Ensure Patients Are Placed Back on Monitor
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Even if continuous cardiac monitoring is ordered, ED patients may be taken off the monitor for transport or to go to the restroom and kept off the monitor due to oversight, warns Andrew Garlisi, MD, MPH, MBA, VAQSF, medical director for Geauga County EMS in Chardon, OH.
Blood pressure may be normal initially but then slip downward unnoticed while the patient is in the radiology department undergoing a CT scan. "The patient may then be returned to the ED and not placed back on the cardiac and blood pressure monitor," says Garlisi. "As the patient slips deeper into the downward spiral of severe sepsis, he or she enters the point of no return and dies."
He gives the example of a diabetic patient with generalized weakness and acute abdominal pain, examined by an EP who suspects sepsis from an intra-abdominal source and orders an intravenous fluid bolus and various ancillary studies, including abdominal CT.
In this case, says Garlisi, the EP assumes the nurse will repeat the vital signs in a timely manner, but is unaware of the nursing policy for repeat vital signs on noncritical patients.
"The EP assumes that the vital signs are rechecked prior to transfer to the CT department, but they are not," he says. The nurse asks the physician if the patient can go to CT off the monitor, the EP enters the order, and a technician brings the patient back to the ED.
"One hour later, the physician returns to the patient's room to discuss the CT results intra-abdominal abscess but the patient is semi-responsive," says Garlisi. "He has weak pulses, and the physician is shocked to discover that the patient is not on the cardiac monitor."
The physician calls for the nurse, who places the patient back on the monitor. The patient's heart rate is 134, and the blood pressure has plummeted to 62/38. Despite resuscitation efforts, the patient dies of septic shock.
"This scenario is a relatively common occurrence in our nation's emergency departments," says Garlisi.
Don't Assume
Electronic orders may give the EP the option to allow patients to be taken off the monitor for transport to CT, he notes. However, since the EP cannot assume that the patient will be placed back on the monitor when he or she returns, Garlisi suggests making this additional entry: "Place the patient back on the cardiac monitor when he/she returns from the radiology department."
If the ED's policy states that patients should be placed back on the monitor after returning from studies performed outside the ED, and they are not, and a downward drift of the blood pressure is missed, Garlisi says this is "a clear violation of their own policies, creating an indefensible position in court."
On the other hand, if the ED had no clearly stated policies regarding patients being placed back on the cardiac monitor after returning from the radiology department, this would also make a malpractice case difficult to defend, says Garlisi.
"The plaintiff attorney could convincingly describe the lack of such policy as an irresponsible, careless, and neglectful act, compromising the safety of the patient," he says.
Even if continuous cardiac monitoring is ordered, ED patients may be taken off the monitor for transport or to go to the restroom and kept off the monitor due to oversight, warns Andrew Garlisi, MD, MPH, MBA, VAQSF, medical director for Geauga County EMS in Chardon, OH.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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