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Based on interview and documentation review it was determined the Hospital had not (yet) fully implemented a corrective action plan related to a patient's unexpected death.

Findings included:

Clinical Record view indicated the Patient, a 33 diabetic, presented to the ED on 2/1/10, at 12:34 PM with a history of a cough and malaise for 5-6 days who currently reported pains in the lower chest, shortness of breath and dry mouth which had started that day.

Review of ED documentation indicated the Patient was triaged, placed in an ED treatment room and place on a cardiac monitor. When the Patient blood sugar was initially checked by the finger-stick method it was 485. The finger-stick test was repeated and identified a blood sugar of 168. A blood sample was drawn and sent for formal laboratory testing, at 1:04 PM, for confirmation of the Patient ' s blood sugar. While awaiting laboratory test results an IV of normal saline was started to address the Patient ' s dehydration. At 2:02 PM the laboratory called and reported the Patient ' s potassium was defined as at a panic level of 2.5. Serum bicarbonate was also severely low at 2.3 and the Patient ' s blood sugar level was high at 509. The Patient was diagnosed with Diabetic Ketoacidosis. Regular insulin, 8 units, was ordered and administered to the Patient via IV drip at 2:00 PM. In addition 20 milliequivalent (mEq) of IV potassium, was ordered infusion, which was finished infusing at 2:46 PM. The Patient reported, at 3:00 PM he was feeling a little better. By 3:00 PM 2 liters of normal saline had infused and a third liter of IV fluids was hung. Repeat laboratory test results were returned at 3:49 PM and identified a blood sugar of 365. Six unit of regular insulin, administered via IV drip was ordered and hung at 3:48 PM. Laboratory arterial blood gas testing, which had been ordered and performed, had also identified the Patient ' s blood PH was critically low at 6.96, the Patient had low levels of partial pressure carbon dioxide at 7.0, partial pressure oxygen levels of 172.0, and a bicarbonate level of less than 3.0. An additional 20 mEq of IV potassium was ordered and started infusing at 3:51 PM. The ED Attending Physician requested the Intensivist assess the Patient for possible admission to the ICU. The Patient was assessed and orders were written at 5:09 PM by the Intensivist to admit the Patient for continued care to the ICU. As part of the Intensivist ' s admission orders laboratory blood test were to be done every 4 hours and the results called to the Intensivist, the Patient ' s IV of normal saline, with 40 mEq of potassium was to infuse at 200 cubic centimeters (cc) per hour, IV insulin was to be administered at an infusion rate of 7 units an hour until the Patient ' s blood sugar was less then 200 and then the IV fluids were to be changed to 5% dextrose one half normal saline with 40 mEq of potassium added, at an infusion rate of 200 cc per hour. The Patient at 5:45 PM reported still feeling a little better. Sodium bicarbonate, 1 ampule was administered at 5:50 PM as ordered. The Intensivist ' s orders were noted and the ordered repeat blood work was draw and sent for laboratory testing at 6:15 PM.

The fifth liter of IV fluids was hung at 7:00 PM. The Patient was placed on a portable monitor at 7:30 and reported doing okay. At 7:47 PM a repeat blood test identified the Patient blood sugar was 210. The Patient was transferred, accompanied by an ED staff nurse, to the ICU at 7:47 PM, at which time the Patient was assessed as being in stable condition.

Review of the Patient ' s laboratory blood test result, drawn at 6:15 PM, identified a potassium level of 3.2. The level although low was not identified by the laboratory as critically low.

Continued review of clinical record documentation did not indicate the test results were reported to the ED, the ED physician or the Intensivist.

Review of ICU documentation indicated the Patient arrived in the ICU at 8:00 PM at which time the Patient was lethargic but speaking. The Patient was placed on a cardiac monitor and cardiac arrhythmias were noted that were quickly becoming more critical. The Intensivist, who had left the Hospital for the night, was called as well as the on-duty Hospitalist to report the Patient status. An EKG along with arterial blood gases were obtained. The blood gas test results identified the Patient's blood PH was still low at 6.95. The IV fluids had been changed, at 8:30 PM, to 5% dextrose half normal saline with 40 mEq of potassium added. A finger-stick blood sugar test identified the Patient ' s blood sugar was now 174. The cardiac arrhythmia worsened and the Patient became unresponsive requiring intubation.

Review of cardiopulmonary resuscitation record documentation indicated the code team was called at 8:50 PM. Chest compression were initiated at 9:00 PM when the Patient ' s exhibited ventricular tachycardia and no palpable pulses were noted. The Patient ' s respirations became agonal and an intubation was performed at 9:10 PM. Resuscitation medications, including Atropine, Epinephrine, Lidocaine, Sodium Bicarbonate, Amiodarone, Dopamine, as well as an insulin drip and 20 mEq of IV potassium were administered. Electrical shock was also delivered with no effect. The Patient ' s remained pulseless and after 2 hours resuscitation efforts were stopped.

Laboratory blood test, performed during the cardiopulmonary resuscitation identified a critically low potassium level of 1.5, at 8:55 PM and at 10:28 PM was reported as less than 1.5. The Patient ' s blood sugar level at 10:28 was very high at 763.

The Risk Manager said following the Patient's death a nurse, who was a Quality Specialist, had reviewed the Patient ' s medical record and identified issues. The Risk Manager said it was then brought to my attention and it was then reviewed at all levels of Quality Resource management at the Hospital including Grand Rounds, Medical M & M Conference and the Patient Care Assessment Conference. Opportunities for improvement were identified.

Review of the Hospital ' s internal investigation indicated an initial formal review of the Patient's case was conducted on 2/10/10. In addition the Cardiac Resuscitation effort was reviewed by the Code Committee on 2/17/10. The findings of the initial formal review team was forwarded for review at the Patient Care Assessment Conference on 3/1/10 who returned the case for a more in depth, detailed review. The Patient ' s case was presented at Grand Rounds by the Attending ED Physician along with a summary of the suggested corrective actions on 4/1/10. The following issues were identified related to the Patient ' s case:

#1 The Patient arterial blood gases were not drawn for 2 hours. When they were ordered they were not drawn in a timely manner.

Additionally the Patient had severe Diabetic Ketoacidosis (DKA) with a critically low potassium level of 2.5. In such cases the American Diabetes Association recommends are for the potassium level be corrected prior to the administration of Insulin, which was not done in this case. The Patient ' s potassium level should have been monitored every hour, which it was not.
#2 The Patient spent hours in the ED after he had been accepted by the ICU Intensivist and the order to transfer the Patient to the ICU was written before there was an ICU bed available. The extended stay in the ED increased the probability of systems breakdown.
#3. ICU level of care patients need to receive greater clinical attention while waiting in the ED for an available ICU bed.
#4. The Intensivist had assumed laboratory values would be called to him however ED nursing staff would not call him with the results unless the order had been written to notify him. The laboratory had no means of notification when a patient was transferred from the ED to an inpatient floor. #5. The Intensivist, who had left the Hospital for the night, had not signing the Patient out to the on duty Hospitalist.

#6. The Hospital Code Committee had reviewed the Patient ' s 2 hour CPR code documentation and identified the Hospital protocol was not met.
#7. There was a lack of continuity by the Intensivist involved in this case.
The following corrective actions that were developed, as part of the Hospital's corrective action plan to address the identified issue had not yet been implemented:

The DKA order sheet although developed by 4/2/10 had not been formally approved for use as of 4/27/10 and it was not scheduled for presentation at the Medical Executive Meeting for review and final approval until 5/11/10.
A Clinical Specialist was scheduled to devote the month of May to conducting hospital -wide " mock codes " for training all floors, shifts and staff. The completion of this corrective action would not be until 5/31/10.
Additional corrective actions developed to address identified issues that had been implemented included:
To improve patient flow from the ED: a patient flow alert system was completed on 2/22/10 that provided for additional nursing resources in the ED when the number of patients in the ED exceeds capacities. An ICU bump list was in the process of being developed to help medical/nursing staff with decisions regarding who to move out of ICU. Emergency Nurse Association Standards were already in place and these standards were reviewed and reinforced with ED Nursing Staff on 4/15/10.

Once an ICU Physician has accepted the Patient for an ICU admission the ICU Physician will continue to manage the patient in the ED. This expectation was reinforces on 2/28/10 with the ICU medical staff. In addition a memo was sent to all Intensivists and Hospitalists, on 4/5/10, that unstable ICU patient should be signed out to the night hospitalist. The Hospital current process of reporting critical lab was reviewed to determine if sending critical lab values to the Physician and not to assigned RN as was currently done, was reviewed. It was determined sending the critical values to the RN was the Best Practice. This review was completed on 2/28/10. 100% of the Intensivist ' s case would be reviewed by a Quality Specialist RN ' s (the quality Specialist were the first to identify this case as needing review). The review was to be ongoing until June 30, 2010.