Patient death

[aspiringrn1987]

I need to vent about a situation, but will try to be as discreet as possible. Patient came to SNF for rehab due to generalized weakness as a result of multiple comorbidities.

Prior to coming to the SNF, patient had been on a long-term anticoagulant therapy which was DCed at the hospital after a fall. Later on a CT scan was done indicating no bleed.

Patient arrives to SNF with no orders for anticoagulant. When medical director comes in for initial visit, I discussed a few issues the patient was having. I also discussed the need to resume anticoagulant therapy. I was in a patient room for a couple of minutes and the doctor wrote orders and handed them to the nurse on the next unit to give to me. Orders did not include anticoagulant. It was hange of shift and I passed all of this information off to the next nurse.

Several days elapse and patient starts to experience redness to the ankle area and complains of moderate pain, describes the pain as burning. The patient was also experiencing edema to the BLE prior to this which she was taking a diuretic for. Assessed circulation, did not find any difference in circulation between the two extremities. Wound care nurse assessed the discoloration and felt it to be an allergic reaction to IV abt. Doctor was notified and an order for a cream was obtained later in the day. Next shift, patient codes and is sent to the hospital via EMS. Hospital codes the patient for over an hour, is unable to get her back. Cause of death ruled as cardiac arrest as a result of massive pulmonary embolism.

Im a newer nurse and I keep questioning what I could have done differently. I do not know the reason the physician chose not to prescribe an anticoagulant. I am assuming the redness and leg pain was most likely a blood clot given the events that occurred later on. How did several shifts miss this? How did I miss it? It did not clinically present as a typical DVT or perhaps my skill as a new nurse just did not detect it. Charge nurse did not suspect the DVT either. I'm just frustrated with the whole system I guess. This was very upsetting to me.

Thanks for listening, and any input that may be given.

[jdub6]

Although it is certainly very possible that the leg swelling was due to clots, it is not the only explanation. Pt could have had afib or could have developed dvt and thrown the clot very quickly.

With BLE chronic edema and bilateral changes i would not have gone straight to DVT at all either- much more likely cellulitis, reaction to med, vascular insufficiency etc.

As for not restarting the anticoagulant I'm just guessing but I've seen many many older sick fall risk pts taken off anticoagulants due to very high fall risk. There is a formula that gives probability of clots given pt condition. If the pt is at a higher risk of falls (and subsequent head bleeds) it makes sense to dc it.

Which brings me to my final point. Even if the med issue was an error or oversight it may not have made a difference. You didn't give an age but did say this was a person with "multiple comorbidities" causing "generalized weakness" severe enough to need rehab. That is a pretty sick pt who is at risk of death from any number of things. The PE could possibly even have occurred if she was anticoagulated. Or she could have died from something else. This was a high risk pt for numerous problems. Combine that with an atypical presentation and sometimes these things can't be prevented even if in hindsight it all makes sense.

Working in a SNF you will see a lot of pts who are getting treated for many problems that all are potentially or eventually lethal. You can't save everyone from everything. Multiple people looked at the meds and multiple people assessed the leg issues. It's no different than if she had died of a ruptured appendix with no prior complaint of and pain or gi sx-an atypical presentation often leads to diagnostic delay and sometimes bad outcomes. No matter how experienced you are you can only see what is in front of you.

[aspiringrn1987]

Although it is certainly very possible that the leg swelling was due to clots, it is not the only explanation. Pt could have had afib or could have developed dvt and thrown the clot very quickly.

With BLE chronic edema and bilateral changes i would not have gone straight to DVT at all either- much more likely cellulitis, reaction to med, vascular insufficiency etc.

As for not restarting the anticoagulant I'm just guessing but I've seen many many older sick fall risk pts taken off anticoagulants due to very high fall risk. There is a formula that gives probability of clots given pt condition. If the pt is at a higher risk of falls (and subsequent head bleeds) it makes sense to dc it.

Which brings me to my final point. Even if the med issue was an error or oversight it may not have made a difference. You didn't give an age but did say this was a person with "multiple comorbidities" causing "generalized weakness" severe enough to need rehab. That is a pretty sick pt who is at risk of death from any number of things. The PE could possibly even have occurred if she was anticoagulated. Or she could have died from something else. This was a high risk pt for numerous problems. Combine that with an atypical presentation and sometimes these things can't be prevented even if in hindsight it all makes sense.

Working in a SNF you will see a lot of pts who are getting treated for many problems that all are potentially or eventually lethal. You can't save everyone from everything. Multiple people looked at the meds and multiple people assessed the leg issues. It's no different than if she had died of a ruptured appendix with no prior complaint of and pain or gi sx-an atypical presentation often leads to diagnostic delay and sometimes bad outcomes. No matter how experienced you are you can only see what is in front of you.

This really made me feel a lot better about the situation. I do not quite remember, but I believe she was previously on the anticoagulant due to a hx of chronic afib. The swelling to her legs I do not think was from a clot. Rather I think the edema masked the clinical presentation for the DVT, but in hindsight that must be what was occurring with the discoloration and pain to the one extremity. The patient had a LOT of other issues going on.

The acuity in the SNF setting is sometimes astounding to me. I have had shifts where I had 20+ patients with numerous ISO/c diff, multiple IV abt, IV fluids, fluid restrictions, daily labs being monitored, and 5-6 wound care treatments on my shift alone. Not to mention all the Coumadin orders I have to chase down, sometimes 3-4 a day from multiple different physicians, the med pass, the family members, the dementia patients, and oh the charting. But I really do love my job. It gets less overwhelming every day.