Detailed Coronial Analysis of a Chest Pain Related Death

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Table of Contents

Introduction
Overview of Coroners Case Report
Critique of the Case
Recommendations
Conclusion
References

Introduction

Working in emergency care requires medical professionals to make accurate and swift decisions, which often save patients’ lives. However, in some cases, errors happen when the team members fail to accurately diagnose the condition and refer a patient for emergency intervention, and these cases should be used to design practices that will help avoid similar mistakes in the future. The coroner’s report reviewed in this paper is for the patient AD who was brought to the emergency department by the Queensland Ambulance Service (QAS) with the diagnosis of the acute coronary syndrome. However, the emergency department team did not perform immediate electrocardiogram (ECG) assessments to evaluate AD’s condition.

The case is an example of a type of task that emergency department employees have to face and the elements of diagnostics that they can overlook, more specifically, in the context of myocardial infarction. The scope of this presentation is the mistakes in communication, patient case assessment, and triaging, which led to the patient’s death. The context, or the basis of this analysis, is the coroner’s report titled “Non-inquest findings into the death of AD” from 2018. Key elements that will be addressed in this paper are medical errors made by the emergency care team, delayed diagnostics and analysis, and signs of myocardial infarction, as well as ways to avoid misdiagnosing a patient in the future. This paper aims to outline the coroner’s report and its essential elements, analyze it using the practice guidelines, and provide recommendations.

Overview of Coroners Case Report

In the “Non-inquest findings into the death of AD,” the coroner reports the key findings of the patient AD who died in the emergency care unit. AD was brought to the hospital by QAS, who performed initial diagnostics. However, as identified in the report, several factors contributed to the failure of recognizing the urgency of the case and performing diagnostics more swiftly, with ECGs performed twenty minutes after the initial arrival and two hours after that. Moreover, the staff did not look through the ECG results that were performed by the QAS team, which would allow them to notice the high takeoff or benign early repolarization and use this warning sign to send the patient for immediate intervention. However, Munro, Cooke, Kiln-Barfoot, and Quinn’s (2018) systemic review did not find evidence that would suggest that pre-hospital ECG significantly decreases the mortality rates. Therefore, critical aspects of the coroner’s case, which will be reviewed in more detail in the following paragraphs, include several errors in miscommunication and diagnostics that lead to an adverse outcome for AD.

The correct triaging of the patients is the key element of primary diagnostics. Triaging is deciding on the order of treatment for a patient, which is crucial for emergency care when the resource allocation can save lives if the patient’s case has to be addressed immediately (QAS, 2020). According to the current guidelines, Category 1 is a patient that requires immediate intervention, while Category 2 is a patient that can wait for an assessment for approximately 10 minutes. AD was initially flagged as Category 2 patient, despite the patient having a heart attack. In the coroner’s report, this appears to be the first and significant error of the emergency department team, which lead to subsequent delays in diagnostics and treatment, even though AD required immediate cardiac intervention.

The symptoms that this patient presented are chest paint, which the patient rated as 5/10 with diaphoresis. QAS also reported that AD had pain radiation, which is a spread of pain from one area to another (QAS, 2020). One can assume that the patient’s report of mild pain has led to the emergency team’s decision to postpone the immediate evaluation. Additionally, the diagnosis of QAS was acute coronary syndrome.

The patient was initially delivered to the emergency department with a complaint of chest pains. The problem outlined in the report that caused the death of this patient is the delayed referral to the emergency intervention cardiology. A timely review of ECG reports is also cited as a critical element of this patient case. In this case, the report was not in a traditional format, which is possibly the reason why STEMI was not diagnosed immediately. The QAS pre-hospital ECG examination might have hinted at the noticeable changes and prompted the referral to emergency cardiology. Instead, the emergency department personnel questioned the high takeoff of AD’s ECG.

Here, the sequence of events that followed the patient’s admission to the emergency department matters. Because AD was identified as Category 2 patient, the personnel performed the first ECG approximately twenty minutes after AD’s arrival. AD was referred for a complex angioplasty, which did not help improve the patient’s condition and did not help this patient survive the large completed anterior myocardial infarction.

Critique of the Case

Key findings of the case suggest that emergency department staff should treat patients with acute coronary syndrome with more attention. According to CENA (2013), one of the key domains of an emergency nurse is the ability to “simultaneously collect and interpret clinical information and presenting problem” (p. 7). Additionally, an emergency nurse should facilitate an appropriate flow of patients through the emergency area. In this case, the coroner reports that the department was particularly busy, which is the possible cause of delays in diagnosing patients. Additionally, the team did not recognize the severity of AD’s symptoms because they did not review the ECG performed by QAS and did not arrange follow-up reviews. Moreover, it appears that the communication between the team working the night shift and the one that worked during the day was impaired as well.

In this report, the coroner critiques the triage for the case since the urgency of the case was inaccurately identified by the staff. According to the Australian College for Emergency Medicine, the Australasian Triage Scale (ATS) is a tool that should be applied to categorize patient cases (“Triage,” n.d.). This technique allows setting the maximum time that a patient can wait before undergoing a medical assessment and receiving treatment. Category 1 patients must receive treatment immediately, while the waiting threshold for Category 2 patients is 10 minutes (“Triage,” n.d.). Regardless, in this case, the patient waited for 20 minutes before the first in-hospital ECG was performed, which is the first warning sign of a significant delay of the medical evaluation and treatment.

Notably, the QAS team diagnosed AD with acute coronary syndrome. The National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (2016) developed a guideline for managing such cases. Such patients should undergo a 12-lead ECG to detect possible myocardial ischemia within 10 minutes of being admitted to the hospital. This did not happen in the case of AD, who did not have a 12-lead ECG arranged at all. Next, the team should use the Suspected ACS Assessment Protocol when proceeding with patient assessment (The National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand, 2016). Finally, very high-risk patients should be treated immediately using invasive care, which also did not happen in the case of AD. Therefore, the emergency department failed to recognize the severity of the case and apply the appropriate protocol of care. Simultaneously collects and interprets clinical information and presenting problems.

Recommendations

This case has several implications for future practice that include more strict adherence to the recommendations by the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand and advanced interpersonal communication. From experience in the emergency care department, the massive inflow of patients, and the inability to adhere to time thresholds for diagnosis due to lack of rescues is common issue. However, this case demonstrates that the symptoms of acute coronary syndrome cannot be ignored.

Closed-loop communication is one of the communication techniques designed to mitigate misunderstandings within interpersonal interactions, which is a critical element of work in the emergency department unit. Curtis and Ramsden (2015) outline this technique as follows – the first individual says something to the second, and the second person repeats information to the first. This reverse helps achieve an essential goal in emergency care – ensuring that the information is communicated correctly and that a person understood the communicated message as intended. For example, if the receiver of the message interprets it incorrectly, the sender indicates this by saying “negative” or any other phrase, and if everything is correct, the sender says “yes.” After indicating that the message was incorrectly interpreted, the sender must repeat the information, and this continues until both parties reach a mutual understanding. In general, the closed-loop method is one of the techniques used to improve communication in healthcare departments, which is one of the most important aspects of effective work (El-Shafy et al., 2018). Therefore, the first recommendation is to use a communication method, such as closed-loop communication when working with patients in the emergency department, to ensure that the information is accurately comprehended.

The application of closed-loop communication is mentioned as a recommendation for improving the work in the emergency department because research suggests that it improves the efficiency of the department’s workflow. Apart from the suggestion by Curtis and Ramsden (2015) in their textbook on emergency care work, studies by El-Shafy et al. (2018) and Hughes et al. (2019) point out improved patient outcomes. One aspect of this communication technique is a significant error reduction. As reported by Hughes et al. (2019), during resuscitation, the use of closed-loop communication allows the leader to communicate the tasks more efficiently and enhance his or her resource management skills. Another finding of this study is that physicians with more experience prefer using this communication technique during emergency work. Additionally, the closed-loop method reduces the time of task completion by 3.6 times (El-Shafy et al., 2018). In the case of AD, the application of the closed-loop method could have improved the diagnostics since the QAS team would report ECG results to the emergency unit and ensure that they use this information during their assessment, which would help avoid the error of miscategorizing this patient.

One of the delays mentioned in the report is the change of staff from the night shift to the morning shift, where communication may have been impaired. Here, the discussed method of communication, the closed-loop, could have helped notify the personnel working during the morning shift of the patient’s condition. Fang et al. (2018) report that this method helps improve the perception of communication in general. This is an important factor because the coroner’s report cites several disagreements that happened during the management of the AD’s case, which may have contributed to the medical error.

Next, practice standards for emergency nursing specialists in Australia should be examined as well. In the coroner’s report, it is mentioned that the emergency staff should read all ECG reports, including those that there done before admission to trace the changes accurately. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (2016) recommend using the 12-lead ECG, which helps detect ischemia and prevent the development of severe impairments. This diagnostic procedure should be undertaken for any patient who presents the symptoms of acute coronary syndrome. Hernandez, Glembocki, and McCoy (2019) report that additional education is necessary to improve the nurse’s knowledge of 12-lead ECG applications and symptoms that indicate the need to use this tool. Miller (2019) states that this tool should be used by nurse practitioners, while Loreto et al. (2016) point out that this is the gold standard for detecting myocardial ischemia. Therefore, it is essential to perform a 12-point ECG evaluation for patients with symptoms similar to those presented by AD.

The issue of triaging patients and timely case assessment is also one of the key themes in this coroner’s report. According to Hundsen et al. (2018), triage errors are commonly associated with increased morbidity and mortality, and the author’s study reports that a significant number of cases are either under or over-triaged. This, perhaps, is an issue of the existing guidelines that lack a more objective way of assessing a patient’s case. Alternatively, triage error can be a result of a need to provide additional training and supervised practice for emergency department employees. In either case, it is recommended to review the ATS scale and evaluation recommendations routinely to avoid incorrectly triaging an individual.

Conclusion

Overall, in this paper, the coroners’ report of the AD patient case where acute coronary syndrome was not addressed promptly is presented. In summary, in this report, the concepts of emergency care and acute coronary syndrome care are illustrated. The main critique of this case is the failure of the emergency team to recognize STEMI and refer the patient for immediate cardiac intervention. This case outlines the issue of critical delays in providing care for AD that lead to a patient’s death. Timely communication and review of reports could have influenced a more swift referral for emergency cardiac intervention. The failure to recognize myocardial arrest in the case of AD is associated with the business of the emergency department upon the patient’s admission and his stable condition throughout the assessment. The relevance to the area of study is the fact that this report outlines the events that happened in the emergency care unit.

References

CENA. (2013). Practice standards for the emergency nursing specialists. Web.
Curtis, K. & Ramsden, C. (2015). Emergency and trauma care for nurses and paramedics. Chatswood, NSW: Elsevier Science Health Science.
El-Shafy, I., Delgado, J., Akerman, M., Bullaro, F., Christopherson, N., & Prince, J. (2018). Closed-loop communication improves task completion in pediatric trauma resuscitation. Journal of Surgical Education, 75(1), 58-64. doi: 10.1016/j.jsurg.2017.06.025
Fang, D.Z., Patil, T., Belitskaya-Levy, I., Marianne Yeung, Keith Posley & Nazima Allaudeen. (2018). Use of a hands free, instantaneous, closed-loop communication device improves perception of communication and workflow integration in an academic teaching hospital: A pilot study. Journal of Medical Systems, 42(4), 1-10. doi: 10.1007/s10916-017-0864-7
Hernandez, J., Glembocki, M., & McCoy, M. (2019). Increasing nursing knowledge of ST-elevated myocardial infarction recognition on 12-Lead electrocardiograms to improve patient outcomes. The Journal of Continuing Education in Nursing, 50(10), 475-480. doi: 10.3928/00220124-20190917-10
Hinson, J., Martinez, D., Schmitz, P., Toerper, M., Radu, D., Scheulen, J. … Levin, S. (2018). Accuracy of emergency department triage using the Emergency Severity Index and independent predictors of under-triage and over-triage in Brazil: A retrospective cohort analysis. International Journal Of Emergency Medicine, 11(1), 1-10. doi: 10.1186/s12245-017-0161-8
Hughes, K., Hughes, P., Cahir, T., Plitt, J., V., Bedrick, E., & Ahmed, R. (2019). Advanced closed-loop communication training: The blindfolded resuscitation. BMJ Simulation And Technology Enhanced Learning, 2019, 1-4. doi: 10.1136/bmjstel-2019-000498
Loreto, L., Andrea, T., Lucia, D., Carla, L., Cristina, P., & Silvio, R. (2016). Accuracy of EASI 12-lead ECGs in monitoring ST-segment and J-point by nurses in the Coronary Care Units. Journal of Clinical Nursing, 25(9-10), 1282-1291. doi: 10.1111/jocn.13168
Miller, S. (2019). 12-lead electrocardiographic interpretation for nurse practitioners. The Journal for Nurse Practitioners, 15(1), 110-117. doi: 10.1016/j.nurpra.2018.10.014
Munro, S. F., Cooke, D., Kiln-Barfoot, V., & Quinn, T. (2018). The use and impact of 12-lead electrocardiograms in acute stroke patients: A systematic review. European Heart Journal: Acute Cardiovascular Care, 7(3), 257–263. doi: 10.1177/2048872615620893
The National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand. (2016). Australian clinical guidelines for the management of acute coronary syndromes 2016. Heart, Lung and Circulation, 25, 895–951.
Triage. (n.d.). Web.
QAS. (2020). Clinical practice guidelines: Cardiac/acute coronary syndrome. Web.

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