Er Death Brings Changes At Florida Hospital

[NRSKarenRN, BSN, RN]

palm beach post

er death brings changes at florida hospital

an internal investigation at st. lucie medical center shows hospital staff needs to communicate more effectively between departments. the review was initiated after a 28-year old woman died more than three hours after arriving at the er last month.

palm beach post, july 11, 2002

http://www.gopbi.com/partners/pbpost/epaper/editions/thursday/martin_stlucie_d3d2f0db2625e1d710f0.html

port st. lucie -- the staff at st. lucie medical center needs to communicate better and all departments that work with the emergency room need to strengthen how they work together, hospital officials announced this week. the changes were sparked by a review after a 28-year-old woman died more than three hours after arriving at st. lucie medical center's crowded emergency room last month.

leilani j. delos santos of port st. lucie arrived at st. lucie medical center about 3 p.m. june 17. that day, the emergency department treated 99 patients, and many critically ill patients arrived the same time delos santos did. two doctors and a physician's assistant were on staff at the time she arrived. delos santos died at 6:21 p.m. of kidney failure and high blood sugar.

hospital spokeswoman ginger king said she could not divulge anything about their internal investigation, which recounted what happened from the time delos santos entered the hospital to the time she died.

as a result, however, she said the hospital will change how departments such as the hospital laboratory communicate with the emergency department. people who work in the emergency room and in departments that work with emergency patients will be trained in communicating the urgency of a situation.

"our reports are, of course, on the computer," king said. "if there's something that needs to be red-flagged, it needs to be telephoned, not just on a computer screen."

delos santos was a lifelong diabetes patient and arrived at the hospital complaining "she was hurting all over," treasure coast medical examiner roger mittleman said. she was conscious, but her condition deteriorated quickly. mittleman ruled her death was by natural causes.

her family could not be reached thursday for comment.

a spokesman for the florida agency for health care administration said he was aware of delos santos' death in the hospital's emergency room, but he could not comment on whether the agency is doing its own investigation.

last november, jensen beach resident dorothy cooper, 88, died after waiting four hours in the martin memorial medical center emergency room in stuart.

although nurses at first thought cooper's illness wasn't life-threatening, the hospital did not have a system in place to rush her in for treatment when she began to deteriorate in the waiting room.

after her death, martin memorial placed a patient care technician in the waiting room to monitor patients as they wait to see a doctor. the hospital also added a third doctor to the emergency room staff.

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[fedupnurse]

And where did this patient care tech learn assessment skills. Thought only RN's could do that?!?!?!?! SO what happens now when the tech screws up and someone else dies. Ten buck says the nurses in the ER will take the fall!

[oramar]

I am not sure anything would have made a difference in this case. Sounds like the woman crashed fast. In cases like those even the quickest treatment makes little difference. If they would have had her on the unit she most likely just crashed and died there also. She was 88 after all. I am with you on your remarks fedupnurse. Is that you planning the get together in Philly over on nurse Spectrum? They said the pass word is "fedup".

[ERNurse752, RN]

The pt who died was only 28. But in a crowded ER when someone comes in c/o "I hurt all over," that doesn't say too much. That's where your triage assessment comes into play, where in your hx you learn the pt is diabetic, so it's a good idea just to dex them right there. Don't know whether they did or not, but that would definitely tell you something more than "I hurt all over," and maybe she would have gotten immediate treatment for DKA to prevent her death...

I agree they probaby need better systems for communication, but this pt hadn't even been treated yet, if she went down in the waiting room.

That falls back on ER overcrowding and understaffing causing prolonged wait times.

The idea of placing a "pt care technician" in the waiting room to monitor pts is pretty scary...they don't have the background to be able to make an assessment, and put pieces of the puzzle together to know when a pt is starting to go bad, unless it's pretty obvious. At least not with the kind of training they get where I'm from...6 weeks.

Legally speaking, it's a disaster waiting to happen...

I know when I was out doing triage, I'd try to keep an eye on people who I thought were pretty sick, but there just wasn't room for them at the moment. Put them somewhere you can see them, tell them to let you know if they start feeling worse, etc...

But, if you're getting slammed with new pts, it's that much harder.

It's a dilemma, and there isn't any perfect, fast solution...it's probably going to take a lot more situations like this to happen before hospitals decide to actually DO something, as opposed to just talking about needing to do something...

[NRSKarenRN, BSN, RN]

Oramar,

Jeff an RN from my area has been trying to get things together here. One of the participants in the nursing rally I had last year.

[oramar]

I looked right at the age of that patient and it looked like 88 to me. That is what I get for not wearing my glasses. Can you imagine me trying to pass meds without my glasses.