Disclaimer: The case described below is entirely fictional, and any resemblance to real situations is only coincidental. This exercise aims to allow you to see the example of a report that a client will receive after requesting an “Expanded Review.”
Final Report – Expanded Review:
Thank You for allowing me to assist you with reviewing the quality of medical care provided to your child in Hospital X. Please read this review carefully and write down any questions you may have. We will discuss your concerns and questions during our follow-up phone conversation. I will schedule it within the next week if you are available.
Summary of the case:
The patient (baby boy – John Smith) was born by urgent cesarean section on 10/21/2022.
Maternal history: Mother (Mary Smith) is a 28-year-old, generally healthy, white woman. She was receiving regular perinatal care during her pregnancy from her obstetrician (Doctor Z). Her prenatal labs included blood type O Rh positive, GBS test positive, RPR negative, and HepB antigen-s negative. Mary Smith presented in labor on 10/20 at 9 a.m. at 39 weeks of gestational age and was admitted to a labor room. The initial phase of her delivery was unremarkable. On 10/22, around 9 a.m., she started having a lot of pain in her lower abdomen. She delivered a baby boy by cesarean section 2 hours later. The cord blood gases from the umbilical vein and artery showed a pH of 6.7.
Birth Hx: Baby was born by urgent C/S (due to decelerations for the last 2 hours). Birth Weight: 3.5 kg. which was appropriate for gestational age. Apgar scores: 1 at 1 minute, 0 at 5 minutes, 0 at 10 minutes, 1 at 15 minutes, 2 at 20 minutes, 5 at 30 minutes. Subsequently, the baby was transferred to an Intermediate care nursery for further care.
Resuscitation in Operating Room: Baby received Positive Pressure Ventilation – PPV (artificial breathing) from 3 minutes of life, chest compressions from 5 minutes, and 3 doses of epinephrine via ET tube placed only at 20 minutes of life. Only one nurse in the OR was available to start CPR on the baby. Another nurse arrived at 2 minutes of life, and a doctor-pediatrician came several minutes later. There were no attempts to insert an umbilical or intraosseous line during resuscitation.
Hospitalization course: The patient was placed on a ventilator and was treated with antibiotics and fluids. X-ray done two hours later showed pneumothorax. The chest tube was inserted. The patient did not show any movements of extremities and had very low muscle tone while in the birth hospital. The pediatrician called a level 3 NICU at 8 hours of life, and the baby was transferred out 9 hours after the birth. The patient died the following day in level 3 NICU at University Center. The autopsy report from the university hospital is not available yet. Doctors performed a head ultrasound at the university center, which showed grade 3 intraventricular hemorrhage.
Statement regarding the standard of care:
Medical management did not meet standards of care. It led to a new disease or symptoms or worsened the existing condition. It resulted in physiological or anatomical impairment, disability or death, and unnecessary prolonged treatment, complications, or admissions.
Justification for the above statement:
Resuscitation was not conducted promptly, there were not enough skilled people in the OR to treat the baby, and they did not follow guidelines for neonatal CPR. Providers did not order a chest X-ray on admission to the NICU. Therefore, they diagnosed a pneumothorax only 2 hours later. Since the X-ray showed an ET tube in the right stem bronchus, the pneumothorax could have been avoided or diagnosed much earlier.
Delayed and inappropriate treatments in the OR and NICU caused the worsening of the physiologic status of the baby. Delayed diagnosis of pneumothorax significantly contributed to the prolonged unstable condition in the NICU (low blood pressure, poor blood perfusion, decreased urine output, and low oxygen levels). All that likely contributed to intracranial bleeding (bleeding in the brain) and subsequent death of the baby.
List of deviations from the standard of care:
- Only one person (nurse) was available in the OR to initiate resuscitation efforts for the baby right after birth. The second nurse arrived at 2 minutes of life, and a pediatrician even later. A neonatologist was absent from the hospital and did not even come in person to consult on the patient. He provided only the consultation on the phone. According to “Guidelines for Perinatal Care” (Ref.2), …” if additional factors are present that increase the likelihood of the need for resuscitation, at least two qualified people should be present solely to manage the baby.” In this case, the obstetrician called for an emergency cesarean section due to the threat to the baby’s life; it is evident that pediatric providers should have anticipated the need for resuscitation and should have had enough personnel and equipment on site.
- Delay in initiation of PPV – positive pressure ventilation. The pediatric providers started positive pressure ventilation only at 3 minutes of life after the second nurse arrived in the OR. It needs to be clarified why there was so much delay. Did the first nurse spend all her time calling for help or assembling equipment for CPR? We don’t know. The baby had clear indications to start PPV almost immediately after birth: the baby’s heart rate was below 100 per minute, and the baby was not breathing and had very poor muscle tone. According to guidelines for neonatal resuscitation (Ref. 1, page 75), “after completing initial steps, PPV is indicated if the baby is not breathing, or if the baby is gasping, or if the baby’s heart rate is less than 100 per minute. When indicated, PPV should be started within 1 minute of birth.”
- Delay in initiation of chest compressions. Chest compressions were started only at 5 minutes of life. According to the Neonatal Resuscitation Program (Ref.1, page 163), the chest compressions should be started “if the baby’s heart rate remains less than 60 per minutes after at least 30 seconds of PPV…” This baby only had a faint heart rate at birth; therefore, PPV should have been started at 1 minute, and chest compressions no later than 1.5 – 2 minutes after the birth.
- The pediatrician arrived only 12 minutes after the birth of the baby. The pediatrician was on call in the hospital. Therefore, it is unacceptable that he was not present in the OR during the cesarean section. Given that it was an emergency cesarean section, providers should have expected the need for resuscitation, and the most qualified people should have been ready in the room.
- Intubation took place at 16 minutes of life after 3 attempts. Intubation is a procedure during which we place a breathing tube called ET into the baby’s trachea. After connecting it to the device, we can push air with oxygen into the baby’s lungs. In this case, there was a significant delay in placing the ET tube. Also, the pediatrician tried three times before he succeeded in doing it “correctly.” It seems that the provider was inexperienced in performing this procedure. We know from the later developments in the NICU that an ET tube was placed in the right stem bronchus, resulting in a right-sided pneumothorax. Guidelines for neonatal resuscitation suggest that inexperienced providers should use another technique of establishing the proper airway, a laryngeal mask. That procedure was not tried in this case (Ref. 1, page 87).
- Epinephrine was administered 3 times via ET tube and not intravenously. Scientists doubt the effectiveness of epinephrine that is delivered via an ET tube. Guidelines strongly recommend that epinephrine be given via intravenous or intraosseous route (Ref.1, Chapter 7).
- Delay in obtaining a chest X-ray. It is customary that after most invasive procedures when we insert something in the baby’s body, we do an x-ray to ensure the proper location of the device. We do it after placing an ET tube or after placing umbilical catheters. If the treatment or diagnostics device is left in the wrong location for a prolonged time, it may cause complications. It took over two hours to take an X-ray in the NICU and find out that an ET tube was in the wrong place and the pneumothorax was present on the right side (read my article about pneumothorax here).
- Delay in diagnosing and treatment of pneumothorax. See my comments under paragraph 7.
- There was a delay in calling the university center to transfer the patient. Each hospital has different capabilities to care for patients. This hospital is designated as a Nursery Level 2, meaning this patient should have been transferred to NICU Level 3 for further treatment. Given that this patient should have also been diagnosed with HIE (Hypoxic Ischemic Encephalopathy), the transfer should have occurred within 6 hours of birth. The recommended HIE treatment (hypothermia) works best if initiated soon after birth. The whole body or head cooling therapies are available only in Level 3 Nurseries.
- The medical providers did not know that the patient should have been diagnosed with HIE (Hypoxic Ischemic Encephalopathy) and most likely qualified for specialized therapy such as whole body or head cooling. The patient had all indications for the diagnosis of HIE (low Apgar score, the need for prolonged resuscitation, low pH in cord blood gases, and abnormal neurological findings after birth). The treatment for moderate or severe HIE is hypothermia, which can be provided only in Level 3 Nurseries. Therefore, prompt communication with such centers was vital.
- The pediatrician consulted a neonatologist by phone, but a neonatologist never came to the NICU to lead stabilization efforts for this baby. The patient had a highly complex course since birth, which exceeded the pediatrician’s competency. The neonatologist was on call from home, but I understand he was expected to come to the hospital within 30 minutes if needed. It is still being determined why it did not happen. This patient was treated for over 8 hours in the birth hospital, required resuscitation, developed pneumothorax, and suffered from HIE. A skilled neonatologist should have been on site to assist the pediatrician with stabilization efforts and transferring this patient to the university NICU.
Additional Comments:
- Records show that Mrs.Smith started complaining of strong abdominal pain 2 hours before the birth. I am not an obstetrics expert, but given that history and reported decelerations during that period, providers should have considered the possibility of uterine rupture much earlier than the decision to perform a cesarean delivery was made. In this case, I strongly encourage the client to request an expert opinion regarding the care provided by an obstetrician.
- The “Code Sheet” was not filled out by providers, and the notes regarding resuscitation entered by the nurse and pediatrician are inconsistent. The neonatologist, who was consulted by the phone, did not write any note at all. It is customary that each nursery has a code sheet on which we record all observations and interventions we performed during the resuscitation.
- It may be of value to review staffing levels in this hospital. The plaintiff’s lawyer should request staffing-level records when the patient was born. Also, reviewing policies and actual practices regarding staffing levels may be of value.
- We need to learn more about the contract between the pediatricians and neonatologists in the birth hospital. Strangely, the neonatologist did not come in person to evaluate this patient.
- I did not receive any notes written by a respiratory therapist. We should find out if he charted periodic evaluations of breath sounds in this patient. RTs should document the settings on the ventilator and their regular assessments of the patient.
- The plaintiff’s lawyer should request statistics about the number of neonatal resuscitations conducted in this hospital annually and the training provided to medical providers on that topic.
- I did not receive consent forms obtained from parents before the doctor performed all the procedures (umbilical lines and chest tube placements).
- Since most deviations from standards of care occurred during the resuscitation of this baby, I strongly recommend reading my full article on this subject.
Things done correctly:
- The doses of antibiotics and fluids prescribed were correct
- The nurse performed Newborn State Screening
- The patient received Vit. K and erythromycin ointment after birth
- The chest tube to treat pneumothorax was inserted correctly, and its location was confirmed by X-ray
- The blood tests ordered were appropriate
References:
- Textbook of Neonatal Resuscitation – 8th edition – American Academy of Pediatrics and American Heart Association, 2021
- Guidelines for Perinatal Care – 8th edition – American Academy of Pediatrics and American College of Obstetrician and Gynecologists, 2017