Latin vs. Hospital for Sick Children Toronto

Latin vs. Hospital for Sick ChildrenToronto 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 ChildrenToronto • Incident happened January 1998 • Settled in court January 2007 • 9 years later • 40 days of hearings • 8-10 experts

Latin vs. Hospital for Sick ChildrenToronto 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 ChildrenToronto 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?

Latin vs. Hospital for Sick ChildrenToronto 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 ChildrenToronto • 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 ChildrenToronto 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 ChildrenToronto • Triaged as urgent – 1240 hrs • Given Tylenol • Directed to Registration • Then waiting room

Latin vs. Hospital for Sick ChildrenToronto • In waiting room “jerking movements” • Back to triage nurse Stable • Back to waiting room • Classification notchanged from urgent to emergent

Latin vs. Hospital for Sick ChildrenToronto • 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 ChildrenToronto 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 ChildrenToronto Secondary Objectives of Triage: • 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 ChildrenToronto 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 ChildrenToronto 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 ChildrenToronto 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 ChildrenToronto 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 ChildrenToronto • 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 ChildrenToronto • 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 Rate – not done as child was crying Rhythm Regular Depth Adequate Air Entry Equal Quality No Difficulty Other 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 ChildrenToronto Charge nurse guilty? YES NO

Latin vs. Hospital for Sick Children Toronto