Presentation on theme: "Latin vs. Hospital for Sick Children Toronto"— Presentation transcript:
1 Latin vs. Hospital for Sick Children Toronto Dr. Madan Roy, MD,FAAP,FRCP(C)Chief, Division of General PediatricsMcMaster Children’s HospitalAssociate Professor, PediatricsMcMaster University
2 Latin vs. Hospital for Sick Children Toronto Incident happened January 1998Settled in court January 20079 years later40 days of hearings8-10 experts
3 Latin vs. Hospital for Sick Children Toronto Issue14 month old Ryleigh Latin had a cough, high fever and prolonged seizure resulting in severe brain damageCould this have been prevented by more timely intervention i.e. triage at presentation to Emergency Department?
4 Latin vs. Hospital for Sick Children Toronto Questions that need to be addressed: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?
5 Latin vs. Hospital for Sick Children Toronto Plaintiffs Ryleigh Latin by way of her parentsDefendants Hospital for Sick Children TorontoSpecifically Margorie Williams, Triage Nurse and Virginia Wilkins, Charge Nurse(No actions against any of the MDs, even ER MD)
6 Latin vs. Hospital for Sick Children Toronto 14 month old healthy femaleHigh fever with episodes of “jerking” at home x 2 x ½ dayBrought to ER, 1240 hrsTriaged as URGENT = CTAS 3
7 Latin vs. Hospital for Sick Children Toronto CTASCanadian Triage and Assessment ScoreResuscitation ImmediateEmergent 15 minutesUrgent minutesSemi-Urgent 60 minutesNon-Urgent minutes
8 Latin vs. Hospital for Sick Children Toronto Triaged as urgent – 1240 hrsGiven TylenolDirected to RegistrationThen waiting room
9 Latin vs. Hospital for Sick Children Toronto In waiting room “jerking movements”Back to triage nurse StableBack to waiting roomClassification not changed from urgent to emergent
10 Latin vs. Hospital for Sick Children Toronto 1400 hrs – in waiting room – generalized seizureSeizure control not obtained until 1535 hrs i.e. status epilepticusSubsequent brain damage severe
11 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
12 Latin vs. Hospital for Sick Children Toronto Secondary Objectives of Triage:To provide a quick, accurate patient assessment upon presenting for treatmentTo provide initial accurate documentation on all patientsTo co-ordinate with the Resource Nurse, the patient flow from the Triage/Waiting area to the available clinical treatment areasTo provide patients and relatives with a liaison with whom they can relate and ask questionsTo provide First Aid to patients presenting for treatment
13 Latin vs. Hospital for Sick Children Toronto How is CTAS arrived at?ABCNot compromisedMore detailed assessmentRespiratory rate, circulation, vital signs, temperature, O2 sats, weight etc.CTAS designation given
14 Latin vs. Hospital for Sick Children Toronto Allegations – Triage NurseDid not obtain a complete set of vital signsDid not diagnose/suspect; dehydration, early shock, sepsisDid not detect PneumoniaDid not properly reassess her and treat her while in the waiting roomDid not classify Ryleigh as Emergent
15 Latin vs. Hospital for Sick Children Toronto Allegations – Charge NurseThere were available rooms for patients to be seen between 1240 hrs to 1400 hrs, but Ryleigh was not assigned to one of these roomsPermitted a stable patient, within the urgent category, to be seen before RyleighPermitted a non-urgent patient to be seen in priority to Ryleigh
16 Latin vs. Hospital for Sick Children Toronto Findings – Triage NurseTriage time – 3 to 5 minutes – average/appropriateVital Signs – blood pressure was not donerespiratory rate not done
17 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?
18 Latin vs. Hospital for Sick Children Toronto Hospital policy – blood pressure to be documentedStandard practice – only done in triage if called forBlood pressure was not taken. Was this a breach in the provision of care?
19 Vital SignsHospital Policy – Blood pressure to be documented at TriageStandard of Practice – only done in triage, if called forDecision – no breach in standard of careCurrent CTAS guidelines – BP is not included as a triage guideline
20 Vital Signs Respiratory Rate – not done as child was crying Rhythm RegularDepth AdequateAir Entry EqualQuality No DifficultyOther Cough since December 29th
21 Vital SignsRespiratory Rate - evidence of respiratory distress as opposed to a documented respiratory rate
22 Pneumonia While in status, “RUL wet” was noted Why was this missed by the triage nurse?Child cryingLikely aspiration secondary to going into statusMom did not report “difficulty breathing” as a concern at triage
23 Dehydration/Early Shock/Sepsis Time of last voidDiaper wet or notFluid intakeMental statusHeart Rate 160/mtTemperature, 39.9o CWarm, well perfused, mucus membranes moist, skin turgor normal
24 Dehydration/Early Shock/Sepsis Pulses – normal (not bounding/not weak)Heart rate 160/mtTemperature of 40o CFindings expected, and not a sign of sepsis
26 Triage Classification Plaintiff Irritability, lack of response to Tylenol, legsjerking/stiffening, were reasons for Emergent (not urgent) Triage, on re- assessment
27 Triage Classification Defense Irritability 14/12 with fever in ER is normal unless inconsolable2- Fever in 14/12 not uncommon and does not warrant Emergent triage
28 Triage Classification Legs stiffening – seizures are only emergencies when they are actively occurring and there is imminent concern with respect to maintaining the airwayHospital guidelines – seizures within 12 hours would be triaged as Urgent not Emergent
29 Triage Classification No documentation of reassessmentCourt looked at her documentation of other charts on that day, her pervious assessments of RyleighReasonable to infer, that an experienced nurse would have done ABC and come to the conclusion that triage category remained urgent
30 Conclusion Triage Nurse Met the standard of care of a reasonable and prudent triage nurseShould have documented the reassessment, but this does not amount to negligence
31 Charge NurseThere were available rooms for patients to be seen between 1240 hrs to 1400 hrs, but Ryleigh was not assigned to one of these roomsPermitted a stable patient, within the urgent category, to be seen before RyleighPermitted a non-urgent patient to be seen in priority to Ryleigh
32 Plaintiff:From 1240 to 1400 hrs there were 9 rooms available
33 Defense:Availability of rooms is only one factorAvailability of nursing resources, physician resources, discharge planners, and patient service aides to clear rooms
34 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 sentOtherwise non-urgent patients would never be seen
36 Etiology of Seizure? Idiopathic status epilepticus? Shock? Viral Encephalitis?
37 Etiology of Seizure? Plaintiff Uncompensated shock Not adequately treated early enoughHypoxic-IschemicStatus EpilepticsBrain damage
38 Etiology of Seizure? Judge On balance of evidence, I cannot come to the conclusion that there was HIE, due to shock/sepsis
39 Etiology of Seizure?Viral Encephalitis – influenza A culture positive, NPS from 21/1 on 26/01/98Subsequent C/S negative i.e. 7 days after admissionLP negativeSerology NegativeJudge – most likely diagnosis