Behind Closed Doors: #4

Would patient have choked to death on a sandwich at home?

CLARA TRAVAGLINI, Independent Executor of the Estate of Bernard M. Travaglini, Deceased, Plaintiff- Appellee, v. INGALLS HEALTH SYSTEM and INGALLS MEMORIAL HOSPITAL, Defendants-Appellants./ No. 1-08-0081

Summary: An elderly gentleman, per physician order, was supposed to be monitored one to one with meals and his food cut to smaller pieces. The patient died after trying to eat a sandwich given to him while unmonitored.

*Published with permission from nursefriendly.com*

It’s a beautiful spring morning and you’re on the way to the Coach store at your favorite mall. There is a 25% off coupon that has been burning a hole in your pocket and you know just what bag you want to use it on. As the front door shuts behind you, the cell phone rings. Without thinking twice, you grab it out of your purse and answer. It’s the hospital. One of the nurses at work has to leave due to a family emergency, her child is being admitted to a local hospital and she’s worried sick. “Of course I’ll come in” you respond. After ending the call you sigh and head back into the house to change out of your Ann Taylor duds and into scrubs. It’s time to switch gears.

An hour later you are stepping onto the floor to relieve your colleague. It’s close to lunchtime and she’s just had two new admissions. One of them is a fresh thoracotomy from PACU complete with chest tubes and a PCA pump. The other is an elderly gentleman admitted for overnight observation to rule out an MI. All together you have four patients and you quickly learn that the patient care assistant was floated to another floor earlier in the morning. Yay. Your colleague tells you she has notated all the physician’s orders and administered the mid- morning medications. She’s gathering her things and hurrying through report, but advises you that everyone is stable and vital signs have been good. You ask if there are precautions on anyone for fall, swallowing, infection etc. She tells you no. You ask about code status for each patient and the look on her face says it all—she wants to get out of here. With an encouraging pat on the shoulder you send the nurse on her way. Clearly there will be some damage control to do.

The lunch trays were passed around during report so you make rounds and look in at your group of patients to ensure they are okay before you begin studying each patient’s vital signs, orders, code status, rhythms, and histories. After introducing yourself and making small talk with each patient you enter into the fourth patient’s room. You discover an elderly gentleman slumped over the lunch tray that sits on the bedside table in front of him. There is a half -eaten sandwich in one hand. He is unresponsive and he has no pulse. You immediately call a code suspecting airway obstruction. The rest of the events become a blur after you lower the head of the bed, grab a stool to stand on, and begin chest compressions. The only thing you hear is a voice providing instructions to “stop cpr, check for a pulse, look for a rhythm, clear, shock, ok start cpr again.”

You are keenly aware of all the people in the room, but have no clue what they are doing. Your own heart is beating fast and you feel a bead of sweat trickle down your forehead….it falls onto the patient’s  chest, it forms a perfect little circle on the gown. The “spot” becomes your only focus now as you “will” that single bead of sweat to somehow start this man’s heart again. “Stop CPR….check for a pulse….check for a rhythm….it’s been 40 minutes guys….does anyone object to calling the time of death?” You’re staring down at the elderly man, your hands still on his chest ready for more compressions, holding your breath…when you hear: “Time of death 12:55 P.M. Thanks everyone.” It’s the patient’s longtime family physician. He’s here.  As the room clears you notice the sandwich on the floor next to the stool.  Your heart sinks and all of a sudden you feel weak. The nice doctor offers his arm to steady you and help you off the stool– “Good job” he says, patting you on the back. Turning toward the door you see her standing there—the patient’s wife. The physician recognizes her immediately and helps her into a chair. He motions for you to shut the door, and you do—grateful for the barrier you now have between yourself and what just happened.

You begin “the walk” back to the desk where all your colleagues pretend not to stare at you  (but you know they are) that’s the hardest. You want the support but then again you just want to be left alone with the whirlwind of feelings and thoughts. Sliding into the chair in front of what was your colleague’s computer, you reach for the mouse and click on the name of the patient who just died to see if you can figure out what could have happened. He was, after all, one of the two new admissions. One by one, you review the physician’s admission orders until you hit one that causes you to want to faint: “Diet: Cardiac, Mechanical soft, finely chopped food, one to one supervision for all meals.”  You bury your face in both hands fighting back tears. It’s time to talk to the charge nurse, the nursing director, and the doctor. As you rise to make the trip to the charge nurse’s office the enormity of the situation overwhelms you….the only positive part of this day so far is that you made it to the nearest trash can in time to throw up….

The Real Thing

Bernard Travaglini, 84, was admitted to Ingalls Memorial Hospital on February 22, 2002 by his longtime physician Dr. H. Bhatia. Mr. Travaglini was being admitted for observation with a diagnosis of generalized malaise—“not feeling well.” The physician had spoken with the nurse who would be caring for Mr. Travaglini asserting that this was a former stroke patient that required one to one monitoring and a diet that required food being cut into smaller pieces for the patient to chew. Dr. Bhatia placed orders reflecting this. The patient’s wife had been performing the meal time routine for quite some time since the stroke and the patient tolerated it well. At 10:54 PM, on the day of admission, Dr. Bhatia was called and notified that Mr. Travaglini had died. Interviews with the patient he shared the room with, the nursing assistant, the nurse, and Dr. Bhatia revealed that: The RN had been given specific verbal instruction by the doctor to monitor the patient while eating and an order reflected the physician’s direction; the patient’s wife had also warned the RN about the patient’s tendency to choke on food if not properly monitored with the right diet; the RN had delegated the task of monitoring the patient while eating to the nursing assistant without first assessing the fitness of the nursing assistant to assist with a patient such as Mr. Travaglini; the nursing assistant was witnessed by the patient’s roommate to have brought the sandwich to Mr. Tavaglini and leaving; the roommate witnessed the patient begin eating the sandwich and immediately choking; the patient struggling violently while he called for the nurses to come and help Mr. Travaglini; and the moment the patient died by recounting “He looked right at me, he looked over at me, and I looked at him, that’s when I know he didn’t make it.” Testimony by members of the code team and the patient’s nurse reflected that providers had a difficult time establishing an airway because large pieces of food were lodged in the trachea and attempts to remove the food were made to clear the airway. Later an autopsy would reveal that the patient had also aspirated particles food into the lungs as well as gastric contents.

Questions for Discussion:

1. 1.     Who should be held responsible for the death of this patient? Why?
2. 2.     What mitigating factors could have interfered with the nurse being more attentive to the need of this patient?
3. 3.     Having spoken with the doctor about the patient’s history for stroke and dysphagia what would have been your first actions?
4. 4.     Would you have delegated the task of meal time monitoring/feeding to a nursing assistant? If so, why? If not, why?
5. 5.     There was no care plan discussed in this case– or nursing diagnoses. Do you think if the nurse would have designed a care plan and nursing diagnoses the outcome would have been different? Why or why not?
6. 6.     The testimony reflected that the patient’s wife had personally spoken with the nurse and emphasized the need for the patient to be monitored while eating—do you think the wife should have taken more responsibility by staying? Should the patient have taken more responsibility (if verbally capable) by telling the nursing assistant he couldn’t eat the sandwich? 
7. 7.     How common do you think a scenario like this is, considering the current healthcare environment of a hospital? Why? Do a “pretend” root cause analysis to examine how this sentinel event could occur. Once you arrive at potential causes, make a plan to prevent them.  

 

Outcome

The jury found in favor of Mr. Travaglini’s widow, awarding her $500,000.00 for the wrongful death of her husband. Despite the wealth of evidence indicating large pieces of the sandwich were removed from the patient’s airway to try and resuscitate him, the hospital countered, arguing that since contents of the stomach were also found in the patient’s trachea upon autopsy he had most likely died of that rather than the turkey sandwich he had tried to eat. The hospital and “corporation” immediately appealed the judgment of the court– citing multiple errors in trial procedures during the case. The appeals court, clearly aggravated by this ploy, provided ample evidence that the hospital and “corporation” had made several mistakes during its own defense and thus the initial verdict in favor of Mr. Travaglini’s widow would prevail.

Discussion

As a bedside nurse I have experienced scenarios like this and been privy to witnessing them. By scenarios—I don’t mean patients choking on food and dying, rather, the dilemma of making sure that the patient who requires monitoring during mealtimes is…well…monitored—and monitored by the right person. Let’s talk about admission orders? We can all recount the numerous times we have seen inappropriate diet orders entered for our new patients right? One of my pet peeves as a heart failure nurse is getting a new patient who is a diabetic and in a full blown heart failure exacerbation being placed on a “cardiac regular” diet by THE CARDIOLOGY TEAM! No sodium restriction, no fluid restriction, no calorie restrictions, no sliding scale insulin or accuchecks ordered—I mean, really?

 I sympathize with the “Hail Mary sprint” we nurses must do (upon realizing the new patient has been placed on a completely inappropriate diet) to beat the dietary cart to the patient’s room to catch the tray. I’ve intercepted dietary order errors for Alzheimers, Parkinson’s and Stroke survivors too. Though it feels like a huge inconvenience to try and find someone to help feed or monitor a patient or to stop your “flow” to assist the patient—remembering there is a lot more to mealtimes than just chewing and swallowing that place a stroke patient at risk for poor outcomes should be incentive enough to do so: “Several aspects of eating difficulties have been identified in stroke patients; for example, problems related to handling food on the plate, transporting food to the mouth, chewing, swallowing and hoarding food in the mouth. Eating difficulties can also be related to lack of energy and aberrant eating speed. Dysphagia occurs in 19–50% of acute stroke patients, but has been found to resolve in many cases within 14 days. Many stroke victims have more than one of these problems in addition to such difficulties as mobility and/or speech.” (Carlsson, 2004)

  The patient diet order: It’s not the first thing most of us hone in on when we get a new patient. We’re looking for STAT labs that must be drawn (blood cultures), IV fluids to get going, K Riders to replace critically low levels, IV pain medication orders to get those 10’s down to a 1 or a 2, or the magic solution that will stop the projectile vomiting. You get it. We’re looking for the big ticket items— The stuff that has to be done N-O-W.  More than likely orders like the patient’s diet, daily Protonix, prophylactic sub-Q heparin, or stool softeners are on your “second line” priority list, the “stuff I’ll go back and confirm later when I get all these other things done.” Who says the triage process just applies to the ER and to call lights? We do it with orders too—especially when we have two or three back to back admissions and discharges. It’s horrible to say—but I’d say that’s normal given all the pressure we are under. Unfortunately, even “normal” can be dangerous, even lethal, to our patients.

So how can we be more vigilent? Care plans people, care plans. Before you roll the eyes, sigh, click away, object, and say you have no time and “you don’t understand, you’ve never been there,” I respectfully ask for a few moments of your patience and an open mind. I have been there—and back—a million times. What it takes is the desire to make sure you are providing best care—there is time, determination and creativity are required.. You see, every time you do an admission assessment—the interview where you ask a plethora of awkward questions that irritate the hell out of the patient and the part where you actually touch the patient—you are building a potential care plan. A care plan for a stroke patient such as the one discussed in this case would have yielded some information you may not have known. For instance, did you know they are at a higher risk for pneumonia? “Pneumonia is a common and important complication of stroke, affecting up to one third of patients. There is a significant increased risk of stroke-associated pneumonia (SAP) in stroke patients with dysphagia, and an even greater risk in patients with aspiration.” (Yeh, 2011) Moreover, the older the stroke patient, the greater the risk for stroke associated pneumonia. Care plans hold you accountable to what is acceptable and standard care for patients such as these.

Make it a habit to save some space on your admission or report sheet– jot down abnormal responses from the patient about mobility, fall history, chewing and swallowing, depression, adverse response to anesthesia, etc. In those moments—you’ve started the process of establishing nursing diagnoses and the foundations for a care plan. A care plan doesn’t just include the reason the patient is in the hospital—it also includes potential contributors that need some exploration and intervention by….all disciplines! It includes our objective observations like dry skin, swelling, behavior, communication style, hearing deficits,  and whether the patient understands or can read material.  Without nursing diagnoses and care plans we lose a lot of the details needed to protect and advocate for our patients. Omitting a care plan  “gives up” a significant amount of our power and ability to prevent sentinel events.

     Reviewing your patient’s history and physicals (admission dictation) is an extremely important part of prevention. Within these paragraphs you will find the most valuable pieces of information needed to care for, protect, and advocate for your patient. Diagnoses like stroke associated dysphagia can be easily overlooked or forgotten. Dysphagia, by the way, is difficulty or inability to swallow food, liquid, or saliva. In some people, it can be associated with pain. “Any condition that damages or weakens the nerves or muscles involved in swallowing can cause a swallowing problem. These conditions include “stroke, head and neck tumors, and nerve diseases such as Parkinson’s and Alzheimers.” (Boczko, 2010)

While looking over the admission note you might identify socioeconomic or psychosocial information that the patient or family did not share with you. You will also discover diagnoses such as PTSD that *many* veterans *do not* like to talk about but that you need to know in order to understand their affect, mood, unique behaviors or preferences they have. (how the room is arranged, noise levels, or how they are to be awakened) The list goes on, really. The question is, what are you up for as a nurse? Do you just want to know the bare minimum to get by for 12 hours, or the assurance that you are providing thoughtful and competent nursing care by going the extra mile….hint–it really isn’t the extra mile since we are taught to do these fundamentals in nursing school.

    Listen, I get that the corporate factory is making it increasingly hard for us nurses to attend to details and troubleshoot from moment to moment because of the high ratios, increased responsibilities, and lack of resources. However, it is still our license and the patients’ lives in our hands. It is our work (or lack thereof) that will be examined and scrutinized in a court of law. Expert nurse witnesses will review your charting, nursing diagnoses, and care plans—or whether there were any at all. Remember, you can’t go back and say “but so and so didn’t do this before my shift.” If “it happens” on your shift—it’s your ball girls and boys. As a nurse I live by the saying “where there is a will there is a way.” I create the time for care plans. I also make it easier to do them by bringing the highest rated, most up to date care plan book with me to work, and making sure I have the best apps on my iPhone for easy access to additional information. Care plans don’t have to be a long tedious process. Lawsuits, time off work, defending your license, living with the thought you could have prevented an injury or death, the effects on your family—that is long and tedious.

SLOW DOWN.

 LISTEN TO FAMILY MEMBERS (yes, they really do know more than you.)

 DON’T RUSH THROUGH SHIFT REPORT!

 

     Shift report is a time when important information can get lost or miscommunicated: “On a typical, busy nursing unit, as many as“40%-70% of their patients” may be transferred or discharged in the course of a 24-hour period.  Each occurrence includes a handoff, the transition of care, and an associated risk of information loss.” (Freitag, 2011)Remember that a balance of Hi-Touch, Hi-thinking, and Hi-Tech nursing care is what will produce the best outcomes for your patients. Take it back to the old school: ABC. Airway, Breathing, Circulation. When you get a new patient ensure that these basics are completely addressed before moving on to your next admission or next two admissions. Write “ABC” on your report sheet to help you remember things like diet, breathing, blood pressure and signs of fluid overload or depletion.  Defensive Corporate Nursing is all about being proactive under the worst conditions while ensuring that the three “T’s” are preserved so that not only our patients receive good care—but our licenses and livelihoods remain protected.

I *suspect* in the case of Mr. Travaglini there *may* have been an imbalance in the three T’s. My guess would be somewhere between Hi- Touch and Hi-Thinking—which is why I emphasized care plans in this discussion. That being said, I have experienced and respect the numerous interruptions we nurses have when trying to critically think about our interventions and assessments. Mary Zellinger, CNS at Emory University Hospital in Atlanta talks about the effects of interruptions on nurses: “Estimates show that a nurse encounters 30 major interruptions per shift. Every time a nurse is interrupted, that nurse has to go back and figure out where he or she was with the task before the interruption and regain the point again.”  (NTI bonus, 2011)

Success in a fast paced corporate nursing environment means arming yourself with any and all tools necessary to reduce your chances of experiencing an unfortunate and preventable sentinel event. Protecting your patients and license is ultimately your responsibility.  Don’t be naïve or misguided. Your employer will not defend you in a case like this and neither will a Board of Nursing.                    

 

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Works Cited

CLARA TRAVAGLINI, Independent Executor of the Estate of Bernard M. Travaglini, Deceased, Plaintiff- Appellee, v. INGALLS HEALTH SYSTEM and INGALLS MEMORIAL HOSPITAL, Defendants-Appellants., 1-08-0081 (APPELLATE COURT OF ILLINOIS, FIRST DISTRICT, SECOND DIVISION November 29, 2009). Retrieved September 9, 2012

NTI Bonus: Causes, Solutions, to Patient Errors . (2011, June). Retrieved September 9, 2012, from AACN Bold Voices: http://www.aacnboldvoicesonline.org

Boczko, F. (2010, October). Dysphagia: address promptly to avoid serious complications. Long- Term Living: For the Continuing Care Professional, pp. 54-55. Retrieved September 9, 2012

Carlsson, E. E. (2004). Stroke and eating difficulties: long term experiences. Journal of Clinical Nursing, 13, 825-834. Retrieved September 9, 2012

Freitag, M. &. (2011). Handoff Communication: Using Failure Modes and Effects Analysis to Improve the Transition In Care Process. Quality Management In Healthcare, 20(2), 103-109. doi:DOI: 10.1097/QMH.0b013e3182136f58

N.A. (2010, January 1). Would patient have choked to death on sandwich at home? Retrieved September 9, 2012, from Free Library: http://www.thefreelibrary.com/Would+patient+have+choked+to+death+on+a+sandwich+at+home%3f-a0219146480

Yeh, S. H. (2011). Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit. Journal of Neurological Sciences(306), 38-41. doi:doi:10.1016/j.jns.2011.04.001

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