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Woman dies in ED waiting room; experts say this happens too often
While intake system is clearly 'broken,' EDs are not without options
The tragic May 9 death of Edith Isabel Rodriguez in the ED waiting room at Martin Luther King Jr. — Harbor Hospital in Los Angeles, grabbed the nation's attention when it was learned that two calls were made by her family to 911 while she was deteriorating in the ED waiting room. As tragic as the case was, however, experts insist that this scene has been duplicated — sans the 911 call — many times over in EDs across the nation. And, they warn, this may just be the tip of the iceberg.
"If you were to ask most emergency physicians, they would tell you they were aware of patients who died in the waiting room or who got a lot sicker," says Ramon Johnson, MD, director of pediatric emergency medicine at Mission Hospital Regional Medical Center in Mission Viejo, CA, and a member of the board of trustees of the American College of Emergency Physicians (ACEP). It was in that capacity that Johnson testified before Congress recently that "the recent death of a patient in the waiting room of the emergency department at Martin Luther King Jr. — Harbor Hospital in Los Angeles is the latest illustration of a problem that has tragically become all too common in emergency departments across the country."
This problem is widely prevalent and only just beginning to be publicized, says Michael Frank, MD, JD, general counsel of Emergency Medicine Physicians (EMP) in Canton, OH. "ED overcrowding is such that the usual procedures most EDs have for getting people in the back where they can be seen are such that people still end up in waiting rooms for hours on end," he says. Frank says such situations "are inevitable, because if no bed is available and someone is really sick, they will deteriorate."
In fact, he continues, EMP has been involved in three cases recently that arose from patient deaths involving ED waiting rooms. One was just dismissed on a motion for summary judgment, Frank says. "The second is in discovery, where our doctors and company were dragged into it even though our first involvement was when we were called after the patient arrested in the waiting room," he says. "The third, which never got to litigation, had a fellow waiting three hours and being diagnosed with a dissecting aortic aneurism when he crumpled during initial assessment in the ED." He died the next day after being resuscitated, Frank says. Even with positive results, the defense of such cases can cost tens of thousands of dollars, he notes.
The case — and what it means
The facts of the Rodriguez case, while in some ways unique, contain lessons for ED managers facing similar issues. According to the Los Angeles Times, Rodriguez had been seen in the ED several times over a three-day period before she died, but each time the medical staff found nothing seriously wrong. Rodriguez received pain medication before being released, and she returned later when the pain intensified but was told to wait in the lobby. She died of a perforated bowel. A security videotape shows the woman writhing for 45 minutes on the floor of the ED lobby; a janitor could be seen cleaning around her.1
The case raises important questions from a risk and safety aspect, says Tom Syzek, MD, FACEP, director of risk management at Premier Health Care Services in Cincinnati. "Is there an established, reasonable system for triaging these patients? Each ED should ask themselves these questions and do yearly risk assessments," says Syzek, noting policies should be in place to identify patients who require immediate attention.
"If they are left in the waiting room for a while, this calls for reassessment from time to time," he insists. "You must have policies and procedures to prevent patients from deteriorating in the waiting room."
Frank agrees, although he adds that more patients can be moved into beds more quickly if a bedside registration system is installed. This, he concedes, requires a "philosophic shift" within the hospital.
Assuming the ED manager is not able to change the hospital philosophy, "there have to be procedures for recognizing those issues or problems for which patients must be seen right now, like testicular pain, chest pain, elderly patients with abdominal pain radiating to the back; you can't triage them to the waiting room," Frank says. But for those patients you do triage to the waiting room, "you have to have a system in place to continually monitor them," he says. "You have to be sure your waiting room is a safe place to wait."
For example, says Frank, he is aware of one case where a patient who deteriorated in the waiting room had not had their vital signs taken. "Beyond that, there have to be repeat assessments, although the exact interval may vary depending on the situation," he advises. "You simply can't send someone to the waiting room and not see them again for three hours."
Beware of frequent fliers
Another important lesson of the Rodriguez case is that ED managers and their staffs must be extremely vigilant when it comes to repeat patients, or frequent fliers, even though their instincts might be just the opposite.
"We might think of frequent fliers as potential drug seekers, uninsured, indigent, derelict; this phenomenon definitely occurs, as we are only human," says Syzek. "But if we fail to overcome our own biases, not only will we get burned, but our ability to provide care gets compromised."
There are patients who "cry wolf," Johnson acknowledges, "but even those patients get sick, so we have to be vigilant when the typical frequent flier presents. Many times patients may be assumed to be malingering, enhancing symptoms, or being overly dramatic — we all see patients like that — but we have to be careful not to miss someone who is very, very ill."
There is no exception in the Emergency Medical Treatment and Labor Act (EMTALA) for frequent fliers or for people who you regard as drug seekers, warns Frank.
So what is the proper approach? "Repeat visitors should be high priority," says Syzek. "This woman [Rodriguez], who returned with increased severity of pain, should have been considered high risk."
In his ED, he notes, one of the things a patient is told as part of their discharge instructions is to come back if their condition worsens. When a patient returns under those conditions, Syzek says, that should send up a red flag. "This is huge in a return visitor," he notes.
Above all, he warns, be on guard for personal biases against such patients. "This falls under the area of cognitive errors, which can offset a good system, and good policies and procedures," he says. "But from a risk perspective, the return of a patient who has been here before is a gift to the ED team to carefully and thoroughly examine the patient — because they followed your discharge instructions."
On the first repeat visit, he says, the patient should receive special attention. "The third time [they present], you'd have to crowbar them out of my ED," he says. "I generally think of admitting them — even if all objective evidence does not point to a diagnosis."
Frank concludes with this final warning: "You're really playing with fire if you have any policy that indicates these patients should be coerced not to return — or worse yet, simply turned away."
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