HospitalInspections.org

Based on medical record review and interviews, in 1 of 15 medical records reviewed, it was determined that there was a lack of integration of emergency services with surgical services resulting in a delay of emergency surgical services. (Patient #1).

This deficiency has the potential for patient harm.


Findings include:


Review of the medical record for patient for patient #1 found that the patient presented to the ED (Emergency Department) via EMS ambulance on 5/24/16 at 2:02 PM with complaint of pain to the left lower extremity after a bite by an unknown insect which resulted in a cool, edematous, pale lower leg with ruptured blisters up to the groin. The PCR pre-hospital care report summary by EMS noted that the patient's skin was " diaphoretic "and no blood pressure reading was able to be obtained by the emergency medical technicians (EMT's).

The patient was triaged at 2:33 PM and assigned an ESI (emergency severity index) of "2", which is very urgent. The triage nurse noted that the patient was pale and had pain in the Left leg rated at a score "8" out of "10" (the highest level of pain severity is ranked as "10".) The pulse oximetry rating was documented as not able to be measured.

The ED MD's assessment at 2:23 PM documented that the leg was cool, edematous with ruptured bullae extending upward to the groin. The patient was diagnosed with severe septic shock related to a necrotizing fasciitis. IV antibiotics were started immediately and a portable X-ray of the LLE was interpreted as evidence of "soft tissue gas." The surgery consult was called at 2:23 PM. The surgical resident was documented as being at the bedside at 2:52 PM, while patient was being intubated at 2:52 PM due to the fact that the oxygen saturation could not be detected and the patient was lethargic with labored breathing. A nursing note reported that at 3:00 PM the " surgical team " was at the patient's bedside. The note also reported that the patient " was placed on a cardiac monitor. " The patient's mother signed consents for surgery for: possible amputation of the left lower extremity, debridement and incision and drainage, and amputation above and below left knee at 3:00 PM.

The surgical consult note at 4:51 PM stated that he was consulted by ED medical staff to evaluate and assess whether the LLE was " necrotizing fasciitis" . The surgical consultant performed a cutdown was performed at the bedside. The discharge from the surgical wound was " only serous drainage." It further stated that the fascia was " intact with no definitive findings of necrotizing fasciitis." The consult reported that " necrotizing soft tissue infection " and " not necrotizing fasciitis was very likely." The surgical plan was noted as " critical care evaluation, IV antibiotics, and ID (infectious disease) consult. " It specifically stated " surgery will continue to evaluate patient, will determine need for emergent debridement or amputation vs. aggressive medical management with supportive care and IV antibiotics. "

The CCM (Critical Care Medicine) MD note at 6:09 PM refers to receiving a 4:20 PM call from the ER to evaluate the patient. Specifically, the note refers to a discussion with the trauma chief and the surgery resident that the plan "is now for the patient to undergo emergent surgery for suspected necrotizing fasciitis and to be transferred to the SICU after surgery. "

Review of consents obtained for the leg cutdown (which was done at ED bedside) , the debridement of the lower left extremity, and/or the above knee amputation found that the mother signed consent forms on 4/24/16 at 3:00 PM.

There was an initial provider note at 5:04 PM, 2.5 hours after a patient re-assessment note, that stated that the patient is in toxic shock, septic shock, and necrotizing fasciitis, with the planned disposition of ICU, pending Critical Care Management, and surgery evaluation.

At 4:51 PM the general surgery resident noted that "surgery will continue to evaluate patient and will determine the need for emergent debridement or amputation versus aggressive medical management with supportive care and IV antibiotics. "

At 4:51 PM, surgery noted that a cutdown was performed at the bedside in the ER to determine if there was necrotizing fasciitis and he documented that " the fascia was intact with no definitive signs of necrotizing fasciitis however, necrotizing extensive soft tissue infection was very likely. "


The patient remained in the ED until 7:39 PM when he clinically deteriorated with bradycardia of 30 BPM (heart beats per minute) and PEA (pulseless electrical activity) . Resuscitative measures, conforming to ACLS (Advanced Cardiac Life Support) failed and the patient was pronounced dead at 8:06 PM.

In a ED provider progress note on 5/24/16 at 2124 (9:24PM) (following the patient's death)it was noted that severe hyperkalemia (high blood potassium levels (6.1)) was discussed with anesthesia team concerning peri-operative arrhythmias, acidosis, and hyperkalemia were aggressively corrected with several liters of IV hydration, insulin, glucose, and calcium, however the patient coded and was pronounced dead.

Further review of the medical record found an attending note, entered at 8:27 PM (after the patient's death), noted, "K (Potassium) level was 5.6 to 6.1 and therefore, OR/SICU was deferred until the hyperkalemia was corrected ." Review of a post-mortem surgical note at 9:37 PM, found that the patient's hyperkalemia (high potassium (K), was "corrected" and that he was "being prepared to go to OR and went into PEA (pulseless electric activity) - arrest and expired at 8:06 PM."


At interview with the Chief of Surgery on 7/8/16 at 2:05 PM, it was stated that the surgery should have been performed sooner. He stated that the potassium probably would not have decreased without dialysis.


At interview with the Surgery Attending consultant on 7/19/16 it was stated that he saw the patient that evening and at 5:00 PM he added the patient to the OR schedule , however, he waited to see if the patient's potassium level would decrease before he would perform the surgery.

Review of the medical record found no urine output for the entire ED visit. Therefore, correction of the hyperkalemia would have required the initiation of hemodialysis.

Failure of the Emergency Department physicians, critical care medicine consultants, and surgery consultants to coordinate care resulted in the patient remaining in the ED for a protracted period of time during which time the patient clinically deteriorated.