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Summary: Patient noncompliance can present serious challenges
nurses and physicians providing care. If aware of the proper
to be taken, what happens when the patient does not agree
or comply with the course of treatment? In this case, a patient
having a coronary artery bypass grafting developed a sternal infection.
When advised by a nurse to return for treatment, the patient refused.
The patient was known to have Insulin-Dependent Diabetes Mellitus.
She would seek medical attention with a history of Angina (chest
pain). Following the episode, she was referred for a diagnostic
"According to latest statistics from the American Heart Association,
roughly 323,000 cardiac catheterizations were performed in the
United States in 1994. The procedure provides doctors with
information about the heart's structure and its ability to function.
Doctors may also use catheterization to perform procedures on the
heart, such as balloon angioplasty.
To perform a cardiac catheterization, a thin catheter is inserted
through a small puncture wound in a blood vessel -- usually the
femoral artery in the leg. Using X-rays for guidance, doctors feed
catheter through the circulatory system until it reaches the heart."2
Following the catheterization, an emergent multiple bypass surgery
was recommended by the Cardiologist.
"What is coronary artery bypass surgery?
A coronary artery bypass graft operation is a type of heart surgery.
is sometimes referred to as CABG or "cabbage." The surgery is done
to reroute, or "bypass," blood around clogged arteries and improve
supply of blood and oxygen to the heart. These arteries are often
clogged by the buildup over time of fat, cholesterol and other
The narrowing of these arteries is called atherosclerosis. It slows
stops the flow of blood through the heart's blood vessels and can lead
to a heart attack."3
The patient would refuse and left the
hospital Against Medical Advice
(AMA). Three days later the patient would return to the
provide an Informed Consent to the operation. It was performed
the Facility's Cardiac Surgery Director assisted by a fourth
""Revascularization with coronary artery bypass graft surgery
(CABG) and percutaneous transluminal coronary angioplasty (PTCA)
is well accepted as a method of relieving anginal pain and thus
improving quality of life. In addition, CABG has been shown to
improve survival in certain subgroups of patients with coronary
disease, which has led to the widespread use of this procedure in
revascularization. In 1991 407 000 bypasses and 303 000 PTCA
procedures were performed.1 Currently, coronary atherectomy,
various laser techniques, and coronary stents are being evaluated as
additional approaches to revascularization."4
Following the coronary artery bypass grafting, the patient would
remain in the
hospital for ten days.
The patient would return for a follow-up visit just under two weeks
later with the surgeon. Assisted by a cardiac nurse, the midsternal
incision was examined, staples were removed. A portion was found
to be purulent, draining and healing poorly.
Cultures were obtained and sent, the patient would be scheduled for
another follow up visit a month later.
Four days later, the patient spiked a temperature. She called
medical center and spoke to the nurse who had assisted the surgeon.
After listening to the patient's complaints, the nurse instructed her
return to the medical center for treatment. She informed the
patient that her test results had come back and multiple infections had been
discovered from the midsternal wound in her chest.
"Approximately 2% to 20% of CABGs are complicated by a surgical-
site infection (SSI).4,5 Much of the literature on SSI following
cardiothoracic surgical procedures focus on deep chest infections,
which, although not frequent (complicating 0.5% to 5% of cardiac
procedures4,5), are important because of the high morbidity,
mortality, and immense costs they add to the healthcare system."5
The patient refused. She stated that it was almost an hour's drive
to the medical facility. In her "condition" she didn't
feel she could
"make" the trip.
She asked the nurse if antibiotics could be "prescribed over the phone"
and started without her being evaluated. The nurse informed her
was not an option.
The nurse informed the patient that it would be best for her to return
to the facility where the operation had been performed. If she
returned her condition could be evaluated and treatment initiated.
patient still refused.
Alternatively the nurse stated that the patient should seek immediate
medical assistance and contact her local physician.
The patient was unable to contact a local physician and did not go to
the Emergency Room immediately. In fact, the patient was not
examined by her physician until almost ten days later.
At that time, ten days after the known Insulin Dependent Diabetic
patient had been informed by the nurse that she had a potentially life
threatening multiple organism infection in her chest, she was
readmitted to a local hospital.
"Surgical-site infection of the sternal wound includes superficial SSI,
deep sternal SSI, sternal osteomyelitis, mediastinitis, and endocarditis.
These often have been pooled together in the analysis of risk factors.
Host intrinsic risk factors that have been linked specifically to SSI
the sternal wound include obesity,4,9-11 diabetes mellitus,4,9-13
current cigarette smoking,9 and steroid therapy,13 the former two risk
factors being the most frequently reported (Table 1). Kluytmans and
colleagues further demonstrated that the risk of developing SSI was
higher in the diabetic patient using insulin therapy than in the diabetic
patient treated with oral agents.12"5
A sternal infection was verified. The patient would require
readmission and surgery to debride the wound and bring the infection
under control. Part of her sternum would be removed in the process.
At the patient's request, the course of events was examined by the
Physician Medical Review Board. She alleged that standards of
had not been maintained. She stated that negligence on the part
surgeon and the nurse had led to her infection and subsequent surgery.
The board dismissed the complaint. They stated there was no clear
evidence of wrongdoing or negligence on the part of the nurse or
The patient filed a lawsuit regardless against the physician, facility
and the nurse accusing negligence. The case was dismissed.
1. Did the nurse fail to observe the applicable standards of care in
conversation with the patient?
2. Was the nurse giving the patient "medical advice" when she
advised her to return for treatment?
3. Did the nurse mislead the patient or make any statements that could
have contributed to the patient's complications?
The physicians and the court when reviewing the nurse's performance
agreed it was appropriate. The nurse was dealing with a known
patient with a history of noncompliance. She instructed and
emphasized to the patient that an infection was present and required
The nurse advised the patient of where the best treatment could be
obtained. The patient was notified that if she could not return
immediately, that treatment should be sought elsewhere on an
The nurse was giving medical advice. In this case, the nurse was
telling the patient exactly what a competent surgeon would have told
her as well.
This is a special situation involving a nurse with advanced skills and
experience in a nursing specialty. Nurses with specialized training
recognized as competent to advise patients on pre-defined situations
according to their level of expertise.
A midsternal infection is a known complication of coronary artery
bypass grafting. The nurse being aware of this was appropriate
counseling of the patient to seek immediate care.
The nurse in the eyes of the law would be and was held to the same
standards as a physician in the advice that was given. The nurse
in fact, maintain the standards of care expected in the situation.
Her responsibility or "duty" to the patient was to advise her of the
medical condition present (a septic infection), make recommendations
for treatment (return to the hospital), inform her of consequences
not being treated and present alternatives.
This duty was fulfilled and recognized repeatedly by the medical
review panel and the courts. It is unfortunate that the noncompliant
patient decided to pursue litigation regardless.
It demonstrates clearly how vulnerable even the most prudent nurses
are to being sued. Often it is the case that nothing has been
wrong, nor is there negligence likely. It's a constitutional
right for an
individual to initiate a lawsuit for real or perceived losses.
Makes an excellent case for carrying a malpractice insurance policy.
For the cost of a typical day's pay, you can have protection against
lawsuits without having to depend on an employer's policy being
adequate to protect you.
3. The American Heart Association. 1999. Bypass
Surgery, Coronary Artery: Retrieved July 4, 1999 from the World
Wide Web: http://www.amhrt.org/Heart_and_Stroke_A_Z_Guide/bypass.html
4. American Heart Association. 1994. Optimal
Risk Factor Management in the Patient After Coronary Revascularization.
Retrieved July 4, 1999 from the World Wide Web: http://www.amhrt.org/Scientific/statements/1994/129401.html
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