ED nursing care of chest pain patient ruled homicide by jury
Case is an ED nurse's 'worst nightmare'
The 49-year-old woman reported classic heart attack symptoms — chest pain, shortness of breath, and nausea — to nurses at an Illinois ED. But according to public records, the patient was seen only briefly by the triage nurse and then waited two hours. When nurses came back to check on the woman, she was dead. A coroner's jury declared it a homicide, which means that the ED nurse involved could be criminally prosecuted.
"This case has definitely created lots of discussion among emergency nurses," reports Evelyn Lyons, RN, MPH, manager of the Illinois Emergency Medical Services for Children program, based at Loyola University Medical Center in Maywood, IL, and president of the Illinois chapter of the Emergency Nurses Association. "There is a really strong reaction from ED nurses throughout our state. We'll be following this case very closely."
The case hit home with ED nurses who are struggling with long wait times and sicker patients, she says. "Our EDs are overcrowded, and we have a nursing shortage," she says. "Nurses are overextended, and EDs are stretched to the seams."
At press time, no criminal charges or lawsuits had been filed, but emergency nurses nationwide are waiting for further news. Kathryn Eberhart, BSN, RN, CEN, a Santa Rosa, CA-based legal nurse consultant and ED nurse at Santa Rosa Memorial Hospital, says she has never heard of this situation happening before. "However, two hours with chest pain? That's too long," says Eberhart. The patient should have been classified as emergent and taken into the ED immediately for an electrocardiogram and work-up, she says.
Since the patient never saw a physician, the triage nurse would be the one on the hook if any charges are brought, says Eberhart. "It's hard for me to understand how a triage nurse could not identify this patient as one of those that you don't put in the waiting room," she says. "You find a bed, notify the charge nurse, and document, document."
Regardless of the details, this case should be a wake-up call for ED nurses, says Eberhart. ED nurses need to be careful and diligent in the triage process, she says. "Triage is a big responsibility and should never be taken lightly," Eberhart says. "Triage is one of the toughest jobs in the ED and should only be performed by experienced nurses."
What happened is "a nurse's worst nightmare," but the circumstances are not unusual for ED nurses dealing with the burden of overcrowding, says Patricia Iyer, MSN, RN, LNCC, president of Flemington, NJ-based Med League Support Services, a legal nurse consulting firm specializing in malpractice and personal injury cases. "No emergency nurse ever wants any patient to wait, but every triage nurse has had to place patients in the waiting room they were uncomfortable with," she says.
Surge in lawsuits?
This is a dramatic case with a dramatic outcome, and thus it is unusual, says Iyer. "However, if the damages are significant, more lawsuits could arise," she says.
Lawsuits claiming "ED nurses made me wait too long" are a real possibility, says Eberhart. "I think we may see an increase in malpractice cases alleging that the patient waited too long," she says. "With overcrowding of EDs, closing of hospitals across the country, and long wait times, really sick people may be waiting for an empty gurney. "
However, the plaintiff has to prove that a long wait resulted in a worsening of their condition, with tangible damages associated with the wait, cautions Iyer. "The dissatisfaction alone of having to wait will not provide the basis of a lawsuit," she says. "Plaintiff attorneys can't afford to take cases involving dissatisfaction without real injuries."
Regardless of liability risks, there is no question that patients are dissatisfied over long waits, says Iyer. "Fast track systems that siphon off the less urgent patients to a separate area of the ED are one way to keep the focus on the sicker patients," she says. People in our culture are generally accustomed to rapid service, Iyer says. "Long waits breed discontent and sow the seeds for a disaster such as the one reported in this story."
To reduce risks in your ED's waiting room, implement the following practices:
- Inform every patient to tell the triage nurse if they feel worse.
Triage nurses should advise patients that if they feel worse or if any other symptoms begin to occur while they are in the waiting area, they need to notify the triage nurse promptly so that they can be reassessed, says Lyons.
"When the patient is elderly or a child, the triage nurse needs to provide these instructions to the parent or caregiver so they can be attentive to any changes in the patient's condition," Lyons says.
- Reassess patients often.
You must continually observe all patients in the waiting room, advises Iyer. Periodic vital signs and re-assessments are needed, particularly when waits are long, she says. "Verify that symptoms have not gotten worse while the patient is in the waiting area," Iyer advises. "Observe the patient, noting the focus of the primary complaints."
Ask questions specific to the patient's complaints; reassess vital signs, pulse oximetry, pain, and skin signs; and look for any new complaints or changing symptoms, says Eberhart.
- Give patients an advocate.
"If there is someone that I feel is at higher risk for injury and yet there is no place to put them, no empty gurneys, and my hands are tied, I make sure they have a family member or friend that will stay with them in the ED waiting room and be an advocate," says Eberhart.
If patients come in alone, they are placed in a wheelchair within view of the triage are, or as a last resort, in front of a secretary or tech in the hallway until a room is available, says Eberhart. "They are placed in a visible place so that the triage nurse can continue with triage of the rest of the patients and yet be able to eyeball the patient that is at high risk or has a complaint that places them in a higher risk category for injury," she says.
- Improve communication.
Always keep the charge nurse updated as to the status of the waiting room and the patients waiting for triage or waiting for a bed, says Eberhart. "Communication is a key factor in any emergency department," she emphasizes.
At Santa Rosa's ED, triage nurses carry a cordless phone and pager at all times to alert other staff when triage becomes overloaded. During these times, a secondary triage area is set up, and an ED technician assists with vital signs and moving patients.
The triage nurse can dial the charge nurse's phone that is carried at all times to keep the charge nurse updated as to the status of triage, adds Eberhart. "Our ED's tracking system [MEDHOST, based in Addison, TX] has an icon that informs the charge nurse of exactly how many patients are waiting," she adds. "With a click, you can see what the chief complaint is and the acuity at triage."
The media coverage of the Illinois case has caused added tension between patients and ED nurses, making good communication even more important, says Elda Ramirez, MSN, RN, PhD, FNP-C, CEN, an ED nurse practitioner at the University of Texas Health Science Center (UTHSC) in Houston and assistant professor of nursing in the emergency care division of UTHSC's School of Nursing. "Patients already have a preconceived notion that we won't help them," she says. "They come in with the attitude, 'If I'm not aggressive and rude, they won't pay attention to me.' The level of hostility has really increased. This disrupts the flow of care."
Sources
For more information about liability risks of long wait times in the ED, contact:
- Kathryn Eberhart, BSN, RN, CEN, Eberhart Medical Legal Consulting, 4706 Devonshire Place, Santa Rosa, CA 95405. Telephone: (707) 538-7056. E-mail: [email protected].
- Patricia Iyer, MSN, RN, LNCC, CLNI, Med League Support Services, 260 Route 202-31, Suite 200, Flemington, NJ 08822. Telephone: (908) 788-8227. Web: www.medleague.com.
- Evelyn Lyons, RN, MPH, Manager, Illinois Emergency Medical Services for Children, Loyola University Medical Center, 2160 S. First Ave., Building 110-LL, Maywood, IL 60153. Telephone: (708) 327-2556. E-mail: [email protected].
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