Failing to take vital signs, when appropriate, and to properly respond to abnormalities, have been identified as issues in many medico-legal cases.
The failure to appropriately perform and document vital signs while assessing a patient is particularly relevant in the case of an acute, undifferentiated, systemic illness, especially in the context of episodic care.
The CMPA conducted a research study to identify the scope of problems related to significant diagnostic delays due to the failure to obtain or interpret vital signs. During the period from 2006-2012, 55 closed medico-legal cases were reviewed. Of these, 29 were legal actions (lawsuits), 21 were complaints to a provincial or territorial medical regulatory authority (College), and 3 were inquests, 1 was a threat of legal action, and 1 was a hospital complaint.
Unfavourable legal outcomes for physicians were noted in a high number of cases (80%). Of the legal cases, 20 of the 29 (69%) were settled. Only one case proceeded to court where a judgment was made in favour of the plaintiff. Children under the age of 10 were disproportionately represented in these cases. The common themes identified were failure to obtain, record, acknowledge, interpret, repeat, or act upon vital signs. The following cases illustrate some of the themes.
Case 1: Communication pathway unreliable
Late on a mid-March Friday afternoon, a 65-year-old female with a history of diabetes and hypertension sees her family physician about a small ulcer on the dorsum of her right foot and extensive cellulitis of the lower leg. Her vitals are: temperature 38 C, pulse 70 bpm, and blood pressure 160/100 mmHg. She is on an oral hypoglycemic, beta blocker, ACE inhibitor, and thiazide diuretic. A culture is taken of the ulcer and arrangements are made with home care for outpatient intravenous antibiotic.
The following week all the clinic staff members are on vacation for mid-term break. The physician has made arrangements with a colleague to cover calls for this week. The secretary neglects to leave an out-of-office phone message on the clinic answering service. Over the ensuing 3 days the home care nurses note temperatures of between 38 and 39 C, a consistent pulse of 60, and a gradual decrease in blood pressure to a systolic of 100. The cellulitis appears to be spreading. The nurses leave messages on the physician's answering service. The culture is positive for MRSA resistant to the antibiotic being used, and this result is faxed to the family physician's office but not to the community nursing agency. By midweek the patient is confused and hypotensive, and is transported to hospital where she succumbs to sepsis.
The family pursues a legal action. Peer expert support cannot be obtained for the care provided and the CMPA, on behalf of the member physician, and the community nursing agency on behalf of the nursing staff, pay a settlement to the patient's estate.
Peer experts made the following comments:
Beta blockers, pacemakers, age, and dysautonomia related to diabetes may prevent a tachycardic response to sepsis.
The systolic blood pressure of 100 might represent relative hypotension given the history of hypertension.
A clearly identified and accessible most responsible physician (MRP) is necessary when treatments are being administered at home.
This patient might have had a better outcome if she had been identified at a formal handover between the primary care physician and the on-call designate.
Case 2: Team communication of vital signs fails
A 78-year-old female calls 911 because of recurrent episodes of near syncope. Her past history is notable for hypertension, coronary artery disease, and mild renal dysfunction. When the paramedics arrive, she is diaphoretic and confused with a pulse of 35 and a systolic pressure of 60. The paramedics are unable to obtain a rhythm strip during the bradycardia. By the time she is placed on the monitor, her pulse increases to 80 and her systolic pressure to 140. The cardiac monitor shows sinus rhythm.
After transporting the patient to a hospital, the paramedics are quickly dispatched to another call. No documentation is left with the hospital. A brief history, including a reference to the bradycardia, is provided to the emergency department by the bedside nurse. When the emergency physician sees the patient the nurse is on break. There is no mention of bradycardia in the nurse's notes. The ECG shows a first degree and right bundle branch block, unchanged from before. After a negative cardiac work up, the patient is discharged home.
Two days later she presents again with similar symptoms and a third-degree heart block. A permanent cardiac pacemaker is implanted. A hospital complaint follows.
Peer experts reviewing this case made the following comments:
Lapses in communication occur, but many are avoidable.
When possible, pre-hospital vital signs should be reviewed as they can contain valuable information.
A conversation between the hospital staff and the paramedics may have alerted them to the possibility of a bradyarrythmia.
As many dysrhythmias are transitory, vital signs recorded by first responders may aid in the diagnosis.
Checking a patient's pulse is often omitted from the physical examination. This simple measure provides a wealth of information: skin temperature and perfusion, volume status, arterial compliance, blood pressure, and cardiac rate and rhythm. Observing a cardiac monitor does not obviate the need to palpate a pulse. Lastly, checking the pulse provides an opportunity to also assess the patient's pattern and rate of respiration.
Case 3: Monitoring of vital signs is important
At noon a 10 kg, 10-month-old infant is taken to the emergency department after having been ill for 2 days with fever, vomiting, profuse diarrhea, and irritability. When admitted, the child is noted to be mottled and irritable with a pulse of 180, temperature 38.4 C, respiratory rate of 40, and oxygen saturation of 98%.
He is triaged to a resuscitation area where he is quickly assessed by a pediatric resident. Blood work and a fluid bolus of 200 cc of normal saline are ordered. Intravenous access cannot be established until an hour after admission and the fluid bolus is not completed until 1500 hours. At 1600 hours a lumbar puncture is performed which is grossly clear. Antibiotics and further fluid are ordered. The resident then speaks with another resident on the general pediatric ward and advises him that the child will need admission for rehydration and observation. No repeat vital signs have been obtained since admission.
The child is transferred to the ward at 1700. The admitting nurse notes the child is mottled with a pulse of 180, respiratory rate of 70, and a temperature of 39 C. He immediately notifies the resident, but the child arrests prior to being seen by the physician. Resuscitation is unsuccessful and an autopsy reveals peritonitis secondary to a ruptured appendix.
A legal action ensues and at trial the judge finds both the physicians and the nurses negligent in their monitoring and treatment of the patient. The CMPA, on behalf of the resident member, and the hospital, on behalf of the nursing staff, share in paying a settlement to the infant's family.
After reviewing this file, the peer experts observed:
Vital signs are, as their name suggests, vital to both life and as indicators of health. They establish the baseline and provide serial and objective information of the status of the patient.
Repeated vital signs are essential components of diligent monitoring and provide the information necessary to assess the effectiveness of treatment and to assist in diagnosis.
Obtaining vital signs in the pediatric population can sometimes be challenging.
Interpreting vital sign abnormalities in pediatrics requires knowledge of age appropriate normal ranges.
When clinically indicated, obtaining, recording, interpreting, acting upon, and, when appropriate, repeating a patient's vital signs stand as a powerful testament to quality and conscientious care.