Latin vs. Hospital for Sick Children Toronto

Latin vs. Hospital for Sick Latin vs. Hospital for Sick ChildrenChildrenTorontoToronto

Dr. Madan Roy, MD,FAAP,FRCP(C)Dr. Madan Roy, MD,FAAP,FRCP(C)Chief, Division of General PediatricsChief, Division of General Pediatrics

McMaster Children’s HospitalMcMaster Children’s HospitalAssociate Professor, PediatricsAssociate Professor, Pediatrics

McMaster UniversityMcMaster University


► Incident happened January 1998Incident happened January 1998►Settled in court January 2007Settled in court January 2007►9 years later9 years later►40 days of hearings40 days of hearings►8-10 experts8-10 experts


IssueIssue►14 month old Ryleigh Latin had a 14 month old Ryleigh Latin had a

cough, high fever and prolonged cough, high fever and prolonged seizure resulting in severe brain seizure resulting in severe brain damagedamage

►Could this have been prevented by Could this have been prevented by more timely intervention i.e. triage at more timely intervention i.e. triage at presentation to Emergency presentation to Emergency Department?Department?


Questions that need to be addressed:Questions that need to be addressed:

1.1. What was the standard of care for What was the standard of care for triage in 1998?triage in 1998?

2.2. Did the defendants, HSC Toronto, Did the defendants, HSC Toronto, breach these standards? breach these standards?

3.3. Did such breach cause the damages Did such breach cause the damages that Ryleigh suffered?that Ryleigh suffered?


PlaintiffsPlaintiffs Ryleigh Latin by way of her Ryleigh Latin by way of her parentsparents

DefendantsDefendants Hospital for Sick Children Hospital for Sick Children TorontoTorontoSpecifically Margorie Specifically Margorie Williams, Triage Nurse and Williams, Triage Nurse and

Virginia Wilkins, Virginia Wilkins, Charge Charge NurseNurse

(No actions against any of the MDs, even (No actions against any of the MDs, even ER MD)ER MD)


►14 month old healthy female14 month old healthy female►High fever with episodes of “jerking” High fever with episodes of “jerking”

at home x 2 x ½ dayat home x 2 x ½ day►Brought to ER, 1240 hrsBrought to ER, 1240 hrs►Triaged as URGENT = CTAS 3Triaged as URGENT = CTAS 3


CTASCTAS

Canadian Triage and Assessment ScoreCanadian Triage and Assessment Score

11 ResuscitationResuscitation ImmediateImmediate

22 EmergentEmergent 15 minutes15 minutes

33 UrgentUrgent 30 minutes30 minutes

44 Semi-UrgentSemi-Urgent 60 minutes60 minutes

55 Non-UrgentNon-Urgent 120 minutes120 minutes


►Triaged as urgent – 1240 hrsTriaged as urgent – 1240 hrs►Given TylenolGiven Tylenol►Directed to Registration Directed to Registration ►Then waiting roomThen waiting room


► In waiting room “jerking In waiting room “jerking movements”movements”

►Back to triage nurseBack to triage nurse Stable Stable►Back to waiting roomBack to waiting room►Classification Classification notnot changed from urgent changed from urgent

to emergentto emergent


►1400 hrs – in waiting room – 1400 hrs – in waiting room – generalized seizuregeneralized seizure

►Seizure control not obtained until 1535 Seizure control not obtained until 1535 hrs i.e. status epilepticus hrs i.e. status epilepticus

►Subsequent brain damage severeSubsequent brain damage severe


Primary Objective of Triage:Primary Objective of Triage:

To assess patient needs and to make a To assess patient needs and to make a professional judgment as to whether professional judgment as to whether the needs are Emergent, Urgent or the needs are Emergent, Urgent or Non-UrgentNon-Urgent

Latin vs. Hospital for Sick Latin vs. Hospital for Sick ChildrenChildrenTorontoTorontoSecondary Objectives of Triage:Secondary Objectives of Triage:

1.1. To provide a quick, accurate patient To provide a quick, accurate patient assessment upon presenting for treatmentassessment upon presenting for treatment

2.2. To provide initial accurate documentation on To provide initial accurate documentation on all patientsall patients

3.3. To co-ordinate with the Resource Nurse, the To co-ordinate with the Resource Nurse, the patient flow from the Triage/Waiting area to patient flow from the Triage/Waiting area to the available clinical treatment areasthe available clinical treatment areas

4.4. To provide patients and relatives with a liaison To provide patients and relatives with a liaison with whom they can relate and ask questionswith whom they can relate and ask questions

5.5. To provide First Aid to patients presenting for To provide First Aid to patients presenting for treatmenttreatment


How is CTAS arrived at?How is CTAS arrived at?►ABCABC►Not compromisedNot compromised►More detailed assessmentMore detailed assessment►Respiratory rate, circulation, vital Respiratory rate, circulation, vital

signs, temperature, Osigns, temperature, O22 sats, weight sats, weight etc.etc.

►CTAS designation givenCTAS designation given


Allegations – Triage NurseAllegations – Triage Nurse►Did not obtain a complete set of vital Did not obtain a complete set of vital

signssigns►Did not diagnose/suspect; dehydration, Did not diagnose/suspect; dehydration,

early shock, sepsisearly shock, sepsis►Did not detect PneumoniaDid not detect Pneumonia►Did not properly reassess her and treat Did not properly reassess her and treat

her while in the waiting roomher while in the waiting room►Did not classify Ryleigh as EmergentDid not classify Ryleigh as Emergent


Allegations – Charge NurseAllegations – Charge Nurse►There were available rooms for There were available rooms for

patients to be seen between 1240 hrs patients to be seen between 1240 hrs to 1400 hrs, but Ryleigh was not to 1400 hrs, but Ryleigh was not assigned to one of these roomsassigned to one of these rooms

►Permitted a stable patient, within the Permitted a stable patient, within the urgent category, to be seen before urgent category, to be seen before RyleighRyleigh

►Permitted a non-urgent patient to be Permitted a non-urgent patient to be seen in priority to Ryleighseen in priority to Ryleigh


Findings – Triage NurseFindings – Triage Nurse►Triage time – 3 to 5 minutes – Triage time – 3 to 5 minutes –

average/appropriateaverage/appropriate►Vital Signs – blood pressure was not Vital Signs – blood pressure was not

donedone

respiratory rate not donerespiratory rate not done


►What was the standard of Practice?What was the standard of Practice?► If not the standard of practice, did her If not the standard of practice, did her

presentation require a full set of vital presentation require a full set of vital signs?signs?


►Hospital policy – blood pressure to be Hospital policy – blood pressure to be documented documented

►Standard practice – only done in triage Standard practice – only done in triage if called for if called for

►Blood pressure was not taken. Was Blood pressure was not taken. Was this a breach in the provision of care?this a breach in the provision of care?

Vital SignsVital Signs

►Hospital Policy – Blood pressure to be Hospital Policy – Blood pressure to be documented at Triagedocumented at Triage

►Standard of Practice – only done in Standard of Practice – only done in triage, if called fortriage, if called for

►Decision – no breach in standard of careDecision – no breach in standard of care►Current CTAS guidelines – BP is Current CTAS guidelines – BP is notnot

included as a triage guidelineincluded as a triage guideline


►Respiratory Rate – not done as child Respiratory Rate – not done as child was cryingwas crying

Rhythm Rhythm RegularRegularDepthDepth AdequateAdequateAir EntryAir Entry EqualEqualQualityQuality No DifficultyNo DifficultyOtherOther Cough since December 29thCough since December 29th


►Respiratory Rate - evidence of Respiratory Rate - evidence of respiratory distress as opposed to a respiratory distress as opposed to a documented respiratory ratedocumented respiratory rate

PneumoniaPneumonia

►While in status, “RUL wet” was notedWhile in status, “RUL wet” was noted►Why was this missed by the triage Why was this missed by the triage

nurse?nurse?►Child cryingChild crying►Likely aspiration secondary to going Likely aspiration secondary to going

into statusinto status►Mom did not report “difficulty Mom did not report “difficulty

breathing” as a concern at triagebreathing” as a concern at triage

Dehydration/Early Dehydration/Early Shock/SepsisShock/Sepsis

►Time of last voidTime of last void►Diaper wet or notDiaper wet or not►Fluid intakeFluid intake►Mental statusMental status►Heart Rate 160/mtHeart Rate 160/mt►Temperature, 39.9Temperature, 39.9o o CC►Warm, well perfused, mucus Warm, well perfused, mucus

membranes moist, skin turgor normalmembranes moist, skin turgor normal


►Pulses – normal (not bounding/not Pulses – normal (not bounding/not weak)weak)

►Heart rate 160/mtHeart rate 160/mt►Temperature of 40Temperature of 40oo C C►Findings expected, and not a sign of Findings expected, and not a sign of

sepsissepsis


Conclusion re: Triage Conclusion re: Triage AssessmentAssessment

AdequateAdequate

Triage ClassificationTriage Classification

PlaintiffPlaintiff Irritability, lack of Irritability, lack of response to response to Tylenol, legsTylenol, legs

jerking/stiffening, were jerking/stiffening, were reasons for reasons for

Emergent (not Emergent (not urgent) urgent) Triage, on re-Triage, on re-assessmentassessment


DefenseDefense 1- Irritability 14/12 with 1- Irritability 14/12 with fever fever in ER is normal unless in ER is normal unless

inconsolableinconsolable

2- Fever in 14/12 not 2- Fever in 14/12 not uncommon and does not uncommon and does not

warrant Emergent warrant Emergent triagetriage


►Legs stiffening – seizures are only Legs stiffening – seizures are only emergencies when they are emergencies when they are activelyactively occurring and there is imminent occurring and there is imminent concern with respect to maintaining the concern with respect to maintaining the airwayairway

►Hospital guidelines – seizures within 12 Hospital guidelines – seizures within 12 hours would be triaged as Urgent hours would be triaged as Urgent notnot EmergentEmergent


►No documentation of reassessmentNo documentation of reassessment►Court looked at her documentation of Court looked at her documentation of

other charts on that day, her pervious other charts on that day, her pervious assessments of Ryleighassessments of Ryleigh

►Reasonable to infer, that an Reasonable to infer, that an experienced nurse would have done experienced nurse would have done ABC and come to the conclusion that ABC and come to the conclusion that triage category remained urgenttriage category remained urgent

ConclusionConclusion

Triage NurseTriage Nurse►Met the standard of care of a Met the standard of care of a

reasonable and prudent triage nursereasonable and prudent triage nurse►Should have documented the Should have documented the

reassessment, but this does not reassessment, but this does not amount to negligenceamount to negligence

Charge NurseCharge Nurse

►There were available rooms for patients There were available rooms for patients to be seen between 1240 hrs to 1400 to be seen between 1240 hrs to 1400 hrs, but Ryleigh was not assigned to hrs, but Ryleigh was not assigned to one of these roomsone of these rooms

►Permitted a stable patient, within the Permitted a stable patient, within the urgent category, to be seen before urgent category, to be seen before RyleighRyleigh

►Permitted a non-urgent patient to be Permitted a non-urgent patient to be seen in priority to Ryleighseen in priority to Ryleigh

Plaintiff:Plaintiff:►From 1240 to 1400 hrs there were 9 From 1240 to 1400 hrs there were 9

rooms availablerooms available

Defense:Defense:►Availability of rooms is only one factorAvailability of rooms is only one factor►Availability of nursing resources, Availability of nursing resources,

physician resources, discharge physician resources, discharge planners, and patient service aides to planners, and patient service aides to clear roomsclear rooms

Non urgent patients seen before urgentNon urgent patients seen before urgent►These take very little time and, often, These take very little time and, often,

while urgent patients are being while urgent patients are being worked up, these are quickly seen and worked up, these are quickly seen and sentsent

►Otherwise non-urgent patients would Otherwise non-urgent patients would never be seen never be seen


Charge nurse acted reasonablyCharge nurse acted reasonably

NOT GUILTYNOT GUILTY

Etiology of Seizure?Etiology of Seizure?

► Idiopathic status epilepticus?Idiopathic status epilepticus?►Shock?Shock?►Viral Encephalitis?Viral Encephalitis?


PlaintiffPlaintiff►Uncompensated shockUncompensated shock►Not adequately treated early enoughNot adequately treated early enough►Hypoxic-IschemicHypoxic-Ischemic►Status EpilepticsStatus Epileptics►Brain damageBrain damage


JudgeJudge►On balance of evidence, I cannot come On balance of evidence, I cannot come

to the conclusion that there was HIE, to the conclusion that there was HIE, due to shock/sepsisdue to shock/sepsis


►Viral Encephalitis – influenza A culture Viral Encephalitis – influenza A culture positive, NPS from 21/1 on 26/01/98positive, NPS from 21/1 on 26/01/98

►Subsequent C/S negative i.e. 7 days Subsequent C/S negative i.e. 7 days after admissionafter admission

►LP negativeLP negative►Serology NegativeSerology Negative

Judge – most likely diagnosisJudge – most likely diagnosis


Judge: Judge: The action is The action is dismisseddismissed

Take Home PointsTake Home Points

►Court systems are fair, but arduous, Court systems are fair, but arduous, prolonged, costly, time consuming, prolonged, costly, time consuming, and a severe strain on the defendantsand a severe strain on the defendants


►CTAS classification, if in ERCTAS classification, if in ER►Ability to justify what you did or did Ability to justify what you did or did

not donot do


►No defendant had any actual No defendant had any actual recollection of the patientrecollection of the patient

►““If it is documented, it is done. If it is If it is documented, it is done. If it is notnot documented it is documented it is notnot done” done”


►We are our worst enemiesWe are our worst enemies►There are always “Experts” who will There are always “Experts” who will

take the plaintiffs sidetake the plaintiffs side►““No Fault” clause No Fault” clause


Charge nurse guilty?Charge nurse guilty?

YESYES

NONO

Latin vs. Hospital for Sick Children Toronto

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