Transcript Latin vs. Hospital for Sick Children Toronto

Latin vs. Hospital for Sick
Children
Toronto
Dr. Madan Roy, MD,FAAP,FRCP(C)
Chief, Division of General Pediatrics
McMaster Children’s Hospital
Associate Professor, Pediatrics
McMaster University
Latin vs. Hospital for Sick Children
Toronto
► Incident
happened January 1998
► Settled in court January 2007
► 9 years later
► 40 days of hearings
► 8-10 experts
Latin vs. Hospital for Sick Children
Toronto
Issue
► 14
month old Ryleigh Latin had a cough,
high fever and prolonged seizure resulting
in severe brain damage
► Could this have been prevented by more
timely intervention i.e. triage at
presentation to Emergency Department?
Latin vs. Hospital for Sick Children
Toronto
Questions that need to be addressed:
1.
2.
3.
What was the standard of care for triage in
1998?
Did the defendants, HSC Toronto, breach
these standards?
Did such breach cause the damages that
Ryleigh suffered?
Latin vs. Hospital for Sick Children
Toronto
Plaintiffs
Ryleigh Latin by way of her
parents
Defendants
Hospital for Sick Children
Toronto
Specifically Margorie
Williams, Triage Nurse and
Virginia Wilkins, Charge
Nurse
(No actions against any of the MDs, even ER MD)
Latin vs. Hospital for Sick Children
Toronto
► 14
month old healthy female
► High fever with episodes of “jerking” at
home x 2 x ½ day
► Brought to ER, 1240 hrs
► Triaged as URGENT = CTAS 3
Latin vs. Hospital for Sick Children
Toronto
1
2
3
4
5
CTAS
Canadian Triage and Assessment Score
Resuscitation
Immediate
Emergent
15 minutes
Urgent
30 minutes
Semi-Urgent
60 minutes
Non-Urgent
120 minutes
Latin vs. Hospital for Sick Children
Toronto
► Triaged
as urgent – 1240 hrs
► Given Tylenol
► Directed to Registration
► Then waiting room
Latin vs. Hospital for Sick Children
Toronto
► In
waiting room
“jerking movements”
► Back to triage nurse
Stable
► Back to waiting room
► Classification not changed from urgent to
emergent
Latin vs. Hospital for Sick Children
Toronto
► 1400
hrs – in waiting room – generalized
seizure
► Seizure control not obtained until 1535 hrs
i.e. status epilepticus
► Subsequent brain damage severe
Latin vs. Hospital for Sick Children
Toronto
Primary Objective of Triage:
To assess patient needs and to make a
professional judgment as to whether the
needs are Emergent, Urgent or Non-Urgent
Latin vs. Hospital for Sick Children
Toronto
Secondary Objectives of Triage:
1.
2.
3.
4.
5.
To provide a quick, accurate patient assessment
upon presenting for treatment
To provide initial accurate documentation on all
patients
To co-ordinate with the Resource Nurse, the patient
flow from the Triage/Waiting area to the available
clinical treatment areas
To provide patients and relatives with a liaison with
whom they can relate and ask questions
To provide First Aid to patients presenting for
treatment
Latin vs. Hospital for Sick Children
Toronto
How is CTAS arrived at?
► ABC
► Not compromised
► More detailed assessment
► Respiratory rate, circulation, vital signs,
temperature, O2 sats, weight etc.
► CTAS designation given
Latin vs. Hospital for Sick Children
Toronto
Allegations – Triage Nurse
► Did
not obtain a complete set of vital signs
► Did not diagnose/suspect; dehydration,
early shock, sepsis
► Did not detect Pneumonia
► Did not properly reassess her and treat her
while in the waiting room
► Did not classify Ryleigh as Emergent
Latin vs. Hospital for Sick Children
Toronto
Allegations – Charge Nurse
► There
were available rooms for patients to
be seen between 1240 hrs to 1400 hrs,
but Ryleigh was not assigned to one of
these rooms
► Permitted a stable patient, within the
urgent category, to be seen before Ryleigh
► Permitted a non-urgent patient to be seen
in priority to Ryleigh
Latin vs. Hospital for Sick Children
Toronto
Findings – Triage Nurse
► Triage
time – 3 to 5 minutes –
average/appropriate
► Vital Signs – blood pressure was not done
respiratory rate not done
Latin vs. Hospital for Sick Children
Toronto
► What
was the standard of Practice?
► If not the standard of practice, did her
presentation require a full set of vital signs?
Latin vs. Hospital for Sick Children
Toronto
► Hospital
policy – blood pressure to be
documented
► Standard practice – only done in triage if
called for
► Blood
pressure was not taken. Was this a
breach in the provision of care?
Vital Signs
► Hospital
Policy – Blood pressure to be
documented at Triage
► Standard of Practice – only done in triage, if
called for
► Decision – no breach in standard of care
► Current CTAS guidelines – BP is not included
as a triage guideline
Vital Signs
► Respiratory
crying
Rhythm
Depth
Air Entry
Quality
Other
Rate – not done as child was
Regular
Adequate
Equal
No Difficulty
Cough since December 29th
Vital Signs
► Respiratory
Rate - evidence of respiratory
distress as opposed to a documented
respiratory rate
Pneumonia
► While
in status, “RUL wet” was noted
► Why was this missed by the triage nurse?
► Child crying
► Likely aspiration secondary to going into
status
► Mom did not report “difficulty breathing” as
a concern at triage
Dehydration/Early Shock/Sepsis
► Time
of last void
► Diaper wet or not
► Fluid intake
► Mental status
► Heart Rate 160/mt
► Temperature, 39.9o C
► Warm, well perfused, mucus membranes
moist, skin turgor normal
Dehydration/Early Shock/Sepsis
► Pulses
– normal (not bounding/not weak)
► Heart rate 160/mt
► Temperature of 40o C
► Findings expected, and not a sign of sepsis
Dehydration/Early Shock/Sepsis
Conclusion re: Triage Assessment
Adequate
Triage Classification
Plaintiff
Irritability, lack of response to
Tylenol, legs
jerking/stiffening, were
reasons for Emergent (not
urgent) Triage, on reassessment
Triage Classification
Defense
1- Irritability 14/12 with fever
in ER is normal unless
inconsolable
2- Fever in 14/12 not
uncommon and does not
warrant Emergent triage
Triage Classification
► Legs
stiffening – seizures are only
emergencies when they are actively
occurring and there is imminent concern
with respect to maintaining the airway
► Hospital guidelines – seizures within 12
hours would be triaged as Urgent not
Emergent
Triage Classification
► No
documentation of reassessment
► Court looked at her documentation of other
charts on that day, her pervious
assessments of Ryleigh
► Reasonable to infer, that an experienced
nurse would have done ABC and come to
the conclusion that triage category
remained urgent
Conclusion
Triage Nurse
► Met
the standard of care of a reasonable
and prudent triage nurse
► Should have documented the reassessment,
but this does not amount to negligence
Charge Nurse
► There
were available rooms for patients to
be seen between 1240 hrs to 1400 hrs, but
Ryleigh was not assigned to one of these
rooms
► Permitted a stable patient, within the urgent
category, to be seen before Ryleigh
► Permitted a non-urgent patient to be seen
in priority to Ryleigh
Plaintiff:
► From
1240 to 1400 hrs there were 9 rooms
available
Defense:
► Availability
of rooms is only one factor
► Availability of nursing resources, physician
resources, discharge planners, and patient
service aides to clear rooms
Non urgent patients seen before urgent
► These take very little time and, often, while
urgent patients are being worked up, these
are quickly seen and sent
► Otherwise non-urgent patients would never
be seen
Conclusion
Charge nurse acted reasonably
NOT GUILTY
Etiology of Seizure?
► Idiopathic
status epilepticus?
► Shock?
► Viral
Encephalitis?
Etiology of Seizure?
Plaintiff
► Uncompensated
shock
► Not adequately treated early enough
► Hypoxic-Ischemic
► Status Epileptics
► Brain damage
Etiology of Seizure?
Judge
► On
balance of evidence, I cannot come to
the conclusion that there was HIE, due to
shock/sepsis
Etiology of Seizure?
► Viral
Encephalitis – influenza A culture
positive, NPS from 21/1 on 26/01/98
► Subsequent C/S negative i.e. 7 days after
admission
► LP negative
► Serology Negative
Judge – most likely diagnosis
Conclusion
Judge: The action is dismissed
Take Home Points
► Court
systems are fair, but arduous,
prolonged, costly, time consuming, and a
severe strain on the defendants
Take Home Points
► CTAS
classification, if in ER
► Ability to justify what you did or did not do
Take Home Points
► No
defendant had any actual recollection of
the patient
► “If it is documented, it is done. If it is not
documented it is not done”
Take Home Points
► We
are our worst enemies
► There are always “Experts” who will take
the plaintiffs side
► “No Fault” clause
Latin vs. Hospital for Sick Children
Toronto
Charge nurse guilty?
YES
NO