Anesthesiology, Pain and Palliative Medicine Case Studies
Healthcare5 Case StudiesUpdated Sep 2026
These five cases come from the working life of a regional care network that runs operating rooms, an acute pain service, and a palliative care consult team. None of the situations is unusual on its own. What makes each one instructive is how information moves between people, and how decisions get made when the record is incomplete or the schedule is full. Read each case with the patient in view first, then the evidence, then the team and the protocols that govern their work. Treat the closing diagrams as prompts for your own mapping.
Case Study 1
Rising pain scores that never crossed the trigger
Tallis Ridge Hospital, a 340-bed general hospital with an acute pain service and a surgical day unit
The situation
Desmond, a patient aged around sixty-five, was admitted to a surgical ward after abdominal surgery. On the first evening his pain was well controlled. Over the next night, the nurse caring for him, Priya, recorded a steady rise in pain scores across three observation rounds. The acute pain service had reviewed him that afternoon and left a written plan. Early the next morning the ward team saw him briefly and attributed the tenderness to the operation. His heart rate had crept upward through the night and his urine output was lower than the previous shift, but each reading sat just under the threshold on the local early warning chart, so no one called the outreach team.
The challenge
The team had to decide whether the pattern was expected post-operative change or an early sign of a complication that needed imaging, senior review, or surgical input. Priya had the trend but not the authority to escalate beyond the ward, and the day team was handing over at the same time as the afternoon list. Nobody held the whole trend in one place, and the local protocol asked for a single escalation decision by a named clinician rather than a shared sense that someone should look.
Analysis
Start with the patient rather than the chart. Desmond's pain scores, heart rate and urine output each told a modest story, but read together they described a trajectory that was moving in one direction. Clinical evidence in this setting is cumulative. A single reading below the trigger line says less than a sequence of readings that each sit a little higher than the last. Teams grounded in Anesthesiology, Pain and Palliative Medicine plot the trend first, then name the finding that would most quickly confirm or rule out a complication. At this stage the useful question is which finding would settle the matter fastest.
The local protocol on deteriorating patients names a trigger chart and a rule that any worried clinician can escalate without waiting for a threshold. Priya's concern was legitimate under that rule, but the trend was not visible to the person who could act on it. The handover at the change of shift covered each observation individually and never put the sequence on one line. A better handover would have included the trend, the time of the last review, and the specific question the nurse wanted answered. Escalation should name a clinician, a time, and a plan for review, so that the decision does not dissolve between teams.
- Observe the trend Plot each reading against the previous three, not against the threshold alone.
- Share the sequence Hand over the trend, the last review time, and the working concern together.
- Decide and name Name the clinician who will act, the time of review, and the plan.
- Reassess and record Recheck the trend at the agreed time and log whether the concern resolved.
Actions taken
- Build a single trend view on the ward chart so that each observation is plotted against the previous three, and any sustained rise is visible at a glance to every team member.
- Add a structured handover line for any patient with a worsening trend, stating the last review time, the working concern, and the question the receiving clinician must answer.
- Require that any escalation under the deterioration protocol is logged with a named clinician, a time for bedside review, and an agreed plan for reassessment.
- Audit escalation timing for trend-based concerns over the next quarter and report the median delay from first documented rise to the outreach call.
Results
Within the first quarter the ward was using the trend view at every handover, and the audit of escalation timing showed a median delay of about two hours from first documented rise to outreach call, down from a little over five. Desmond recovered without a return to the operating room, but the team agreed the value lay in the decision record rather than the outcome. Two further trend-based calls in the same period were both early signs of a complication, caught before it became acute. What changed was who could see the sequence and when.
Questions for discussion
- Which element of the ward observations would you plot first, and what would have to change on the chart for a rising trend to be visible without a calculation?
- How should a nurse with a worried concern and no authority beyond the ward decide between waiting for the next round and calling for review now?
- What would a named escalation decision need to contain before you would accept it as complete at the change of shift?
Case Study 2
A latex flag left behind at the changeover
Greyfield Ambulatory Surgery Center, a multi-specialty day surgery unit with a shared recovery area
The situation
Imogen, a patient aged around fifty, was booked for a short day procedure on the afternoon list at Greyfield Ambulatory Surgery Center. Her pre-assessment form recorded a latex sensitivity and asked for latex-free equipment. The anesthesia nurse, Bongani, completed the intra-procedure record correctly but handed her over to the recovery nurse, Tomasz, during a busy changeover. The handover covered the procedure, the observations and the expected discharge time. It did not include the latex flag, which lived on the pre-assessment form and not on the recovery record. Twenty minutes later a second nurse, Ruth, noticed the flag while checking the consent documentation and stopped the use of a latex-containing cuff before it reached the patient.
The challenge
The team had to decide how to close the gap without turning every handover into a long recital. Tomasz had acted reasonably on what he was given, and the recovery area was running at full capacity with three patients waiting for beds. The question was whether the safeguard should depend on individual memory, on the form, or on a structure that forced the flag into the shared record. Imogen had not come to harm, but the near miss exposed a gap that the existing checklist did not cover.
Analysis
What the patient needed was information that followed her from the pre-assessment form through the procedure and into the recovery bay. A sensitivity recorded once and never repeated is a risk that depends on someone remembering to read the right page. Reviews of handover failures in procedural settings often find that omissions cluster at transitions, particularly when the critical fact lives in a document the receiving clinician does not routinely open. Teams trained in this field map where each safety-critical fact is first recorded, where it is copied, and where it is last seen, because gaps tend to sit between those points.
The handover standard in use here asks for a structured summary covering identity, procedure, observations, allergies and sensitivities, and any outstanding actions, delivered at the bedside and confirmed by the receiving nurse. The standard was in place, and the pre-assessment form had been completed. The failure was in the translation step: the sensitivity was not carried across to the recovery record, and the handover was delivered from memory rather than from the structured summary. Coordination at changeovers depends on the sending nurse having the full picture and the receiving nurse having a reason to ask for it.
Actions taken
- Add a fixed line to the recovery handover template for any known sensitivity, so that material and equipment flags are read aloud and recorded on the bay record.
- Require the receiving nurse to repeat back the sensitivity and the discharge plan before the sending nurse leaves the bay, and record the confirmation with initials.
- Place a latex and sensitivity status field on the bay tracking board and the anesthesia record, so the flag is visible before any equipment is opened.
- Measure handover omissions for six weeks by auditing a sample of changeovers for the four protected items, and report the rate to the quality committee.
Results
Imogen was discharged that afternoon with the flag on her record. Over the following six weeks the recovery area audited changeovers against four protected items. In the first window, 19 of 140 changeovers omitted at least one item. After the template change the rate fell to 4 of 150, and the bay board flag was read aloud at 146 of those changes. The team kept the repeat-back step, because the audit showed that the template alone did not close the gap for the sensitivities that were recorded late.
Questions for discussion
- Which of the protected items in your own handover would be lost first if the sending nurse were interrupted, and where would it be recorded instead?
- How would you decide whether a repeat-back step adds real safety or simply adds time at a busy changeover?
- What evidence from your own unit would show whether the omissions sit with the sender, the receiver, or the record design?
Case Study 3
Referral surge with six pumps left for the week
Calder Reach Hospital, a 520-bed tertiary hospital with a regional acute pain service and an inpatient palliative team
The situation
Calder Reach's acute pain service covers the surgical wards, the maternity unit and the emergency department on weekdays with two consultant anesthetists and one specialist nurse, Oluwaseun. In the second week of the quarter, referrals rose sharply after a run of major orthopedic lists, and the service had 31 open requests on the board by Monday morning. The pump pool, shared with the wards, had only six units available for the week. The service lead, Amara, had to choose how to allocate reviews and equipment without a formal rota change. Two ward managers asked for their referrals to be treated first, and the emergency department asked for same-day cover on the evening shift.
The challenge
The decision had to protect the patients with the highest need for review without leaving the wards with no route to escalate. Every option moved risk somewhere. Prioritizing the emergency department would leave postoperative patients waiting longer for reviews that had already been requested. Spreading the reviews evenly would dilute the time available for the most complex cases. The pump shortage added a second constraint, because a rationing choice made on equipment could look like a clinical judgment to the people waiting for it.
Analysis
Patient need comes first, since capacity decisions are easiest to make badly from the queue alone. The open requests differed in urgency: some were for patients with uncontrolled pain after surgery, some for ongoing review, and some for symptom questions that could wait a day. A simple priority list based on time of request would have put the stable patients ahead of the unstable ones. The service used its documented scoring tool, which weighs pain severity, functional limitation, the presence of a monitoring concern and the time since the last review. That structured triage is slower but makes each decision's reasons visible to the wards.
The referral standard set a maximum wait for each category and allowed reassignment across consultants when that limit was breached. That gave Amara a documented route for the decision, but the standard did not say how to handle equipment, which sat with the wards and was governed by a separate pool agreement. She brought the two ward managers and the emergency department lead into one short call. The call agreed which referrals would take precedence, which would move to the next day with a named reviewer, and which pumps would be held for patients who needed continuous monitoring. One call protects quality because everyone hears the same reasons.
Actions taken
- Adopt the severity-based triage as the default for the referral board, with the scoring tool recorded against every request so that wards can see the reason for each decision.
- Hold two review sessions each day in reserve for emergency and same-day requests, and release any unused session to the queue by midday.
- Reserve the pump pool for patients who need continuous monitoring first, and agree the rule in writing with the ward managers before it is applied.
- Send each ward manager a weekly summary of their referrals, showing category, wait, and reason for any deferral, so that the trade-offs stay visible to them.
Results
The service combined the severity-based triage with a protected reserve of two review sessions each day. Over the following weeks, the open board fell from 31 requests to under 12 without new staff. Urgent reviews were completed within the category limit in every week, and the number of routine follow-ups that slipped past their window rose, which the team had expected and recorded. The pump pool was held for continuous monitoring first, and ward managers were given a weekly summary of their referrals so that the reasons were visible. Emergency cover ran on two evenings.
Questions for discussion
- Which of the five options would you have rejected first, and what would your reason tell the ward managers about how you value their referrals?
- How would you measure whether a reserve of review sessions protected the urgent cases or simply left routine patients waiting longer?
- When equipment and clinician time run short together, which should be allocated first, and who should be in the room when that decision is made?
Case Study 4
Inconsistent review timing across three community hospitals
Penhallow Health Partners, a network of three community hospitals with a shared acute pain and palliative service
The situation
Penhallow Health Partners runs three community hospitals, each with its own surgical ward and a shared acute pain service that reviews patients by referral. Over the last audit period, the network's quality group noticed that the proportion of patients reviewed within the expected window varied widely between sites, and that patients at one site more often needed a second escalation. The indicators were anonymized at the patient level and reported by site and by surgical service. The quality lead, Hanna, pulled a sample of 212 records from the last period to see whether the variation reflected case mix, documentation, or the way reviews were requested.
The challenge
The group had to separate real differences in care from differences in how care was recorded or requested. Sites with heavier surgical lists would be expected to show more reviews, and a higher escalation rate could mean better detection rather than worse control. The indicators had been designed for a single site, and the definition of a review as completed differed between the electronic record and the paper referral log. Hanna needed a way to test the variation before anyone changed practice at any site.
Analysis
The patient question sits underneath the indicator. A review inside the expected window matters because it is the point where a pain plan is checked against what the patient is actually experiencing, and a second escalation often means the first plan did not fit. The network's indicators counted reviews and escalations, but they did not capture the interval between the first documented concern and the team's response. Without that interval, a prompt review and a delayed one could look identical. Hanna proposed adding the elapsed time from first concern as a clinical evidence field, so each review could be read against the moment the concern was raised.
The network's shared escalation protocol asks that any patient with a second request for review be discussed at the site huddle within the same working day, and that the referring team records the reason for the request in a common field. Two sites used the paper referral log, which had no reason field, and the third recorded completed reviews only after consultant sign-off. That made the same clinical activity look different across sites. The protocol was sound on paper, but the sites were not applying it to the same definition of a review. Coordination improves when the team agrees what counts as done before comparing how often it happens.
- 1Define the measureAgree one written definition of a completed review at every site.
- 2Capture the reasonRecord the reason for each second request and the elapsed time.
- 3Pilot at one siteRun the revised form for six weeks against two comparison sites.
- 4Review with leadsDiscuss results monthly and change the huddle rule only if needed.
Actions taken
- Agree one written definition of a completed review across all three sites, covering what is recorded, who signs it, and where it is stored.
- Add a reason-for-request field and an elapsed-time field to the referral form at every site, so both can be extracted from the same source.
- Run a six-week pilot in which one site uses the revised form and the other two continue as before, then compare case-mix-adjusted review timing and escalation rates.
- Review the pilot results at the monthly quality meeting with the consultants and nurse leads, and adjust the huddle rule only if the timing gap persists.
Results
The pilot ran for six weeks at the largest site. The reason field showed that about two thirds of second requests followed new symptoms after discharge, which pointed the group toward community follow-up as the next target. Median time from first concern to review fell at the pilot site by a little under a day, while the other two sites were unchanged. The group did not claim a finding yet, because the pilot covered a single surgical service and a short window of lists.
Questions for discussion
- Which of the three sites' definitions of a completed review would you expect to produce the most misleading comparison, and why?
- What case-mix factors would you need to adjust for before attributing a timing difference to the referring team?
- How much variation in a monitored indicator should trigger a change in practice, and who should agree that threshold in advance?
Case Study 5
Conflicting instructions about what a daughter may hear
Fenwick Crossing Hospital, a 280-bed hospital with a palliative care consult team and a standing ethics consult service
The situation
Edwin, a patient aged around eighty with advanced lung disease, was admitted to the medical ward at Fenwick Crossing Hospital for a planned symptom review. He had an advance care plan that named his daughter Lena as first contact. On the third day he told the palliative consult nurse, Dario, that he did not want Lena told the details of his prognosis, and that he wanted his son, who lived abroad, to receive the information instead. Lena had attended most conversations and was waiting for an update. The ward team was unsure whether Edwin's request should override the plan on file, and whether they could share anything with Lena.
The challenge
The team had to balance Edwin's present wishes against a document written earlier, while keeping Lena informed enough to support him without breaching what he had asked. The choice was not only about information. A decision made quietly by one nurse would leave Lena feeling excluded, and a rushed disclosure would leave Edwin feeling that his request had been ignored. Dario needed to know whether he could decline to share details without deceiving Lena, and who was entitled to decide when the instruction and the plan conflicted.
Analysis
Edwin's needs anchor the decision, and they go beyond the information itself: he wants his choice heard and recorded in his own words. The team holds three sources, the conversation, the advance care plan and the nursing notes, and they do not agree. Weighing one above the others without asking Edwin again would be a guess. A capacity assessment belongs to the treating clinicians, and it should document what Edwin understood, what he decided, and whether that decision holds across more than one conversation. Preferences about disclosure can change, so the most useful evidence is a current wish that has been repeated and written down.
Two documents govern this decision: the consent and confidentiality policy and the advance care planning standard. The first says a competent adult may limit what is shared with family, and that staff should ask and record the answer. The second says a plan on file should be reviewed when wishes change, and that a named contact is not automatically entitled to clinical detail. Escalation runs to the consultant in charge and the ethics consult service, who help reconcile the two documents. The ward should not settle this alone, and Lena should be told who is handling it and when she will hear back.
- On the third dayEdwin asks that Lena not receive the prognosis details.
- Same day, first huddleWard team reviews the plan and agrees not to disclose until clarified.
- Within one working dayEthics consult reviews the conflict and names the decision maker.
- Next conversationEdwin repeats his wishes with Dario present, and the team records them.
- Before dischargeLena receives a written update on what was decided and why.
Actions taken
- Ask Edwin directly how he wants information shared with Lena and his son, and record his answer in his own words on the ward record and the advance care plan.
- Request an ethics consult to reconcile the instruction with the plan on file, and name the consultant who will make the final decision on disclosure.
- Agree with Lena what she can be told now, such as that the team is reviewing his wishes and when she will hear back, without sharing the prognosis.
- Set a short review point for the same team, within a defined working period, to confirm that Edwin's wishes have been recorded and that Lena has been updated.
Results
Edwin confirmed in a later conversation, with Dario present, that he wanted Lena to be told the general direction of his care and that the prognosis discussion should wait until he chose to have it. His son was given a telephone update with his agreement, recorded on the same day. The ethics consult helped the team write a single note that said who had decided what and why, which Lena read at her request. Lena remained unhappy that the conversation had taken place without her, and the note recorded that. That honesty, rather than a neat outcome, was the result the group valued most.
Questions for discussion
- At what point would you have stopped the ward discussion and asked for the ethics consult, and what would have changed if Edwin had been unable to repeat his wishes?
- How would you tell Lena what the team can say without implying that information is being withheld from her for her own good?
- Which parts of the advance care plan should be reviewed automatically when a patient asks for a different contact, and who owns that review?
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