The Importance of Implementing Updated Guidelines in a Timely Manner.

The Importance of Implementing Updated Guidelines in a Timely Manner.

Setting the Scene

In this case, the Patient suffered a stillbirth at 7 months gestation after no foetal heartbeat had been detected. Following the birth of her baby she was discharged, and attended by a bereavement midwife and the post-natal check was noted as being satisfactory. Four weeks after the still birth, she developed a rash on her lower leg (calf) and went to a hospital Emergency Department complaining of feeling unwell for the past 3 days. She was assessed as having a streptococcal infection, given an IV course of antibiotics and discharged to her GP’s care. Four days later, the GP suspected a DVT in the lower leg and referred her to a DVT clinic where a scan confirmed the presence of a DVT which was ‘likely provoked by the recent pregnancy.’ She was prescribed an 8-week course of Clexane (a drug to prevent blood clots).

At approximately 12 weeks gestation, the Patient was assessed for the risks of VTE (Venous Thromboembolism) using local guidance, which was based on the College of Gynaecologists (RCOG) 2009 VTE Guidelines. She was assessed as being low risk despite being a smoker (which partially raises the risk). She was reassessed on admission for the birth and post-partum when it was confirmed that the baby was deceased. Again, the hospital followed the 2009 guidelines for VTE risk and she was considered to be low risk. Had the 2015 guidance been applied, the patient would have qualified for 10 days of postnatal thromboprophylaxis.

The salient point of this case study is the fact that the local hospital guidance was based on the 2009 RCOG guidelines, that had been superseded by an updated version in 2015, which contained significant changes. This case was some 18 months to 2 years later and there should have been ample time for the hospital to implement the new guidelines.

Main Learning Points

• The 2015 updated guidelines assess that being a smoker and suffering a stillbirth increases the risk of a VTE, and therefore, the Patient should have been assessed as intermediate, rather than low risk. Under the protocols of the 2009 guidelines, she was assessed as low risk.

• Guidelines in all areas of medicine are constantly being updated. Sometimes they are extremely complicated and involve new methods, drugs or multiple departments. This was not the case with the RCOG 2015 guidelines. They did not involve the use of new drugs or methods; only in how the assessments of classifying risk were made and, in this case, it was crucial information that was missed.

• VTEs are one of the major causes of maternal death and therefore the hospital should have implemented the updated guidelines swiftly, preferably within 6-12 months but certainly not almost 2 years later. • The Patient was assessed for VTE three times and on each occasion was wrongly assessed as low risk.

Reducing the Risk of Litigation

By not implementing the updated VTE guidelines for a serious condition in pregnancy, the hospital put themselves at an enhanced risk of litigation.

TMLEP recommends the following:

• Guidelines and training for staff should be introduced as quickly as possible, particularly in serious conditions where the new protocols are not particularly different or complicated.

• It would be expected that VTE assessment guidelines would be considered a priority by a hospital, since it is one of the leading causes of maternal death in pregnancy.

To Summarise

It would have been expected that the hospital would have implemented the 2015 guidelines within 12 months. If they had done so, the Patient would have been assessed as intermediate risk and, on discharge after the stillbirth, would have been given a course of anti-coagulant drugs to try to prevent a VTE occurring.

References

  • Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Mr Jonathan Ash, Consultant Obstetrician & Gynaecologist.. (2020). The Importance of Implementing Updated Guidelines in a Timely Manner.. TMLEP Clinical Risk Case Studies. 4 (9), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.