Category / Hospital

by Susan

Cerebral Palsy Awareness Month

I almost let March slip by without recognizing Cerebral Palsy Month! The Cerebral Palsy Foundation is a wealth of resources for patients and caregivers. As I was perusing the site, I found the fact sheet link that provides a good starting point for parents and caregivers to understand the developmental issues associated with cerebral palsy.

Cerebral palsy (CP) is a condition that affects movement and muscle tone occurring as a result of a brain injury or abnormal development before, during or after birth. The cause could be related to preterm birth, infection, malnutrition or an injury caused by negligence of a medical provider or hospital.

Sometimes, parents do not know that there was negligence during the birth of their child until a few months to years later. Symptoms of CP differ in type and severity. A child with CP will exhibit deficits with movement and posture. There may be some noticeable signs of intellectual disabilities, impaired communication skills, vision and hearing deficits. Your child may experience seizures, excessive drooling and weakness in the arms/legs.

Some cases of CP are more noticeable than others. Sometimes, parents notice the growth development is different from the other children at that age. Your child should be meeting certain milestones during the first several years of their lives. For example, at 2 years old, the movement/physical developmental milestones include the ability kick a ball, run, walk, and eat with a spoon.

There is no cure, yet. The child with CP will need a lifetime of care and medical equipment. Adults with CP have an increased risk of medical issues secondary to the CP. Some will develop bladder/bowel incontinence, hypertension, osteoarthritis, depression and pulmonary diseases.

When the birth injury is suspected to be caused by medical negligence, have an attorney look to see what happened behind the hospital doors.

 

by Susan

Mom went to the urgent care for her chest pain……

Continuing with the February heart theme, let’s explore chest pain. This a common complaint that brings patients to the see the doctor. Chest pain is one of those vague medical complaints that could occur for many reasons. It is never a symptom to ignore or take lightly. The problem most often faced as a patient is, what to do when you have chest pain. Of course, this will depend on a lot of different factors; age, medical history, location and severity of the pain, etc. Some patients will go to an urgent care center, thinking that they will avoid long Emergency Department wait times.

Is the urgent care setting appropriate for a chest pain evaluation?

Well, that is a loaded question. For now, let’s look at a scenario where the urgent care setting was not appropriate.

Imagine your 70-year-old mother called to let you know that she was having chest and back pain that started that morning. She said the pain worsened after she cleaned the house. Your mother mentioned she had a cold for a few days and thought her chest may be sore from coughing. When she was describing the symptoms to you over the phone, she was audibly short of breath. You mother assured you that the chest pain symptoms were strictly from her coughing, and she was going to call her primary care doctor.

The PCP was able to fit her into the schedule the following day.

A few hours later, your mother calls the PCP back with worsening symptoms. She complained of nausea, was sweaty, and the chest pain was a little worse. The nurse on the phone tells her to go to the local urgent care center for evaluation.

Upon arrival to the urgent care center, your mother checks in with the receptionist and you both have a seat in the waiting room. About an hour later, your mother was called to the treatment area. The nursing assistant that was taking the vital signs was concerned that your mother’s blood pressure and heart rate was high and alerted the nurse. Your mother was whisked back into a room. Another hour drifts by and you see an ambulance pull into the parking lot. The paramedics hurriedly get the stretcher from the back of the truck and enter the building.

The nurse comes to the waiting room and informs you that your mother is having a heart attack and needs to go to the hospital. The nurse explained that there were some abnormal findings on the ECG and her blood work showed elevated troponin levels. Troponin is a protein found in the cells of the heart muscle and when those cells are damaged, the protein is released into the blood. Troponin is not detected in the blood of someone with a healthy heart.

At the hospital, the doctor calls your name and invites you into a conference room. The doctor explains that there was a blockage in your mother’s coronary artery and needed surgical intervention to restore the blood supply to her heart. As she was being prepped for the percutaneous coronary intervention (PCI), her heart went into an arrhythmia, and she was receiving cardiopulmonary resuscitation (CPR). The prognosis was not good, and the doctor asks if you would like to come back and see your mother.

The door opens into the trauma bay where your mother is lying, unresponsive in the hospital bed. How did this happen? How did the soreness from coughing in your mother’s chest result in her being surrounded in a room full of strangers trying to keep her alive? Unfortunately, the team’s efforts to get your mother’s heart back into a regular rhythm was not successful, and she died.

You are left with a million questions running through your head, but you cannot process anything but grief.

Analysis:

This is a 70-year-old woman with a past medical history of high cholesterol, high blood pressure and asthma. She called the primary care provider with complaints of cough, chest pain and back pain. Then called back a few hours later with worsening symptoms and told the nurse at the PCP that she was sweating and nauseated. The nurse sent her to the urgent care instead of the hospital where she could have quickly received the surgical interventions that she needed to open up her coronary artery before and save her life.

The nurse at the PCP had a record of her past medical history which included hypertension and high cholesterol. The past medical history, coupled with her new onset chest pain, nausea, sweating and shortness of breath should have been a red flag to send her to the emergency room for a cardiac work up.

Did the providers at the urgent care center call 911 soon enough? By the time she arrived at the urgent care center, time was critical. The past medical history was unknown to the urgent care providers and the chief complaint was “cough” as entered into the medical record by the receptionist. With a complaint of cough, the nurse did not prioritize that patient in the triage queue. The urgent care providers were at a disadvantage with not knowing those vital pieces of information.

Part of my job as a legal nurse analyst helping the family members navigate the medical records and explain what happened to their loved one. While having the answers will not make a difference in the outcome, it may bring some closure.

 

 

 

 

 

 

by Susan

Why was she left in the emergency department hallway?

It is no secret that emergency departments are overwhelmed. Hospital emergency departments have been battling high volumes of patients with limited resources even before the COVID-19 pandemic. Patients wait in the emergency department even after they have been admitted as an inpatient because there are not enough inpatient rooms or personnel to staff the units. This is called emergency department boarding. You are being boarded in the emergency department, but the emergency doctors are no longer responsible for your care.

Let’s put ourselves in a scenario of how emergency room boarding could cause a medical error.

You brought your 70-year-old mother to the emergency department (ED) because she was having a headache. She was brought back right away. The triage nurse checked her vital signs, and a physician came to see her in the triage room. It was determined that mom needed a CT of her head. She was taken back fairly quickly to the radiology department and shortly after the doctor told you that the CT was normal.

After the CT, your mother was placed in a stretcher that the nurse parked in the hallway because there were no emergency rooms available.

Another doctor came to see your mother and determined that she will be admitted so that they could run some additional tests and monitor her condition.

Your mother has technically been admitted and considered an inpatient but continued to stay in the ED. This is called emergency department boarding.

What could be so bad about that? Your mother is in the emergency department, those doctors are equipped for everything!

The problem is the emergency medicine doctors are no longer overseeing her care. The admitting doctor is in charge of her care. You know, the one who barely introduced himself in the hallway and said that your mother would be going upstairs? There was not time to even catch his name.

The one nurse caring for your mother was being pulled in many directions in the busy ED and has not come by in a while.

Rather quickly, your mother’s condition changed. She seemed pretty drowsy and weak; although she had been given some medications. She was unable to help herself up out of bed to go to the bathroom. You called for the nurse. The ED nurse was overwhelmed with her emergency patients and asked the patient care tech (PCT) to assist your mother to the bathroom.

The PCT noticed that your mother was having trouble using her right side to push up out of the bed. The PCT did not record in the medical record that there were any difficulties assisting your mother and did not say anything to the nurse. You thought that your mother was just a little wobbly from the medicine that she was given, and you did not give it much thought.

About 6 hours later, your mother finally gets transported from the ED to her inpatient room.

Your mother was getting moved from the stretcher to the hospital bed and the admitting nurse noticed that she was unable to move her right arm or leg at all. The nurse called a rapid response, which alerts a team of doctors and nurses to assess a change in patient’s condition. The team determined that your mother had a stroke. The blood supply to her brain was being blocked by a blood clot.

Unfortunately, too much time had passed to give her a medication called tissue plasminogen activator (TPA), that is used to break down blood clots. TPA is recommended to be administered 3-4.5 hours after onset of stroke symptoms.

This delay in time in recognizing the right sided weakness in the emergency department hallway resulted injury to the brain which left your mother with permanent functional impairments.

Those patients that are boarding in the emergency department are vulnerable because they do not receive the same level of care as they would being admitted to the floor.  Several studies showed that emergency department boarding increased ventilator-associated pneumonia, critical care unit mortality, and overall admission.

Emergency department boarding was discussed in an article published in the Journal of the American Medical Association (JAMA). Emergency department boarding refers to holding admitted patients in the ED, often in hallways, while awaiting an inpatient bed. The Joint Commission identified boarding as a patient safety risk that should not exceed 4 hours.1 Downstream harms include increased medical errors, compromises to patient privacy, and increased mortality.2 Boarding is a key indicator of overwhelmed resources and may be more likely to occur when hospital occupancy exceeds 85% to 90%.3

Leave a comment and let me know if you have any stories or questions about emergency department boarding leading to medical errors: