Patient Deterioration – Emergency Department

Key Words

Emergency Room, Patient Deterioration, Acute Care, System Failure, Triage Assessment, Communication

Abstract

A patient sustained permanent neurological damage following a neurological deterioration in the Emergency Department (ED). Expert opinion concluded the quality of the care provided was indefensible.

Case Summary

At 17:36 hours, the patient presented to the ED at a tertiary care facility, reporting neurological symptoms that had been present for one week. A review of the patient’s medical history revealed the patient had attended another medical facility prior to this admission.

At 18:52, the patient was triaged at a CTAS Level 3. As the patient waited to be seen by the attending physician, the patient’s condition began to significantly deteriorate.

At 23:30 hours, the patient was seen by the attending physician and a computerized tomography (CT) scan was ordered. At 23:40, the CT scan was conducted.

At 04:40 the next day, the patient was seen by a neurologist, who noted the presence of an internal carotid artery dissection.

At 15:25, the patient was admitted to the Intensive Care Unit (ICU), where it was determined the patient had suffered a serious stroke and sustained permanent neurological damage.

Medical Legal Findings

Expert review of the case was critical of the care provided to the patient. Following the patient’s initial presentation to the ED at 17:36, the patient waited for 90 minutes prior to being triaged. In addition, the experts questioned the triage level assigned to the patient, suggesting the level was inappropriate, given the patient’s significant medical history and continued deterioration.

Experts also noted that following the patient’s initial triage assessment at 18:52, the patient was not re-assessed until 20:45, at which point it was noted that the patient had begun to rapidly deteriorate. Further, the patient’s CT scans were not read for one hour due to a PACS system failure.

Reflections

Reflecting on your practice as well as your hospital’s ED policies, procedures and processes:

1. Based on the information available in this case, discuss the assignment of triage CTAS Level 3.
   1. Was it appropriate and reasonable for the patient’s re-assessment to take place two hours after the initial triage assessment?
   2. Would your answer be different if the ED was ‘busier than normal’?
2. Discuss the role of interdisciplinary simulation in ED patient safety.
3. Once performed, the CT scans were not read for one hour due a system failure. Discuss your facility’s local process in place to address unexpected system downtimes?