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Based on observation, interview, and record review, the Emergency Department (ED) medical staff failed to ensure the medications recommended for successful resuscitation of a pediatric patient were available in the pediatric emergency cart. This failed practice resulted in the potential for preventable pediatric deaths in the ED.

Findings:

The pediatric emergency cart was reviewed on November 4, 2014, at 11:45 a.m., accompanied by RN 2. The cart was observed to have multiple drawers, each a different color, and a defibrillator (a machine used to, "shock," a patient to convert them from a life threatening heart rhythm to a non life threatening rhythm) sitting on top of the cart. RN 2 stated the ED used the Broselow system for pediatric emergencies and resuscitation.

(The Broselow system includes a color coded tape measure that relates a child's height as measured by the tape to his/her weight to provide medical instructions including emergency medication dosages, the size of equipment that should be used, and the level of shock voltage to be used when using a defibrillator. The tape is accompanied by a cart with color coded drawers that correlate with the colors on the tape. If a pediatric patient's length measures in the red zone on the tape, the medication dosages and shock voltage listed in the red zone on the tape, and the equipment and supplies located in the red drawer in the cart are appropriate for use on that size child. Medications can be given intravenously (IV) or down an endotracheal tube (ETT - a tube that is passed through the vocal chords, down the trachea, and into the lungs) in the absence of a patent IV site. ETT medication doses are higher than IV doses because they are not injected directly into the blood stream, but are injected into the lungs and absorbed into the blood stream from the lung surface.)

RN 2 demonstrated the use of the cart by pulling out the Broselow tape and explaining how the system worked. The RN stated if a child came to the ED in full arrest (heart and lungs stopped with cardiopulmonary resuscitation [CPR] in progress) whose length fell in the red zone of the tape, the ED team would use the medication doses listed in the red zone of the tape and the supplies and equipment located in the red drawer of the cart. The red zone of the tape indicated the following:

a. Epinephrine 1:10,000 concentration was to be given IV for resuscitation. The dose that was indicated for a child that size was 0.085 milligrams (mg), or 0.85 milliliters (ml);

b. Epinephrine 1:1,000 concentration (10 times stronger than the IV form) was to be given into the ETT. The dose indicated for a child that size was 0.85 mg, or 0.85 ml;

c. Atropine 0.1 mg/ml concentration was to be given IV for resuscitation. The dose that was indicated for a child that size was 0.17 mg, or 1.7 ml; and,

d. Atropine 0.4 mg/ml concentration (four times stronger than the IV form) was to be given into the ETT. The dose that was indicated for that size child was 0.45 mg, or 1.1 ml.

A review of the pediatric cart medication list and drug tray, approved by the Pharmacy and Therapeutics Committee and the Medical Executive Committee in November 2013, indicated the following:

aa. Epinephrine 1:10,000 (for IV use) concentration was on the medication list and in the medication tray, but there was no epinephrine 1:1,000 (for ETT use).

RN 2 stated she had never noticed epinephrine 1:1,000 was not in the medication tray. She was unable to verbalize how much epinephrine 1:10,000 she would give in the ETT if there was not a patent IV line, to equal the necessary dose.

[If 0.85 ml (the indicated number of ml for ETT administration) was given using epinephrine 1:10,000 (the only concentration available) into the ETT, the child would receive 1/10th of the dose needed for a chance to make their heart beat again];

bb. Atropine 0.1 mg/ml (for IV use) concentration was on the medication list and in the medication tray, but there was no atropine 0.4 mg/ml (for ETT use).

RN 2 stated she had never noticed atropine 0.4 mg/ml was not in the medication tray. She was unable to verbalize how much atropine 0.4 mg/ml she would give in the ETT if there was not a patent IV line, to equal the necessary dose.

[If 1.1 ml (the indicated number of ml for ETT administration) was given using atropine 0.1 mg/ml (the only concentration available) into the ETT, the child would receive 1/4 of the dose needed for a chance to make their heart beat again].

Based on observation, interview, and record review, the facility failed to ensure Emergency Department (ED) nursing staff:

1. Provided appropriate triage assessments for three of 18 patients whose triage assessments were reviewed (Patients 101, 109, and 200) when their chief complaint was not adequately addressed, resulting in inappropriate determination of care needs for Patients 101 and 109, and the potential for inappropriate care for Patient 200;

2. Provided appropriate pain assessments and reassessments for three of 11 patients who complained of pain (Patients 203, 205, and 218) when no follow up assessment was done after interventions for initial pain, resulting in the potential for unnecessary suffering and a return to the ED for further treatment;

3. Had knowledge of the operation of the pediatric emergency cart when one Registered Nurse (RN 2) was unable to demonstrate proper operation of the defibrillator, as well as dosing and location of life saving medications, resulting in the potential for preventable death in pediatric patients.

Findings:

1. During a tour of the ED on November 4, 2014, at 9:50 a.m., an ED Registered Nurse (RN) was observed sitting at a reception area located in the ED lobby. The reception desk contained a computer for registering patients and entering orders, a machine for taking vital signs, a scale to weight patients on arrival, a chair for patients to sit in while they were being assessed by the RN, gloves for the nurse to wear, and a biohazard trash can to discard patient care items. A pediatric patient (child) was observed sitting on his mother's lap. The RN was taking his vital signs and asking his mother questions about the reason for his visit.

The facility policy titled, "Emergency Department Scope of Service," was reviewed on November 4, 2014. The policy indicated patients would be triaged on arrival by an RN, and assigned an Emergency Severity Index (ESI) level based on the severity of their illness or injury. According to the policy, level 4 and 5 patients would remain in the lobby to be seen by a mid level provider (physician's assistant or nurse practitioner) through the Rapid Medical Screening (RME) process or until a bed became available.

The facility policy titled, "Triage: Five Level," was reviewed on November 4, 2014. The policy indicated the five level ESI process was used to categorize patients into five groups depending on the severity of their illness or injury (from level one - most urgent, to level five - least urgent). According to the policy, the ED RN would triage the patient in order to determine the priority of care necessary and the appropriate area for further evaluation and treatment.

The training information provided to the ED RNs who performed triage was reviewed on November 6, 2014. The information indicated a patient with a level four ESI was stable and could, "safely wait hours to be seen," by a provider.

a. The record for Patient 101 was reviewed on November 5, 2014. Patient 101, a 23 month old male, was sent to the ED on October 18, 2014, from his primary care physician, for "testicle problems." According to the record, the RN checked the child's vital signs and level of pain at triage. There was no evidence the RN assessed the area where the pain was located (the groin/testicular area). The RN assigned an ESI level four (less urgent), and placed the child in the waiting room to wait to be seen in the RME area.

The record indicated Patient 101 was evaluated by a non-physician provider (a nurse practitioner) in the RME 56 minutes after being placed in the lobby to wait. The examination by the nurse practitioner revealed the child had an incarcerated inguinal hernia (a piece of intestine protruding through an abnormal opening in the abdominal wall in the groin area. The intestine becomes stuck in the opening, the blood supply to the intestine becomes restricted, and the intestinal tissue begins to die) and a possible testicular torsion (the spermadic cord that the testicle is attached to twists, cutting off the testicle's blood supply. Prolonged waiting to correct the problem can result in long term fertility issues, and death of the testicular tissue).

The provider's notes indicated the hernia was visible (could be seen if looked at) and palpable (could be felt if touched), and efforts to try to reduce it (push it back through the hole in the abdominal wall so the blood supply could be restored) were unsuccessful.

According to the record, Patient 101 was medicated for pain twice, an ultrasound was done to confirm the physical findings, then he was transferred by ambulance to a Children's Hospital for a higher level of care.

b. The record for Patient 109 was reviewed on November 6, 2014. Patient 109, a 56 year old female, presented to the ED on May 15, 2014, complaining of a head injury after a fall. The ED RN who triaged the patient documented the patient complained of, "bumping," the back of her head after she fell while hiking up a rocky hill, she had ringing in her ears, and she complained of pain in the back of her head and shoulder. There was no evidence the RN assessed the patient's neurological status (for abnormalities), the appearance of her shoulder (for deformities), or the back of her head (for a wound). The RN assigned an ESI level four (less urgent) and placed the patient in the lobby to wait to be seen in the RME area.

The record indicated when Patient 109 was evaluated by a physician, she had a bleeding wound on the back of her head (arterial in nature with active bleeding) and she thought she may have lost consciousness when she fell. The physician ordered a Computerized Axial Tomography (CAT) scan that revealed Patient 109 had a subdural hematoma (bleeding into her brain). The patient was transferred to a trauma center for a higher level of care.

c. A review of Patient 200's record was conducted. Patient 200 presented to the ED on November 4, 2014, at 9:39 a.m., and was triaged. The patient's chief complaint was vaginal bleeding.

Further record review failed to show that an obstetric/gynecological, (OB/GYN) history was obtained at the time Patient 200 was triaged in the ED. The record did not reflect the patient's last menstrual period, the amount of vaginal bleeding, the number of pregnancies, miscarriages, and/or live deliveries the patient had.

A review of the "Emergency Department Course/Medical Decision Making" dated November 4, 2014, at 12:34 p.m. was conducted. The impression by the ED physician was that Patient 200 had a, "Threatened miscarriage and an acute lower urinary tract infection (kidney infection)."

Further record review indicated the section of the electronic medical record (EMR) dated November 4, 2014, at 9:39 a.m., which reflected, OB/GYN history showed the triage nurse documented, "N/A" (not applicable).

A review of the facility policy, "Emergency Department Triage: Five Level" (undated) was conducted. The procedure indicated all pregnant patients would be triaged and assessed by a RN and triage documentation would include, at a minimum, estimated fetal age, estimated gestational age (number of weeks pregnant), last menstrual period, and estimated date of confinement (due date).

During an interview with the ED Clinical Supervisor (CS) on November 6, 2014, at 11:25 a.m., the CS stated she was responsible for training the ED nurses to appropriately triage patients. The CS stated according to what she taught them, the triage nurses should assess, "whatever the patient complains about." She stated if there was a wound, they should look at it and describe it; if there was a head injury, they should perform neurological checks and document them; if there was a breathing problem, they should listen to breath sounds; if there was pain, they should look for abnormalities in the area (if applicable); and if there was vaginal bleeding, they should inquire about the pregnancy history, last menstrual period, and amount of bleeding. The CS stated if there was a need to expose the patient, she would expect them to take the patient to a private area, but, "they need to look, listen, and feel." The CS stated the nurse who triaged Patient 101 should have looked at and palpated the area of his pain. She stated the nurse who triaged Patient 109 should have looked at and described the wound, and should have performed a neurological exam to include whether or not the patient lost consciousness.

According to the Agency for Healthcare Research and Quality, the triage nurse should perform a brief, focused assessment and assign the patient a triage acuity level, which is a proxy measure of how long an individual patient can safely wait for medical examination and treatment. With more patients waiting longer in the waiting room, the accuracy of the triage acuity level is even more critical than ever before. Under-categorization (undertriage) leaves the patient at risk for deterioration while waiting.

2. a. A review of the ED policy, "Assessment and Reassessment In The Emergency Department" (undated), was conducted. The policy indicated, "Vital signs (including pain assessment) are to be assessed upon arrival...after medicine administered for pain (per policy) and within 30 minutes of discharge or transfer."

A review of Patient 203's record was conducted. Patient 203 was brought in by ambulance to the facility's ED on October 2, 2014, at 11:59 p.m., with a chief complaint of moderate abdominal pain in the right upper and lower abdomen. Patient 203 also complained of having nausea and vomiting for two days.

On October 2, 2014, at 12:12 a.m., on a scale from 1-10, with 10 reflecting the highest level of pain, Patient 203 described her pain at a level "10," radiating to her back. At 12:32 a.m., the patient was given Toradol 30 milligrams (pain medication) intravenously.

The record reflected on October 3, 2014, at 1:57 a.m., an hour and a half after having received the Toradol, Patient 203 indicated her a pain level was "5."

Patient 203 was subsequently diagnosed with gallstones and discharged home at 6:30 a.m., four and a half hours following the last documented pain assessment.

b. A review of Patient 205's record was conducted. Patient 205 was admitted to the facility's ED on October 3, 2014, at 10:15 a.m., with chief complaints of moderate and diffuse abdominal pain, nausea and vomiting for four days.

Patient 205 described his pain upon admission at a level 8 on a scale of 1-10, with 10 reflecting the highest level of pain.

At 11:56 a.m., Patient 205 received 2 milligrams of Morphine (narcotic pain medication) intravenously. The next pain assessment was conducted at 12:51 p.m., two hours after having received the Morphine.

Patient 205 was transferred to an observation room on October 3, 2014, at 4:20 p.m. The last pain assessment conducted was at 2:57 p.m., an hour and 20 minutes prior to the patient's transfer.

c. A review of Patient 218's record was conducted. Patient 218 was admitted to the facility's ED on October 3, 2014, at 12:08 p.m., with a chief complaint of rectal bleeding, in addition to having diarrhea and abdominal pain.

Patient 218 described her pain on October 3, 2014, at 12:17 p.m., at a level "8" on a scale of 1-10, with 10 reflecting the highest level of pain.

On October 3, 2014, at 12:52 p.m., Patient 218 received Norco (pain medication) orally for a pain level of "7." The response to the Norco was documented at 1:52 p.m., as "yes," or having been effective. No number to further quantify the pain level per the 1-10 pain scale was documented.

Patient 218 was subsequently discharged home at 3:03 p.m., an hour later with no reassessment of her pain 15 minutes prior to discharge.

An interview was conducted with Registered Nurse (RN) 1 on November 5, 2014, at 10:30 a.m. RN 1 stated after administering an intravenous pain medication, a reassessment of the patient's pain level was to be conducted within a half hour after having received the medication.

An interview was conducted with the ED Clinical Supervisor (CS) on November 5, 2014, at 10:45 a.m. The CS stated all vital signs, including a pain reassessment using a scale from 1-10, were to be conducted within 15 minutes of a patient's discharge or transfer.

3. The pediatric emergency cart was reviewed on November 4, 2014, at 11:45 a.m., accompanied by RN 2. The cart was observed to have multiple drawers, each a different color, and a defibrillator (a machine used to, "shock," a patient to convert them from a life threatening heart rhythm to a non life threatening rhythm) sitting on top of the cart. RN 2 stated the ED used the Broselow system for pediatric emergencies and resuscitation.

(The Broselow system includes a color coded tape measure that relates a child's height as measured by the tape to his/her weight to provide medical instructions including emergency medication dosages, the size of equipment that should be used, and the level of shock voltage to be used when using a defibrillator. The tape is accompanied by a cart with color coded drawers that correlate with the colors on the tape. If a pediatric patient's length measures in the red zone on the tape, the medication dosages and shock voltage listed in the red zone on the tape, and the equipment and supplies located in the red drawer in the cart are appropriate for use on that size child. Medications can be given intravenously (IV) or down an endotracheal tube (ETT - a tube that is passed through the vocal chords, down the trachea, and into the lungs) in the absence of a patent IV site. ETT medication doses are higher than IV doses because they are not injected directly into the blood stream, but are injected into the lungs and absorbed into the blood stream from the lung surface.)

RN 2 demonstrated the use of the cart by pulling out the Broselow tape and explaining how the system worked. The RN stated if a child came to the ED in full arrest (heart and lungs stopped with cardiopulmonary resuscitation [CPR] in progress) whose length fell in the red zone of the tape, the ED team would use the medication doses listed in the red zone of the tape and the supplies and equipment located in the red drawer of the cart. The red zone of the tape indicated the following:

a. Epinephrine 1:10,000 concentration was to be given IV for resuscitation. The dose that was indicated for a child that size was 0.085 milligrams (mg), or 0.85 milliliters (ml);

b. Epinephrine 1:1,000 concentration (10 times stronger than the IV form) was to be given into the ETT. The dose indicated for a child that size was 0.85 mg, or 0.85 ml;

c. Atropine 0.1 mg/ml concentration was to be given IV for resuscitation. The dose that was indicated for a child that size was 0.17 mg, or 1.7 ml;

d. Atropine 0.4 mg/ml concentration (four times stronger than the IV form) was to be given into the ETT. The dose that was indicated for that size child was 0.45 mg, or 1.1 ml; and,

e. If shocking was necessary, the voltage indicated was 17 joules, followed by 33 joules, followed by 33-80 joules.

A review of the pediatric cart medication list and tray indicated the following:

aa. Epinephrine 1:10,000 (for IV use) concentration was on the medication list and in the medication tray, but there was no epinephrine 1:1,000 (for ETT use).

RN 2 stated she had never noticed epinephrine 1:1,000 was not in the medication tray. She was unable to verbalize how much epinephrine 1:10,000 she would give in the ETT if there was not a patent IV line, to equal the necessary dose.

If 0.85 ml (the indicated number of ml for ETT administration) was given using epinephrine 1:10,000 (the only concentration available) into the ETT, the child would receive 1/10th of the dose needed for a chance to make their heart beat again;

bb. Atropine 0.1 mg/ml (for IV use) concentration was on the medication list and in the medication tray, but there was no atropine 0.4 mg/ml (for ETT use).

RN 2 stated she had never noticed atropine 0.4 mg/ml was not in the medication tray. She was unable to verbalize how much atropine 0.4 mg/ml she would give in the ETT if there was not a patent IV line, to equal the necessary dose.

If 1.1 ml (the indicated number of ml for ETT administration) was given using atropine 0.1 mg/ml (the only concentration available) into the ETT, the child would receive 1/4 of the dose needed for a chance to make their heart beat again; and,

cc. RN 2 turned the defibrillator on, and the joules defaulted to 50. RN 2 was not able to locate the necessary number of joules to shock with for a child in the red zone of the tape. RN 2 was not able to demonstrate how to increase or decrease the number of joules the machine was programmed to deliver.