Included in the notes from the morning’s ward round, which stated that the patient was medically fit for discharge, this short statement demonstrated that none of the 4 doctors in attendance had reviewed any of the nursing notes, or actually looked at the patients colostomy, in at least 6 days. Because if they had, they would have seen that the protruding section of large bowel that made up the colostomy site was not pink nor warm, but black, necrotic. It was dead. A small hard lump of strangulated flesh, set within the warm, softness of the patient’s belly.
The patient, David, was 9 days post-colostomy, a kind of surgery in which the colon (large intestine) is shortened and the newly cut end diverted through an opening created in the abdominal wall, known as a stoma (Latin for “mouth”). Post-op, patients are expected to make a quick recovery – mobilising after just a few hours and building up to a solid diet within a few days. David had hit all the milestones necessary on the road to a successful discharge. He was up and out of bed within 12 hours, had a successful trail without (urinary) catheter within 24 hours, was off his patient-controlled morphine pump by day 2 and had his midline wound staples removed on day 7. In this time, he had built up from sips to clear fluids, to free fluids, to a low fibre diet, and his stoma had been active with a good output correlating with his intake. He had been trained by the specialist stoma nurse and was emptying and changing his colostomy bag with their supervision.
When the doctors had spoken to him on their round that morning, he was able to tell the team that he wasn’t in pain, was eating and drinking well, that his output was good, and that he was able to care for his stoma independently. Happy with his answers, and after checking his midline wound, the team were pleased to be able to tell him they would be discharging him that day. They accepted his thanks, said their goodbyes, left the ward and David began packing his bags. Not too long later, dressed and raring to go, he asked his nurse if he needed to wait for anything or could just call a taxi and was taken aback by their response.
David’s trust in his medical team contrasted with his experience of the unreliability of the nursing team. Throughout his time as an inpatient, he’d seen at least some members of his surgeon’s team everyday – even at the weekend. Whereas his nursing team changed twice a day, every day, with new and rotating staff. When he had seen the same nurse more than once, they might have been working elsewhere on the ward or had days off in between shifts. He was constantly being asked the same questions and having to repeat important information. And was always either updating them on things they should know, or they were suddenly changing things without warning.
This meant that when David was told by his nurse that, despite what his doctor said earlier, they weren’t actually going to be discharging him today, he knew that she must be mistaken. And when she tried to explain that the nursing team were disputing the doctors’ decision, he was furious. He had been told by his surgeon that he was medically fit for discharge and, as the authority on these matters, his surgeon should be listened to.
He told the nurse this. Indignantly sharing his various observations about their incompetence and listing a number of occasions when, even though they knew what they should be doing, they hadn’t been organised enough to get it done: He had been scheduled to go for surgery at 8am, but had waited on the ward until mid-afternoon; there had been a huge delay taking down his morphine pump; and after being told that he could start eating solid food, they never ordered his lunch.
Unrecognised by him, however, the nursing team had actually been working incredibly hard to keep him safe. When an emergency admission on the day of his surgery led to it being cancelled, they had fought for him to still be taken down later that day – arguing that existing comorbidities meant he was at high risk of complications from not being able to eat, drink and take his regular medications for any sustained amount of time. Similarly, after surgery, they needed to make sure alternative oral medication was available when they removed his morphine pump. An adverse reaction to analgesia had meant they had to consult with a specialist pain team and then wait for his doctors to prescribe based on their advice before it could be taken down. Finally, although they had known he should be moving onto solid food, without written documentation from the medical team regarding this decision, they could not just let him start eating. After chasing and failing to get it confirmed in time for lunch service, one of the nurses had had to run to the kitchen to collect a packed lunch for him later that afternoon.
Even now, their decision to delay his discharge was in his best interests. Stoma necrosis is considered a medical emergency that usually requires urgent consultation with surgical services. While minor stoma discolorations can be monitored closely during the early postoperative period without requiring surgical intervention, severe necrosis necessitates timely stoma revision.
The nursing team had first noticed discolouration in David’s colostomy site when changing his stoma bag 6 days ago. They had highlighted this via David’s electronic health record (EHR) and uploaded images for the medical team to review. That was on the Wednesday.
On Thursday, they had told the surgical team told directly. Having already assessed the patient and without seeing the stoma, the doctors had documented a plan to discharge David after the weekend. They were just about to leave when David’s nurse caught up with them and passed on their concerns. The nurse documented this interaction, and that the surgeon confirmed that it should be closely monitored and to keep him updated.
The next day, however, the surgical team came early, before bedside staff had had a chance to empty and change David’s stoma bag. Contained within an opaque brown bag that was full of faecal liquid, and working under time restraints, they did not wait for it to be uncovered. When the stoma nurses changed the bag later that day, the bedside nurses took and uploaded new images and messaged the team to say they were available. It was late afternoon before one of the junior doctors messaged back instructions to “continue to monitor”.
Following this instruction, both times David’s stoma bag was changed over the weekend they had added new images to the EHR; documenting the spread of greying flesh slowly turned black. They continued to keep a record of their interactions with the surgical team, including two requests for reviews from the on-call staff (both Saturday and Sunday) but were advised by them to wait until the senior surgeons were back on Monday.
By Monday the stoma was clearly dead. And yet, despite this, the surgeons continued with their planned discharge. How could this happen?
Whilst stoma necrosis is a recognised complication of colostomy surgeries (with some associated risk from surgical technique, emergency operations, obesity and anatomical differences) identifying a root cause for individual cases is near impossible, and it is normally assumed to be a combination of factors. Similarly, the delays in diagnosing David’s stoma necrosis came from a combination of factors that hindered communication and decision making, making it impossible to pinpoint individual responsibility.
Firstly, strict demarcations around roles and responsibilities meant that, whilst highly skilled at conducting colostomy surgery, it is highly unlikely that any of the surgeons or junior doctors have ever changed a patient’s colostomy bag. Almost all wound and stoma care is conducted by nurses postoperatively. And whilst a wound might be uncovered by the surgical team and then left to be redressed by the nursing staff, the extremely high likelihood of the stoma bag being full of faeces means that doctors are very unlikely to uncover or request for the site to be uncovered during a ward round. Instead, the site is only ever really uncovered when the bag needs changing. This done either by ward or specialist stoma nurses until the patient is adequately trained. This means that doctors were completely reliant on patient and nurse feedback as to what the site looked like.
Opportunities for feedback was, however, very limited. On this surgical ward the bedside rounds happened quickly and early, before the consultants went into surgery for the day. I’m not sure whether it was a requirement or a formality for bedside nurses to be involved in rounding, but I do know that whilst the nurses were keen to be there, doctors would often conduct them regardless of their presence. When they arrived on the ward they would go straight to the patient’s bed space. If the nurse looking after the patient did not witness their arrival and drop what they are doing to join, they were not sort out or waited for. Instead, they were expected to consult the doctors notes in the EHR for any updates they might have missed. This meant that while the nurse managed to catch them before they left rounds on Thursday, no nurse was present for the surgeons’ conversations with David. Meaning that their observations regarding David’s colostomy remained absent from the ward round notes.
Furthermore, whilst ward nursing staff will work a whole shift at the bedside, other teams are often spread across multiple wards, departments and even buildings. Meaning that majority of cross-team communication outside of ward visits happens over the phone or via the EHR. The excess of data contained in the EHR means it has been designed to streamline information, with many sections hidden or inaccessible, depending on your role. The lack of tech available on the wards also means that doctors on their rounds are often forced to use their own mobile phones during rounds, using an app that presents only a limited view of patient records. Because of this, and because they were so short on time, doctors routinely just opened and followed on from the last ward round notes; copying and pasting relevant information, checking and updating test results and actions, but bypassing any nursing or miscellaneous entries.
For these reasons, perhaps, the pictures, notes and messages concerning David’s possible stoma necrosis were missed by the surgeons. Furthermore, where these gaps might have been normally filled in by the patient, because David – who was aware of the nurses concerns and assumed the doctors must be up-to-date with everything – was never asked by the surgeons about the colour of his stoma, he never thought to mention it. It is likely that, on Thursday, without the ability to routinely undertake stoma site checks, and without a nurse present to tell them otherwise, it is likely that the junior doctor taking notes for the team simply did not update a note that had been copy and pasted across from Tuesdays ward round stating “colostomy pink and warm to touch”. This error was then carried over to the following Monday.
Back to Monday afternoon, David’s nurse listened patiently to his complaints and then apologised for all the delays and issues he had experienced with his care so far. This wasn’t done to pacify him. It was partially said as an honest admission that things could possibly have been done differently and better. But mostly it was said because there was nothing to be gained by pointing fingers at other teams or team members when the majority of delays were down to due process.
Unfortunately for bedside nursing staff, their role meant they were often the face of every delay, mistake and miscommunication, even if not directly responsible. Whilst it may have been true that on some of the instances of delayed treatment David listed the nurses were “waiting for the doctors”, to respond this way would have done nothing to resolve any of the systemic issues that led to these delays: the imposed restrictions of the electronic records system, staff working patterns, and teams operating in silo, leading to gaps in communication and lengthy deferrals to senior decision makers.
David’s nurse apologised again that he had to wait but explained that their concerns regarding his stoma needed to be resolved before he could go. Recognising that he had a good relationship with the specialist stoma nurses, feeling seen and supported by them during their almost daily interactions, they reassured him that they would be along to oversee things and made arrangements for one of the medical team to come back to assess the stoma site with the bag removed.
By mid-afternoon David’s notes had been amended to document that his stoma was necrotic. Before the evening, he had undergone a pre-operative assessment and been consented for urgent surgery booked for the next day. David’s second surgery went well and he was successfully discharged 10 days later.
He never did forgive the nurses for messing up the first one so badly.