isolation from peers due to frequent hospital admissions.Isolation from peers due to frequent hospital admissions. Fear of dying, previous death of sibling verses invincibility fable.Fear of dying, previous death of sibling verses invincibility fable. Developmental considerations.Developmental considerations.

(Adams, McQuellin & Nagy, 1996)(Adams, McQuellin & Nagy, 1996)

Poor discharge planningPoor discharge planning Patient was discharged from hospital with insufficient supply of Patient was discharged from hospital with insufficient supply of

medication.medication.

Issues arisingIssues arising

Legal issuesLegal issues

Pharmac’s objective is to secure for eligible people in need of Pharmac’s objective is to secure for eligible people in need of pharmaceuticals the best health outcomes that are reasonably achievable pharmaceuticals the best health outcomes that are reasonably achievable

from pharmaceutical treatment and within it’s budget.from pharmaceutical treatment and within it’s budget.

Under Crown Entities Act 2004 Pharmac must consistently act to achieve it’s Under Crown Entities Act 2004 Pharmac must consistently act to achieve it’s

objectives whilst performing it’s function.objectives whilst performing it’s function.

In order for Pharmac to fulfill it’s obligations the clinician must complete a In order for Pharmac to fulfill it’s obligations the clinician must complete a 16 page application form and the patient must be regularly reassessed.16 page application form and the patient must be regularly reassessed.

(www.pharmac.govt.nz)(www.pharmac.govt.nz)

Issues arisingIssues arising

Ethical issuesEthical issues Code of health and disability services consumers rights, right 4.Code of health and disability services consumers rights, right 4.

Every consumer has the right to have services provided in a manner Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of that minimises the potential harm to, and optimises the quality of life of, that consumer.life of, that consumer.

Providers should cooperate with each other to ensure the consumer Providers should cooperate with each other to ensure the consumer has quality care.has quality care.

Beneficence and justice are fundamental values of NZNO and are Beneficence and justice are fundamental values of NZNO and are recognised in the code of conduct for nurses.recognised in the code of conduct for nurses.

Issues arisingIssues arising

Political issuesPolitical issues Cost to New Zealand of ongoing treatment.Cost to New Zealand of ongoing treatment.

Currently there are in excess of 300 children and adults with CF in Currently there are in excess of 300 children and adults with CF in New Zealand. New Zealand.

Cost to hospital pharmacy while waiting for ‘Special Authority’ Cost to hospital pharmacy while waiting for ‘Special Authority’ number.number.

Health professional resources taken up by continual reassessment Health professional resources taken up by continual reassessment for eligibility of medication.for eligibility of medication.

RecommendationsRecommendations

If there is a strong possibility that a ‘special authority’ number If there is a strong possibility that a ‘special authority’ number will be required from Pharmac for a patient to receive will be required from Pharmac for a patient to receive medication after discharge, consideration should be given medication after discharge, consideration should be given to this matter well before the patient leaves hospital.to this matter well before the patient leaves hospital.

If this special authorisation is not in place prior to discharge If this special authorisation is not in place prior to discharge then the patient should be sent home ‘on leave’ to then the patient should be sent home ‘on leave’ to minimise disruption for the patient and family.minimise disruption for the patient and family.

Young paediatricians should be given the knowledge and Young paediatricians should be given the knowledge and confidence to advocate for their patients.confidence to advocate for their patients.

ConclusionConclusion

IncidentIncident

AdvocacyAdvocacy

Pathophysiology of CFPathophysiology of CF

MedicationMedication

Nursing prioritiesNursing priorities

Wider issuesWider issues

RecommendationsRecommendations

The endThe end