Woman’s Stroke Progressed in ED without Intervention

Commentators

• Jonathan Einbinder, MD, MPH

Transcript

An 83-year-old woman with a history of multiple stroke risk factors was brought to the Emergency Department by her daughter who noticed her mother “sounded strange” during a phone conversation.

She was seen 45 minutes later by the triage nurse, who noted confusion, garbled speech, and a mild right facial droop. Neither the patient nor her daughter could pinpoint when the symptoms had begun. Her history included hypertension, heart disease, hypercholesterolemia, and possible transient ischemic attacks (TIAs).

Based on her assumption that the neurologic symptoms had started more than three hours prior, the triage nurse assigned the patient a triage score of 3, and directed her to the waiting room until a physician was available to examine her. Her daughter was told that her mother had likely had a stroke and would be given medication in the hospital. She was instructed to notify someone if her mother’s symptoms progressed while they were waiting.

Two hours after arrival, the patient’s daughter notified ED personnel that her mother had new onset of right-sided paralysis. She was told there were “many major cases” in the ED. The mother was taken to a room, and a little more than 3 hours after arriving in the ED, she was evaluated by the ED physician. They documented near-total right paralysis and possible initial symptom onset 4 hours prior.

A CT scan showed no acute hemorrhage. After a neurology consult and consideration of the event time course and the patient’s age, the ED physician decided not to administer thrombolytics. The patient received Plavix and was admitted to the floor. An MRI showed acute posterior temporal lobe and basal ganglia infarctions.

On her third day of hospitalization, the patient—whose symptoms and gait had been improving—fell while getting out of bed and was noted to have increased right-sided weakness. She was started on heparin. During her stay she was diagnosed with new versus paroxysmal atrial fibrillation.

Eight days after her stroke, the patient was transferred to a short-term rehabilitation center. Her facial droop resolved within one month; she has minimal right-sided incoordination and balance problems. Embarrassment over her mild expressive aphasia makes her reluctant to participate in certain activities. Since her stroke, she has had falls resulting in a right hip fracture that required surgery and a right proximal humerus fracture.

The patient sued the triage nurse, claiming that a delay in proper diagnosis and treatment of an acute stroke led to permanent neurologic sequelae. The case was settled in the medium range.

To discuss the patient safety and risk management aspects of this case, we turn to Dr. Jonathan Einbinder. Dr. Einbinder is a general internist at Brigham and Women’s Hospital and Vice President of Advanced Data Analytics and Coding at CRICO.

Q.) Jonathan, it seemed like there needed to be a better process for stroke evaluation and then how to respond after the symptoms were identified. Could you walk us through that just a little bit?

A.) Sure and I think the important thing is to, in the situation of triage, to keep things as standard as possible and as simple as possible in terms of activating a system. And in this case, the triage nurse had to make a judgment as to whether the patient was having stroke symptoms. She also had to take a history and make a judgment as to how long those symptoms had been going on and whether the patient was within the window where prompt treatment might have been possible.

The triage nurse was doing this in the context of a busy emergency department. It sounds like they were actually at or over capacity at the time, and that’s something that should never enter into a triage decision yet, of course, we’re all human and, of course, it did and it does.

And what you’d really like to have happen is a very straightforward, completely reliable process or highly reliable process where if a patient with stroke symptoms comes in, the nurse can activate the appropriate resources, no questions asked, no judgment, no recrimination, no eye rolling, second guessing, etc., and then patients can get evaluated and get the treatment they need if they need it. And if there is no treatment possible, that’s okay too. What you don’t want to have happen is somebody fall through the cracks when they could have been treated.

Q.) What are the take-homes that you could see?

So I think that there are several take homes for this case study, and the first was the need for a highly reliable triage process that minimizes bias and environmental factors. Obviously, that also involves having a good process in place, having good training of the individuals, having ideally reinforcement and measurement of performance with regard to that protocol as well would be very important. In this case, the nurse made a judgment that the patient’s stroke was outside the window where it could have been treated and also didn’t recognize that the stroke might have been an evolution. Really what needed to happen was the patient needed to be evaluated by a stroke team and by a neurologist very promptly to decide whether any treatment was indicated or possible.

In addition, the triage nurse took into account the environmental factors, so triaging the patient at a lower level of priority because of the current overcapacity state of the emergency department. It sounds like they were really being inundated with cases and patient care. And one of the lessons of triage is you should always triage the patient the same regardless of the capacity. You may need to make resource decisions based on available resources, but you shouldn’t make triage decisions as such. So the patient should have been triaged the same whether the ER was empty or whether it was overcapacity.

Q.) So it’s your sense maybe that it wasn’t about preparation and training, but it was about the environment in this case?

A.) I think so and I think also about, maybe I’m reading too much into this, but all of us clinicians see patients and have conscious and unconscious biases; we have environmental factors that are affecting how we evaluate a situation. There’s everything that’s going into a decision like this. Again, the purpose of a really highly reliable triage process is to remove or minimize the effect of those environmental factors on the conscious and unconscious biases.

Q.) In the aftermath of the case, it sort of illustrates maybe some of the ways that we can make things better after an adverse event or make things worse. What are the take homes that you could see?

A.) In terms of what leads to in this case a malpractice claim or suit, there are nonclinical factors unrelated to negligence or the quality of care the affect whether or not a suit is filed. In this case leaving the patient in the emergency department waiting area with her daughter where the daughter felt maybe that her mother wasn’t getting adequate care, that she wasn’t being seen and heard and that the daughter’s concerns weren’t being taken into account, those are all conditions that are set up for an adversarial relationship and a potential malpractice suit if things go poorly.

In addition in this case, there was one other factor that happened is that clinicians actually blamed each other. And they blamed each other both verbally to the family, indicating ‘I wouldn’t have done that,’ or ‘that shouldn’t happen.’ And then also, I understand in the medical record there is a little bit of finger pointing. And that is a situation that, even if there isn’t any deviation from the standard of care or any negligence, it’s going to not lead to a good outcome with regard to any malpractice litigation.

Q.) Thank you very much, Jonathan Einbinder. Jonathan is a general internist at Brigham and Women’s Hospital and Vice President of Advanced Data Analytics and Coding at CRICO. I’m Tom Augello for Malpractice Insider.