Do MI patients leave your ED? Know the risks
Inadequate assessment could bring lawsuit
A patient with chest pain is diagnosed with gastroesophageal reflux disease, walks out of your ED, and has a myocardial infarction (MI) a week later. Could this happen in your ED?
A recent study found that 3% of ED chest pain patients are not diagnosed with heart trouble, but they wind up having a heart attack within the next month.1 Misdiagnosis of chest pain is one of the top liability risks in the ED, says Chadwick D. Miller, MD, the study’s principle investigator and assistant residency director for the department of emergency medicine at Winston-Salem, NC-based Wake Forest University. "The study’s findings point out that we are certainly still missing some of these cases up front with our initial impression," he says.
If you don’t properly triage and assess chest pain patients, you could be liable in a malpractice lawsuit, warns Patricia Iyer, RN, MSN, LNCC, president of Flemington, NJ-based Med League Support Services, a legal nurse consulting firm specializing in malpractice and personal injury cases. "The study reinforces that it is imperative that the ED nurse perform an appropriate assessment of a patient whose chief complaint is chest pain," she says.
To reduce liability risks when assessing patients with chest pain, do the following:
- Document appropriately.
"Document the nature of the pain, including the location, intensity, radiation, precipitating and relieving factors," says Iyer. "The nurse may be named in the lawsuit if inaccurate information is documented." This clinical information is relied upon by the physician in the diagnostic phase of the evaluation of the patient, she stresses.
- Ask the right questions at triage.
If you don’t have a high index of suspicion that the patient’s pain is related to a cardiac event, the patient may be mistriaged, warns Donna Cohen, RN, BSN, nurse manager for emergency services at Trinitas Hospital in Elizabeth, NJ. "If the nurse does not send a potential cardiac patient immediately to the treatment area for an electrocardiogram which would diagnose the MI, she might potentially be held liable," she says. "If a patient wants to sue, they will name everyone who provided any care to them."
Always get the following information when triaging a chest pain patient, says Cohen: Time of onset of pain; pain scale scores; location of pain, associated symptoms such as nausea, vomiting, shortness of breath, diaphoresis, and pain in the arm, neck, back, jaw; what relieves the pain; whether the pain occurs with exercise or at rest; if the pain is constant or intermittent; if the pain has ever happened before; and history of cardiac problems or drug use.
There is a tendency to think that younger patients can’t be having a cardiac-related event, says Cohen. "This is bad thinking. I have seen some patients come to the ED that are in their 30s that have ruled in for an MI," she says. "It is not the nurse’s responsibility to diagnose. We must gather all the facts and get the patient into the treatment area as soon as possible to rule out a cardiac event, regardless of age."
- Take patient history seriously.
If you assume a patient’s pain is noncardiac, treatment delays or a missed diagnosis can occur, warns Miller. "There may be an upfront assessment of whether someone is cardiac or noncardiac, which affects the speed with which a patient is triaged, put in a bed, put on a monitor, and chest pain protocols are started," he adds.
If patients report a history of coronary disease, this should be a major red flag, says Miller.
"Even if patients present with chest pain that is thought to be noncardiac, if they have a history of coronary disease, I would take that much more seriously," he says. "Treat those patients as if it was a coronary event until you know otherwise."
- Speak up when the patient is not receiving proper care.
If one or more key factors of a cardiac work-up are missing or not documented, the nurse and physician are at risk if the patient suffers harm after a misdiagnosis, says Mary Ann Shea, JD, RN, a St. Louis-based legal nurse consultant.
The consequences associated with a missed chest pain diagnosis can be deadly, she underscores. "The diagnosis of noncardiac chest pain’ should only attach after a thorough work-up to rule out a cardiac basis for the symptoms," she says. "However, this evaluation is often cut short in the ED for a number of reasons."
Make sure that all the key components of your assessment are communicated to the physician, advises Shea. "Do not assume that the patient will report information to the physician, or that the physician will always read what was written in the ED nursing assessment," she says.
When you are aware of, or should be aware of, inadequate treatment by a physician, you have an obligation to intervene on behalf of the patient, stresses Shea. "Chain-of-command procedures may need to be invoked, as the nurse attempts to rectify what could be inadequate or improper treatment," she says. "Doing so can prevent patient injury and the resultant lawsuit."
Sources
For more information on assessment of chest pain patients, contact:
- Donna Michele Cohen, RN, BSN, Nurse Manager, Emergency Services, Trinitas Hospital, 225 Williamson St., Elizabeth, NJ 07202. Telephone: (908) 994-5239. Fax: (908) 994-5805. E-mail: [email protected].
- Patricia Iyer, MSN, RN, LNCC, President, Med League Support Services, 260 Route 202-31, Suite 200, Flemington, NJ 08822. Telephone: (908) 788-8227. Fax: (908) 806-4511. E-mail: [email protected]. Web: www.medleague.com.
- Chadwick D. Miller, MD, Assistant Residency Director, Department of Emergency Medicine, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157-1089. Telephone: (336) 716-4626. Fax: (336) 716-5438. E-mail: [email protected].
- Mary Ann Shea, JD, RN, Attorney at Law/Registered Nurse, P.O. Box 220013, St. Louis, MO 63122. Telephone: (314) 822-8220. Fax: (314) 966-0722. E-mail: [email protected].
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