Description of Event or Problem · 0
ADULT FEMALE PRESENTED TO THE HOSPITAL FOR SHOCK AND WAS INTUBATED. SHE HAD A POTENTIAL FISTULA THAT NEEDED CLOSURE AND WAS S/P EXPLORATORY LAPAROTOMY FOR GASTRIC ULCER PERFORATION. SHE HAD RECENT A COVID-19 INFECTION. THE PATIENT WAS PLACED ON A VENTILATOR IMMEDIATELY. ONE WEEK LATER SHE HAD A TRACHEOSTOMY PLACED WITHOUT COMPLICATIONS DUE TO RESPIRATORY COMPROMISE. SHE HAD SEPSIS WITH A GASTRIC LEAK COMPLICATED BY ACUTE ON CHRONIC RESPIRATORY FAILURE. THE PATIENT HAD A NASOGASTRIC (NG) TUBE AND SEVERAL DAYS LATER THAT NG TUBE WAS EXCHANGED FOR AN IRIS FEEDING TUBE TO START TUBE FEEDING. SHE HAD HER IRIS FEEDING TUBE REPLACED TWICE AFTER THAT(MODEL 461055E). IN THE NEXT MORNING THE Y-PORT ON THE IRIS FEEDING TUBE BROKE. THE DIRECT CARE NURSE (DCN) PAGED THE RAPID RESPONSE TEAM (RRT) NURSE, WHO IS TRAINED TO USE THE IRIS FEEDING TUBE SYSTEM, TO REPLACE THE TUBE. THE RRT NURSE ARRIVED AT 0530 WITH A NURSE THEY WERE TRAINING AND REPLACED THE IRIS FEEDING TUBE ON THE FIRST ATTEMPT (MODEL 461255E). AT 0623 THE RADIOLOGIST NOTIFIED THE DCN THAT THE FEEDING TUBE WAS WITHIN THE LEFT LOWER LOBE OF THE LUNG. THE DCN PAGED RRT NURSE AND COMMUNICATED THE FINDINGS. THE RRT NURSE RETURNED AND REMOVED THE IRIS FEEDING TUBE. MULTIPLE ATTEMPTS WERE THEN MADE TO REPLACE IT WITH A NEW ONE (MODEL 461255E). THE PATIENT BEGAN TO DECOMPENSATE WITH INCREASED END TIDAL CO2 READINGS INTO THE 80¿S, OXYGEN SATURATION READINGS INTO THE 80¿S, AND LOWER TIDAL VOLUMES. RESPIRATORY THERAPY WAS PAGED AND ARRIVED TO ASSIST THE PATIENT IN RECOVERY. THE DECISION WAS MADE TO STOP THE INSERTION AT THAT TIME, THE IRIS FEEDING TUBE WAS REMOVED, AND THE RRT NURSE LEFT. MINUTES LATER THE OXYGEN SATURATIONS BEGAN TO DROP AGAIN INTO THE 70¿S. THE RRT NURSE WAS CALLED AGAIN TO RETURN TO THE ROOM AT 0657. PRIOR TO LEAVING THE CRITICAL CARE UNIT, THE RRT NURSE LET THE INTENSIVIST KNOW THE PAGE WAS FOR A PATIENT WHO HAD JUST HAD A MALPOSITIONED IRIS FEEDING TUBE REMOVED. THE PATIENT THEN LOST HER PULSE, AND A CODE BLUE WAS CALLED AT 0706. ALL ACLS PROTOCOLS WERE FOLLOWED INCLUDING A CHEST TUBE PLACEMENT FOR A POTENTIAL PNEUMOTHORAX. THE TEAM WAS UNABLE TO ACHIEVE RETURN OF SPONTANEOUS CIRCULATION AFTER 20 MINUTES AND EFFORTS WERE CEASED. SHE WAS PRONOUNCED DEAD AT 0727. THE POLICY FOR NASO-OROENTERIC TUBE PLACEMENT FOR ADULTS AND PEDIATRICS INDICATES ONLY A NURSE WHO HAS COMPLETED THE COMPETENCY BE ABLE TO PLACE THESE IRIS FEEDING TUBES AND STIPULATES THAT IF THE TUBE HAS PERFORATED THE GI TRACT OR THE PLEURAL SPACES, AS EVIDENCED BY RADIOGRAPH, DO NOT REMOVE THE TUBE. IMMEDIATELY CONTACT A LICENSED INDEPENDENT PRACTITIONER (LIP) TO ASSESS THE SITUATION AND EVALUATE THE NEED FOR A CHEST TUBE. THE POLICY ADVISES LEAVING THE TUBE IN PLACE AND NOTIFYING AN LIP.