Nurses cause 7-hour delay in treatment of cardiac patient.

CASE ON POINT: Hillcrest Baptist Medical Center v. Wade, 2005 WL 1837004 S.W.3d--TX

ISSUE: What could justify a 7-hour delay in treating a cardiac patient? Nothing!

CASE FACTS: Thirty-eight year-old Penny Wade went to the Emergency Department at Hillcrest Baptist Medical Center at 3:45 a.m., on February 4, 2002. At 3:52 a.m., she was triaged by a nurse, who noted that she smoked a pack of cigarettes a day. The nurse failed to note a family history of coronary artery disease. Thirty minutes later, a night-shift nurse assessed the patient but did not place her on a cardiac monitor. At 5:07 a.m., Dr. Norwid, an emergency room physician, saw the patient, and ordered an electrocardiogram (EKG) and lab tests. The patient was then transferred to a bed with a cardiac monitor. Myocardial Infarction (MCI) protocol was initiated. The EKG performed at 5:26 a.m. was described by Dr. Norwid as "worrisome." The EKG showed deep Q waves and a bit of ST elevation from V1 through V4. Dr. Norwid turned the patient over to Dr. Welter, another emergency room physician. At 5:40 a.m., a nitroglycerin drip was started reducing the patient's pain from 8 of 10, to 1 of 10 by 6:15 a.m. At 7:00 a.m., a day-shift nurse assumed care of the patient. At 7:31 a.m., a second EKG was performed. At 8:40 a.m., blood was drawn for additional lab tests. The second EKG demonstrated changes from the earlier EKG. There was now ST segment elevation in the lateral leads. Cardiac enzymes were elevated. The patient was sent for a CT scan without a cardiac monitor and without a registered nurse trained in Advanced Cardiac Life Support (ACLS). The patient vomited twice between 9:15 a.m. and 10:30 a.m. Her blood pressure dropped slightly. She was treated with Phenergan and a saline bolus. After reviewing the patient's EKG, a cardiologist immediately proceeded to her at I 1:06 a.m. At 12:05 p.m., the patient was taken to the cardiac catheterization lab. Angiograms demonstrated a 100% occlusion of the left anterior descending artery. It was treated with balloon angioplasty and stenting. The patient, left with significantly impaired cardiac ejection function (requiring implantation of a cardioverter/defribrillator and the possibility of a heart transplant in the future), sued the hospital for nursing negligence. The trial court denied the hospital's motion for summary judgment. The hospital appealed.

COURT'S OPINION: The Court of Appeals of Texas affirmed the judgment of the trial court. While the relationship of health care providers to each other was not clear, the fact that the hospital was responsible for the negligence of its nurses under the Doctrine of Respondeat Superior was crystal clear. The court noted that the plaintiff filed three expert medical witness affidavits as to the merits of her contention regarding the negligence of the nurses. Two were by physicians with expertise in the appropriate field. The third was by an emergency room nurse who explained that the national standard of care for emergency rooms is to have an AMI protocol to ensure that patients experiencing AMIs are immediately recognized to limit damage by cardiac ischemia.

LEGAL COMMENTARY: The nurse-expert opined that "the very purpose of the hospital's AMI protocol was to provide a clinical pathway to expedite patients with AMI to receive definite medical treatment." The standard of care is to limit the time the heart muscle is being denied adequate oxygen. The expert simplified her point by stating "time means muscle." This explains the goal for care of AMI patients. AMI protocol allows a maximum time of 60 minutes to make a decision to administer a thrombolytic or opt for coronary angioplasty. Accordingly, the expert opined that to accomplish this an EKG must be done within ten and no longer than 20 minutes after a patient arrives in the emergency room. The standard of care for a triage nurse is to be able to quickly recognize possible AMI patients and ensure there is no delay in physician management or performing an EKG. If a triage nurse fails to recognize AMI symptoms, the treating nurse has the responsibility to summon a physician and arrange for an EKG as quickly as possible. Unfortunately for the patient in this case neither the triage nurse nor the treating nurse followed proper protocol. As a result of the failure of the triage nurse, followed by the failure of the treating nurse the patient underwent a delay in treatment that spanned a period of well over two and one half hours. This was inexcusable! The nurse-expert further opined that if a physician fails to take appropriate action under AMI protocols, a nurse has a duty to act immediately (through her chain of command) to ensure that a call to cardiology is made.