Let me hear your perspective...

yupnv80, BSN, RN · Dec 23, 2019

What happened between 17:51 - 00:57? There wasn’t an MRI ordered? When the patient arrived to the floor, did they call a stroke alert?

JKL33 · Dec 23, 2019

21 minutes ago, mi_dreamin said:
Help me understand. How did this happen? We're the nurses just burnt out? Did they miss the symptoms and decline because they weren't looking for it? Help me come to terms with this ?

Sounds like something that should be reviewed. Your option would be to use your facility's incident reporting mechanism to indicate your findings and whatever elements of concern were present.

My first assumption would not be nurse burnout.

Beyond that it is up to the ED medical director and manager to review what happened with the patient's course of care.

What happened when she got to the floor?

mi_dreamin, BSN · Dec 23, 2019

No MRI was ordered. We called MD to bedside immediately but no stroke alert was called d/t being outside tpa window. MD ordered aspirin supository and said she needed an MRI in the morning. We did the initial NIHSS as none had been done. Beyond that I don't know what they ordered for her.

I assume she just laid in the ED before coming to the floor. I didn't personally speak to the ED nurse but it sounds like basically nothing happened, which is what is so upsetting. It sounds like she had progressive loss of function in addition to positive head CT and they did nothing for ten hours then sent her to the floor.

She wasn't assigned as my patient but I did put in an incident report and we called our director (our manager didn't answer).

yupnv80, BSN, RN · Dec 23, 2019

That must have been frustrating. And it doesn’t really matter that the patient has a history of substance abuse. The fact of the matter is the NIHSS wasn’t initially done in the ED...

JKL33 · Dec 23, 2019

11 hours ago, mi_dreamin said:
No MRI was ordered. We called MD to bedside immediately but no stroke alert was called d/t being outside tpa window. MD ordered aspirin supository and said she needed an MRI in the morning. We did the initial NIHSS as none had been done. Beyond that I don't know what they ordered for her.
I assume she just laid in the ED before coming to the floor. I didn't personally speak to the ED nurse but it sounds like basically nothing happened, which is what is so upsetting. It sounds like she had progressive loss of function in addition to positive head CT and they did nothing for ten hours then sent her to the floor.
She wasn't assigned as my patient but I did put in an incident report and we called our director (our manager didn't answer).

The bottom line is that you can't make all the assumptions you are making. You don't know if she was a candidate for intervention at the time of her presentation. You describe the patient as minimally responsive but then don't describe anyone being concerned about her airway, etc... Two basic possibilities (and there are more, I'm just asking which is more likely on a basic level): A young adult came to ED with acute stroke and multiple people did nothing and left her lay there, or a young adult came to ED with some degree of AMS and something on head CT and at that time was not a candidate for intervention so they admitted her for additional studies in the A.M. and to set up resources.

JKL33 · Dec 23, 2019

One more thing: There is kind of an insinuation that the positive UDS influenced everyone to not care and to do nothing. IME that is not how things roll these days; the ED sees so many positive UDSs...it is almost meaningless unless it is the *only* significant finding and it perfectly explains the presentation. The UDS is not the priority test in a situation of acute AMS; it's just as likely they didn't have the result prior to their other testing and initial decision-making. The most likely thing here is that the patient was not a candidate for intervention at the time of presentation.

But with regard to substance abuse here is something I have seen quite a few times: The patient's LOs/acquaintances/friends/associates do not bring the patient for medical care in a timely manner because they believe the patient is "just" high/drugged out again/whatever. And that is a problem that can have very serious consequences.

I have no idea what happened in this case; these comments are simply to show that we can't leap to conclusions.

mi_dreamin, BSN · Dec 23, 2019

1 hour ago, JKL33 said:
The bottom line is that you can't make all the assumptions you are making. You don't know if she was a candidate for intervention at the time of her presentation. You describe the patient as minimally responsive but then don't describe anyone being concerned about her airway, etc... Two basic possibilities (and there are more, I'm just asking which is more likely on a basic level): A young adult came to ED with acute stroke and multiple people did nothing and left her lay there, or a young adult came to ED with some degree of AMS and something on head CT and at that time was not a candidate for intervention so they admitted her for additional studies in the A.M. and to set up resources.

I'm not disagreeing with you, however, based on our protocol they should have at least done a stroke assessment and then modifieds Q4H.

I do know for a fact that she had a decline in function. I'm not even saying she was a candidate for tpa at the time of presentation, I'm just saying that it seems like somebody should have done more for her.

MunoRN, RN · Dec 23, 2019

There's not a lot of info provided on why she came into the ED initially, but based on the information what you describe could have been inappropriate and appropriate care.

If the CT showed an embolic stroke, then the stroke was likely close to 24 hours old or older, no TPA is indicated. If it was hemorrhagic then no TPA is indicated, IF her initial presentation was AMS, then serial NIH testing is not typically indicated.

Other than getting her to have come in a day or two earlier, I'm not sure what you feel should have been done differently.

Susie2310 · Dec 24, 2019

Around 1500 a patient with known history of substance abuse presented to the ED. UDS was positive for methamphetamines and cocaine and functional ability at this time was unclear.

We are told that at 1751 the head CT was completed and the impression is acute/sub-acute infarct with MRI recommended.

Nearly seven hours pass since the head CT and we are not told of any assessments, monitoring, or care provided to the patient. At 0057 the ED RN calls the floor to give report, saying that the patient was going to be discharged but that the patient was unable to walk. When the floor RN asks about the head CT the ED RN is reported to have said something along the lines of "her brain is fried with drugs." At 0130 the patient arrived to the floor in the condition described.

The CT impression was that the patient had had an embolic stroke. Approximately ten and a half hours passed from the time the patient presented to the ED to the time the patient arrived on the floor. The OP says that no NIHSS was done in the ED and and that he/she knew for a fact that the patient had a decline in function.

Regardless of whether TPA was indicated for the patient, patient assessments/monitoring and appropriate interventions would have been appropriate care in the ED, and it would have been appropriate to admit the patient to the appropriate level of care timely.

Advanced Practice Columnist / Guide · Dec 24, 2019

OP, I'm all for nurses initiating an internal review in cases of suspicion of substandard care. In my opinion, situations like this calls for multidisciplinary communication to find answers. I do appreciate your concern that there might have been some nursing related assessments that were missed while the patient was in the ED.

What was the patient's presenting complaint when she was triaged in the ED? What was the reason for this patient's admission to your floor? was it for stroke or unspecified encephalopathy (after all she was UDS positive on arrival, and in some patients, amphetamine washout can manifest as severe depression in mental status given some time has elapsed since she first presented).

When you talk about head CT's to diagnose stroke, you have to be specific about which was done. There is the plain old non-contrast head CT which will only tell you that there is no evidence of hemorrhage and may reveal subacute and past strokes. MRI's are not always used in acute stroke. The standard for stroke imaging is Head CT with Perfusion. This test uses a dye to "light up" the cerebral arteries and allows the providers to determine if there are salvageable areas in the brain that can be saved with a catheter directed embolectomy. The tPA window may be over but Neuro IR embolectomy window can extend beyond the tPA window and many patients still regain function. Think of it as similar to "door to cath lab in an MI" but with stroke.

Were these tests considered and what was the decision making involved as far as weighing the benefits and risks of doing them in this patient. Was embolectomy an option that is available in your hospital and if not was a stroke center called and declined the patient for a reason. The only way you will get your answers is to talk to the actual providers who were involved in the decision making process.

mi_dreamin, BSN · Dec 24, 2019

I definitely appreciate all of your feedback. I guess the thing about it for me is that they weren't calling it anything, not a stroke, not encephalopathy, just, "her brain is fried." They provided no treatment beyond some fluids.

I guess I just wanted to know if what happened sounds like a reasonable series of events considering the facts as presented.

Unfortunately I cannot talk to the providers involved, which is why I wanted some insight into why things may have happened the way they did.

Thank you to everyone who replied, you gave me food for thought!