Chest Pain Patients Having Bad Outcomes in Waiting Rooms
Chest Pain Patients Having Bad Outcomes in Waiting Rooms
Incidents expected to increase
"Unfortunately, while health care access continues to decline, the episodes of bad outcomes in waiting rooms can only rise. It is just that simple," says Ann Robinson, MSN, RN, CEN, LNC, principal of Robinson Consulting, a Cambridge, MD-based legal nurse consulting company. "EDs everywhere are experiencing this, and if they haven't, it is simply a matter of time until they do."
In one case, a 24-year-old man presented to an ED with severe chest pain and blood pressure of 132/88, pulse 126, temperature of 99 degrees Fahrenheit, and pulse oxygen saturation 99 percent on room air. He appeared otherwise healthy and described no recent illnesses or previous history of similar chest discomfort.
"The emergency department was busy and the triage nurse thought the patient could wait in the waiting room," says Christine Macaulay, RN, MSN, CEN, nursing practice and safety specialist at The Children's Hospital of Philadelphia. "Two hours after the initial triage, the patient returned to the triage nurse complaining of severe pain, requesting to be seen immediately."
The staff told the patient's family that he would be seen as quickly as possible, after patients with more serious conditions were seen. Shortly afterward, the patient collapsed in the waiting room. "Advanced life support was required to revive the patient, who had suffered a myocardial infarction," says Macaulay. The patient recovered, but suffered significant heart failure.
Prevent these disasters
"Door-to physician times should ideally be no greater than 60 minutes. If there is a problem with space or staffing, then that needs to be rectified in order to prevent disasters," says Tom Scaletta, MD, president of Emergency Excellence, a Chicago-based organization that improves patient care and efficiency in the ED while controlling costs. Scaletta is also medical director of a high-volume community hospital in a Chicago suburb.
Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and director-at-large for the American Association of Legal Nurse Consultants, recently reviewed a case involving a 45-year-old man who came to an ED with complaints of chest pain that had radiated to his arm and had been a dull ache for a number of hours. The triage nurse took vital signs which were relatively normal, noted that the patient was pale, but that the pain was 4/10 and that there were no current associated symptoms.
"She sent the patient to the waiting room. After approximately one hour, the patient returned to the triage nurse asking when he would be seen," says Ridgely. "The nurse did not take another set of signs, and she did not ask if the patient's pain was worse or if anything had changed. She merely indicated that he would be next to be seen."
After 90 minutes in the waiting room, the patient was taken to the back for evaluation where he was found to be actively infarcting. "Although he was rushed for cardiac catheterization, he did not survive," says Ridgely. "The triage nurse was named in the lawsuit. Although she indicated that she didn't think that he was having a heart attack when she triaged him, she also admitted that she was unable to actually determine whether or not he was infarcting."
The nurse admitted that she should have had the patient evaluated immediately and performed an EKG, but based on her triage, she believed at that time that she was doing the right thing. "The case settled in favor of the plaintiff's estate for an undisclosed amount. The ED nurse continued to practice at that institution," says Ridgely.
In this case, the ED nurse involved not only failed to have the patient seen, she also failed to re-check vital signs while he was in the waiting room, and she failed to assess the quality of the pain. "Had any of these measures been implemented, the nurse may have had a different verdict," says Ridgely. "The assumption would have been that she knew that this was a cardiac process and was intervening in a timely and efficient manner."
Ridgely says that "ED nurses, while they are good clinicians, often get so wrapped up in the minutia that they forget to add common sense to the mix," she says. "This patient had complained of pain for a number of hours. The fact that the pain was radiating to the arm should have led the nurse to think heart before anything else."
The ED nurse would then have followed the protocols for chest pain, which would have included having the patient evaluated by an physician right away. "Perhaps if the patient was treated immediately, he would have arrived at the cath lab sooner and survived,'" says Ridgely.
"Patients with serious disease should be in the ED, not in the waiting room," says Robert Broida, MD, FACEP, COO of Physicians Specialty Limited, Risk Retention Group in Canton, OH. "For those patients in the waiting room, proper risk management requires that the hospital have a policy that requires frequent re-evaluation by the triage nurse."
Broida recommend a formal re-evaluation by the triage nurse every hour. "Have a index of suspicion for atypical symptoms of ACS such as fatigue, near-syncope, and bradycardia," he says.
Anytime patients have to wait in the waiting room, and especially those with any cardiac symptoms, a nurse must be able to visually observe them, says Scaletta. "Also, waiting patients should be instructed and encouraged to report any new or worse symptoms," he says.
"Unfortunately, while health care access continues to decline, the episodes of bad outcomes in waiting rooms can only rise.Subscribe Now for Access
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