NURSING AND THE LAW AMELDA LANGSLOW LLB
Infection control and tho
polo of nursing caro plans
THE CASE IN THIS
MONTH'S COLUMN IS
OF PARTICULAR INTEREST
GIVEN THAT A NURSING
CARE PLAN WAS CEN-
TRAL TO THE NURSES'
DEFENCE IN LITIGATION.
In Starkcy v Cannell and others' the
plaintiff claimed she had suffered
renal damage and almost total
loss of hearing as a resuh of the
negligence of an obstetrician, a
nephrologist, a vascular surgeon and
two private hospitals in Melboume,
At issue was the nursing manage-
ment of a Hickman catheter and the
administration of an antibiotic (gen-
tamicin) and a diuretic (fruseniide).
MEDICAL BACKGROUND
On 2 June 1987, Bronwyn Starkey
aged 30, and eight weeks pregnant
with her first child, was admitted to
hospital v^/ith constant vomiting.
An insulin dependent diabetic,
Bronwyn also suffered from inter-
mittent psyehiathc disorders
including depression. Her father
was the referring doctor and she
came under the care of an endocri-
nologist and an obstetrician.
Bronwyn was discharged on 4 June
oniy to be readmitted the following
day. She was given intravenous
therapy with a number of drugs
including Largactil and discharged
on 13 June. Four days later she
was admitted to a second hospital
witb vomiting and a urinary tract
infection. Antibiotics cleared the
infection and a nephrologist found
some evidence of mild diabetic
nephropalhy.
The obstetrician remained
Bronwyn's treating doctor during
her five subsequent visits to the sec-
ond hospital. The medical team,
which now included a psychiatrist
and a gastroenterologist, eould Rnd
no obvious cause or specific treat-
ment for the vomiting.
Bronwyn"s depression continued as
did her weight loss. The endoerinol-
30 VOLUME 3 NO 9 AUSTRALIAN NURSING JOURNAL • APRIL 1996
ogist, who specialised in diabetes,
said in his notes on 26 October that
he had 'not seen a pregnaney
behave like tbis' and on 5
November: 'Again, what more ean
we do. She is nauseated and vomit-
ing, has a very flat affeet and is not
taking her Largaetil.'
Because of Bronwyn's poor oral
intake, difficulty with intravenous
access and nutritional deprivation, a
Hickman catheter was inserted
under general anaesthetic on 20
November and total parenteral
nutrition commeneed using an
IVAC pump.
The Nursing Care Plan read:
'20,11,87 - Hickman catheter
inserted, {Nursing goal) - 'to main-
tain patency of catheter and prevent
ascending infection', (Nursing
action) - 'strict aseptic technique
when changing dressing and lines
i.e, sterile gown, gloves, mask-
maintain IV therapy as ordered by
The possihie causes of infection included surgical
infection, postoperative infection as a result of some
unidentified event, and negligent handling hy a nurse.
doctor - observe insertion site -
observe temperature, pulse and
resp(iration) for.,.infection...main-
tam F(luid) Bialance) C(bart).'
Bronwyn was noted as being very
drowsy and lethargie over the next
few days and tbe vomiting contin-
ued intermittently.
THE RECORDS
25 November: catheter site (chest
wound) was dressed using betadine;
tbe lines changed using sterile tech-
nique and faulty IV AC pump
changed. The endocrinologist noted
ibal Bronwyn looked 'more
stunned", "more Parksonian', and
asked the psychiatrist to review the
Largactil dose.
26 November: Second pump was
not functioning. Burette installed.
By the evening the neck wound
(which had been cheeked and
cleaned with chlorhexidene in the
morning) was 'red and inflamed'
Bronwyn was noted to have 'the
shakes on and off. A full blood test
and removal of the sutures ordered
by obstetrician,
27 November: Nurse B recorded:
'Wound re-dressed. Sutures
removed. Steri strips and light
gauze applied. Bronwyn was com-
plaining of tingling lips and legs,
feeling eold and was very shaky.
A resident doctor believed her to
be hyperventilating. At 6 pm her
temperature was 38''C and the
obstetrician prescribed eephalothin
(Keflin) and ordered a full blood
examination and blood cultures. Her
creatinine level was .07 mmol/l.
28 November: 6.30 am, Bronwyn
flushed, with rapid pulse and a tem-
perature of 39"C. Septicaemia
suspected. Gentamiein adminis-
tered. The catheter left in place and
given the now serious risk to both
mother and baby, a eaesarean sec-
tion was performed and a baby girl
(Emma) successfully delivered.
High temperatures persisted,
Gentamiein 12 hourly. Oedema
noted,
30 November: Hickman catheter
removed.
1 December: Gentamiein levels
tested. Bronwyn's general condition
improved Temperature 37.8°C.
2 December: The endocrinologist
noted 'Settling well, I think the
infection is coming under control
but would like another 24 hrs more
of intravenous antibiotics'. A creati-
nine level of 0.17 mmol/1 was
reported from a blood sample taken
at 8.45 am. First abnormal reading.
Gentamicin was administered at 9pm.
December 3: Blood pressure rose.
Evidence of protein in urine. Output
dropped markedly. Her creatinine
level was 0.28 mmol/1 and acute
renal failure was diagnosed. On the
nephrologist's recommendation
Gentamicin stopped. Lasix adminis-
tered and Bronwyn was transferred
under his care to the Nephrology
ward at a third hospital.
5 December: IV Lasix (250 mg)
was administered at 11.15 am.
Bronwyn complained of deafness in
ber right ear during the morning. A
resident doctor detected slight deaf-
ness in botb ears. Noted as 'very
witbdrawn' on 5 and 6 December,
7 December: Nephrologist ordered
a furtber dose of Lasix (250 mg) to
be given orally at 10 am. By luncb-
time, Bronwyn's hearing was
described as 'drastically decreased
to the extent that she can barely
bear, Sbe is relying on lip reading
and writing notes.'
10 December: Audiometry sbowed
a moderate to profound hearing toss
in the right ear and severe hearing
loss in the left ear. The renal failure
subsided.
24 December: Bronwyn transferred
back to tbe second bospital where
she remained until March 1988.
Her near total deafness remains per-
manent.
PLAINTIFF'S ARGUMENT
INFECTION
Justice Mandie found Bronwyn very
vulnerable to infection because of
ber diabetes, malnutrition, pregnan-
cy, surgical wounds and the CVP
line. Tbe possible causes of infec-
tion included surgical infection,
postoperative infection as a result of
some unidentified event, and negli-
gent handling by a nurse.
It was generally agreed that there
was no altemative to the use of the
Hickman catheter in a patient so ill
and that it would cany a significant
risk of infection and subsequent
septicaemia. Gentamicin was agreed
to be the correct prescription for
septicaemia and the Gentamicin lev-
els taken on 1 December indicated
satisfactory renal function.
However it was argued that the
septicaemia (infective agent staphy-
lococcus epidermidis) developed
as a result of the lack of aseptic
handling by nurses at the second
hospital and that no proper proto-
cols or nursing care plans were in
place. Bronwyn gave evidence, as
did her parents, that they bad seen
nursing staff attending the CVP line
and dressings witbout gloves or
The plan had heen descrihed hy medical
witnesses as 'a taiior-made nursing care
pian for a patient with a Hici<man catheter'
and Justice iVIandie was satisfied that it
provided an adequate procedure and
protocol...
masks and without washing tbeir
hands.
The court was told that on one occa-
sion Bronwyn had been in a sitting
room wben the pump started beep-
ing and a nurse was called in wbo
couldn't get it going. She had then
folded back tbe dressing of the
catheter to arrange or adjust fhe
junction of the line. Tbe nurse had
wom a gown but no gloves and had
not washed her hands. When giving
evidence. Bronwyn's father said
that a second nurse who was walk-
ing by was called in:
'She was asked by the first nurse to
assist in the adjustment of the drip
or the intravenous flow. She again
attended to the reservoir and the
pump. Then withdrew the covering
dressing again, disconnected it, and
then in some way tried to manipu-
late the tube lo get the drip
flowing.'
With what success, if any, on this
occasion?
'Apparently it started to flow again
and she was satisfied with their
efforts.'
The second nurse, wbat. if anything,
did she bave upon her bands?
'Nothing.'
What did she have upon her face?
APRILig96 • VOLUME 3 HO 9AUSTRALIAN NURSING iOURHAL
^No mask.'
What did she have by way of a
gown?
'No gown.'
Wbat precautions, if any, bad you
seen her take by way of cleansing
ber hands before doing this?
'She made no attempt to cleanse her
hands.'
Bronwyn's mother gave evidence
tbat on 27 November a nurse had re-
dressed tbe chest wound without
gloves, mask or gown,
Wbat bappened next?
'When she walked out, I was really
shocked and I went straight over to
Bronwyn and 1 said. That sister
didn 7 have an\ sterile gown, mask
or gloves on.'
Wbat did Bronwyn reply?
'Bronwyn just said, "Yes. a lot do, a
lot don't".'
ASEPTIC TECHNIQUE
An expert medical witness- told tbe
court tbat strict aseptic technique
meant no part of the human body
can touch the lines running from tbe
bag to the Hickman catheter unless
It is either protected by sterile
glo\es or the line is being managed
without touching the connection at
the end.
He said tbat if a nurse was not going
to use gloves, sbe or he should
scrub his or ber hands with an anti-
septic for 30 seconds or so. Gloves
were not required for the installation
of a new line or for bag changes.
Washing hands and a "no-touch"
tecbnique were sufficient together
witb the painting or swabbing of •
31
• the ends of the lines with disin-
fectant.
However gloves should be used
when dealing with any disconnec-
tion and reconnection of an existing
line. In his opinion, wearing gowns,
masks or hats was less important
than gloves and of little, if any, rele-
vance to an infection resulting from
staphylococcus epidermidis.
Justice Mandie accepted this evi-
dence, but was not satisfied that it
would be a failure to take reason-
able care to omit the painting or
swabbing of the lines with disinfec-
tant, in the circumstances.
Justice Mandie found it hard to
comprehend that Bronwyn's father.
as a medical practitioner who must
have understood aseptic technique,
and was aware of his daughter's
high susceptibility to infection, had
not complained about the sitting
room incident at the time. He found
inconsistencies in his evidence and
was not satisfied that any discon-
nection of the line or lack of aseptic
technique had occurred.
Further, the incident was probably
too early to be the infecting event,
because the evidence showed that if
bacteria entered the blood stream,
through the lumen of the catheter,
the onset of infection would be very
rapid.
The Judge also questioned the relia-
bility of Bronwyn's mother's
evidence and accepted that Nurse B
would have observed aseptic tech-
niques when re-dressing the wound
on 27 November, though she had no
recollection of the incident.
Justice Mandie also found good
grounds to question the accuracy
and reliability of Bronwyn's recol-
lection of events. At the relevant
time her memory would have been
impaired by a major tranquilliser,
she was very sick and was noted as
drowsy, lethargic and non-commu-
nicative.
THE NURSING CARE PLAN
The Judge found the nurses had
been properly trained in the use of
aseptic techniques and had a nursing
care plan which was kept at the foot
of the bed to instruct their care.
32 VOLUME 3 NO 9 AUSTRALIAN NURSING JOURNAL • APRIL 1996
The plan had been described by
medical witnesses as 'a tailor-made
nursing care plan for a patient with
a Hickman catheter' and Justice
Mandie was satisfied that it provid-
ed an adequate procedure and
protocol and that medical staff were
entitled to rely on the nursing care
plan as reasonably assuring proper
handling of the catheter by the nurses.
Although the possibility of isolated
instances of negligence could not be
excluded, he was not satisfied that it
had occurred in the way, or to the
extent, alleged.
Reviewing all the evidence, the
Judge round that on a balance of
probabilities, a surgical infection
suggested by the neck wound, was
the likely cause of the infection and
Eighteen nurses...were called as witnesses
in this case. Eight years atter the event, it
was understandahie that the majority ceuid
not rememher Bronwyn as a patient...there-
tore the hospitai records hecame decisive.
septicaemia. Neither the nurses or
the vascular stirgeon had been negli-
gent in their care.
GENTAMICIN
Judge Mandie found Bronwyn's
condition had remained potentially
life threatening during early
December and blood tests had not
yet determined the infective agent.
Acute renal failure and deafness
were side effects of gentamicin, but
Bronwyn's condition could have
deteriorated rapidly had it been
stopped.
The risk to her life outweighed
these risks. The elevated creatinine
levels had indicated significant
renal dysfunction, but expert evi-
dence did not establish that a
reasonably competent obstetrician
would have done other than admin-
ister the 2 December dose.
Permanent deafness resulted, but
had not been caused by the obstetri-
cian's negligence.
LASIX
Bronwyn argued that the nephrolo-
gist was negligent in ordering the
intravenous Lasix which may have
contributed to her loss of hearing.
Justice Mandie found:
• she was close to needing dialysis
with its own associated risks when
the Lasix was administered;
• that a high throughput of fluids
was necessary to prevent further
deterioration of renal function; and,
• that there had been no reasonable
alternative.
The likely cause of the deafness was
not the diuretic {an extremely
uncommon occurrence) but the gen-
tamicin.
Eighteen nurses who were on duty
at the second hospital were called as
witnesses in this case. Eight years
after the event, it was understand-
able that the majority could not
remember Bronwyn as a patient
(Nurse B, for example could not
recall redressing the wound on 27
November) therefore the hospital
records became decisive.
Documentation, as we have seen
many times before, can make or
break the defence of a hospital. •
REFERENCES
1 Justice Mandie delivered judgment in
the Supreme Court of Victoria {Starkey v
Connell S others No 12477 of 1990) on
July 26 1994.
2 This 63 page judgment contains much
useful expert medical opinion on infection
in hospitals but I can find no reference to
expert nursing opinion.