Pinpoint Triage Practices that Increase Your Risk of Missed MI
Editor's Note:This is the first of a two-part series on missed myocardial infarction [MI] cases. This month, we report on the best practices for reducing liability risks involving triage, and review cases of chest pain patients involving adverse outcomes in ED waiting rooms. Next month's issue will cover specific documentation practices which can impact the outcome of a patient's lawsuit alleging a missed myocardial infarction being discharged from the ED.
Half of acute myocardial infarction (AMI) patients, including 44% who met criteria for a ST-elevation myocardial infarction (STEMI), were given a low acuity triage score when they presented to an Ontario ED. The low triage score was linked to significant delays for EKGs and reperfusion therapy, including a 15-minute increase in median door-to-needle time. Based on the study's findings, the researchers estimate that about 100 AMI patients in Ontario die each year because of delays associated with low ED triage scores.1
Clare Atzema, MD, the study's lead author and a scientist at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada, says she was surprised by the study's findings. "We did expect some low acuity triage to occur, given how difficult many AMI patients are to identify, but not for half of all AMI patients," says Atzema.
The potential liability risks for triage of chest pain stem from the fact that "if the patient is having an STEMI, we know from other research that every minute of delay counts, in terms of their risk of mortality," says Atzema.
For the patients in the study, the delay to reperfusion was about 15 minutes if they were given a low-priority triage score, after accounting for all the other factors that are likely to cause delays. "We can estimate, based on other studies, that this 15-minute delay results in 11 lives lost per 1,000 patients treated at five-year follow-up, solely due to low-priority triage," says Atzema.
Missed acute coronary syndromes (ACS) represent the number one cause of medical malpractice payouts in closed claims, according to data from the Physician Insurers Association of America.2 "For many years, missed MI has been the number one ED dollar loss category. Atypical findings are still missed in many patients," says Robert Broida, MD, FACEP, COO of Physicians Specialty Limited, Risk Retention Group in Canton, OH.
As for decreasing the risk of low-priority triage in AMI patients, Atzema recommends performing EKGs at triage. "Increasing the amount of standardized triage training for triage nurses, with a small but specific component on the AMI patient, is another option," says Atzema.
"Cross-training of triage nurses from low-volume centers at high-volume AMI EDs also may help," says Atzema. "We found in a separate study that at the EDs with the highest volume of AMI patients per year, AMI patients were much less likely to be given a low-priority triage score. Practice seems to make perfect, similar to other volume outcome associations in medicine."3
Ultimately though, Atzema says that a certain proportion of AMI patients will always be mistriaged. "In the U.S., 2% of AMI patients are sent home after a full ED evaluation by a physician," says Atzema. "Thus, it will never be possible to identify all AMI patients using the necessarily brief triage evaluation, although I believe that we can do significantly better than 50%."
According to Tom Scaletta, MD, president of Emergency Excellence, a Chicago-based organization that improves patient care and efficiency in the ED while controlling costs, all adults 18 to 50 years old with chest pain and any suspicion of coronary artery syndrome should be given an Emergency Severity Index (ESI) triage score of ESI 2.
"Since age over 50 is a risk factor, all these patients with chest pain should be ESI 2," Scaletta says. "Gender and race must not be factors in determining the triage acuity. ESI 2 must wait no longer than 10 minutes to be placed in the clinical area."
Others with chest pain must wait no longer 10 minutes for an ECG, and ideally the ECG should be given within five minutes of arrival, says Scaletta. "If there is any abnormality on the ECG, unless it is pre-existing, the patient should be ESI 2," he says. "It is important to pull the most recent prior ECG, when one exists, and have a physician review both. Otherwise, the patient may be ESI 3 or 4 and the atypical character of the pain and absence risk factors reflected in documentation."
Here are other practices to reduce liability risks involving triage of AMI patients:
Use only experienced nurses at triage.
According to Ann Robinson, MSN, RN, CEN, LNC, principal of Robinson Consulting, a Cambridge, MD-based legal nurse consulting company, the biggest high-risk factor regarding triage and missed AMI is having nurses in the role of triage without the requisite experience and education required to perform it effectively.
"Many new nurses are now able to work in high acuity settings like EDs without having had adequate experience," says Robinson. "They may not recognize potentially ominous presentations which the experienced nurse would more likely identify."
To reduce the risk of under-triaging, Robinson says "there seems to be little substitute for experience. Until you have seen people who look well but you know from experience are not, there is just little to make up for that," she says.
Less experienced triage nurses often do not consider epidemiological considerations when patients present with varied complaints, says Robinson. For example, if a female in her 50s with comorbidities such as diabetes and hypertension presents with vague somatic complaints, the more experienced nurse would consider the possibility that this patient could be having an MI.
Broida recommends that all nurses who perform triage have a minimum of six months ED experience and have preferably taken a formal triage training course. "There is no substitute for proper training and experience," he says.
Have an effective process in place to notify the ED physician of abnormal results.
When a 47-year-old diabetic female presented to a triage nurse with a complaint of chest pain and a history of diabetes and hypertension, an EKG was performed within 10 minutes by a technician. "It was interpreted as an acute, evolving myocardial infarction, but the technician who performed the test simply put it on the patient's chart without notifying the nurses or physician," according to Christine Macaulay, RN, MSN, CEN, nursing practice and safety specialist at The Children's Hospital of Philadelphia.
The EKG was discovered an hour later by an ED physician, just before the patient went into cardiac arrest. "Resuscitation was largely unsuccessful. The decedent was transferred to another hospital, where attempts to unblock the artery were unsuccessful," says Macaulay. "The decedent lapsed into a coma and remained in a locked-in state until her death twenty months later." According to a published account, a $2 million settlement was reached.
"The best practice is that the EKG is performed and delivered to the emergency physician within 10 minutes of the patient hitting the door," says Broida.
Admit patients based on history.
Robinson notes that the literature shows that a third or more of AMIs present with normal EKGs and little or no subjective complaints.
"Until the future brings us more direct diagnostics, there is little to do except watch these folks," Robinson says. "Some institutions elect to do that with a 23-hour observation, for example, and some elect not to."
According to Broida, "Patients should be admitted based on history. The physician's suspicion of ACS is more sensitive than any current ancillary test. If you rely on tests to make the diagnosis, you will get burned."
Treat all chest pain as possibly cardiac until this is ruled out diagnostically.
Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and director-at-large for the American Association of Legal Nurse Consultants,, says that since there is no way to diagnose an AMI without specific diagnostics, "the practice of filtering patients who presents with chest pain and attempting to re-categorize to another area seems to be risky."
For instance, a 40-year-old female with no risk factors presents to the ED complaining of chest pain which is not very sharp, non-radiating and relatively non-specific. The triage nurse may view this patient as a low risk for an MI and give her a low acuity triage score.
"This patient may wait in the triage area for an hour or more before being seen. The EKG and initial blood work become delayed," says Ridgely. "This patient goes on to have an AMI with severe disability or death and a lawsuit ensues. Everyone is shocked, because this patient had such a low acuity triage score and no risk factors. But the fact remains that the patient's complaints were diluted by the low risk factors."
Ridgely recommends treating all patients with chest pain as high acuity, regardless of risks or presenting symptoms. "This would certainly be a good argument to absolve the triage nurse from litigation," she says. "With a high acuity score given for chest pain, there would be no wait time for the EKG or laboratory work."
Ridgely says she "doesn't see much lenience" in how a jury would interpret giving a low acuity triage score for a patient who was actually having an MI. "It would seem that all chest pain, regardless of risk, should be treated as a potential MI until ruled out. It would further seem irresponsible to assign low acuity to a chest pain patient," she says. "I could not imagine a high acuity patient being in the holding or triage area for hours without attention or without frequent vital signs taken."
Remember that presentations may be subtle.
Broida says that "many clinicians fall into the trap of focusing solely on classic AMI symptoms such as crushing substernal chest pain, and ignoring the more subtle presentations of ACS," he says. "By doing so, they will mis-triage patients."
Broida says that you need to have a high index of suspicion for occult disease, and remember that shortness of breath, syncope, bradycardia, and even fatigue all can be ACS symptoms, especially in younger or female patients. "All potential ACS patients should have an ECG within five to 10 minutes of hitting the door," says Broida.
Broida recommends that each hospital have an up-to-date ED chest pain/ACS policy which is regularly reinforced by ED leadership. "Physician triage helps limit under-triage, but the same clinical principles apply," he adds.
William Sullivan, DO, JD, FACEP, director of emergency services at St. Mary's Hospital in Steator, IL, says that one concept that may help doctors avoid missing myocardial infarctions is to realize that the patients who have many cardiac risk factors and typical symptoms are not usually the patients in whom myocardial infarctions are missed.
"Simply put, typical heart attacks are often obvious," says Sullivan. "We don't usually miss the elderly 'chest-clutchers.' We miss the low-risk patients with atypical symptoms."
Sullivan gives the example of an 80-year-old sweaty dyspneic diabetic lady with chest pressure. She has a significant risk of having a cardiac event, but presents a low risk of missing a potential cardiac event because any health care provider would likely assume that she was having a cardiac event until proven otherwise.
Now, consider the 32-year-old male who was having "indigestion" who belched, and whose stomach now feels better. "He presents a low risk of cardiac disease, but if cardiac disease is present, that disease is much more likely to be missed because of the patient's atypical complaints," says Sullivan.
Sullivan says that there is simply no reasonable way to catch every single patient with cardiac disease. "Looking at a patient's risk factors and history in addition to the patient's complaints and physical examination may help us pick up on subtle cases of cardiac disease," he says. "But I don't think we'll ever reach 100% diagnostic accuracy."
Sullivan says that "one of the other things that emergency physicians have to work on is ECG interpretation," he says. "Up to 25% of malpractice claims against emergency physicians for misdiagnosis of chest pain involved either improper interpretation of the ECG or a failure to compare to an old ECG."
Have ED nursing leadership retrospectively review all lower acuity cases with a presenting complaint of chest pain that end up being admitted to the hospital.
By doing this, says Scaletta, "opportunities to improve the triage process can be uncovered. They will mostly find patients that did fine but should have been ESI 2. By correcting this behavior through gentle feedback and education, they will make the ED safer."
References
1. Atzema CL, Austin PC, Tu JV, et al. Emergency department triage of acute myocardial infarction patients and the effect on outcomes. Ann Emerg Med 2009; 53:736-745.
2. Physician Insurers Association of America. PIAA Claim Trend Analysis. Rockville, MD: Physicians Insurers Association of America, 2004.
3. Atzema C, Schull MJ, Austin PC, et al. Emergency department triage of acute myocardial infarction patients: Predictors of low acuity triage. Am J Emerg Med (In press).
Sources
Clare Atzema MD, M.Sc., FRCPC, Scientist, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Phone: (416) 480-6100, ext. 4835. E-mail: [email protected]
Robert Broida, MD, FACEP, Chief Operating Officer, Physicians Specialty Limited, Risk Retention Group, Canton, OH. Phone: (330) 493-4443, Ext. 1307. E-mail: [email protected].
Tom Scaletta, MD, FAAEM, President, Emergency Excellence, Chicago. Phone: (877) 700-3639. E-mail: [email protected]. Web: www.emergencyexcellence.com.
Elisabeth Ridgely, BS, RN, LNCC. Phone: (610) 496-8610. E-mail: [email protected].
William Sullivan, DO, JD, Frankfort, IL. Phone: (708) 323-1015. E-mail: wps013@ gmail.com.
Ann Robinson, MSN, RN, CEN, LNC, Robinson Consulting, LLC, Cambridge, MD. Phone: (410) 463-3770. E-mail: [email protected].
Christine B. Macaulay, RN, MSN, CEN, Nursing Practice and Patient Safety Specialist, The Children's Hospital of Philadelphia. Phone: (215) 590-0739. E-mail: [email protected].
This is the first of a two-part series on missed myocardial infarction [MI] cases. This month, we report on the best practices for reducing liability risks involving triage, and review cases of chest pain patients involving adverse outcomes in ED waiting rooms.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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