Thanks to Guest Blogger, Legal Nurse Consultant Jean M. Klingenberger, MBA/MHA, BSN, RN, who took the time to write the following article. Legal Nurse Consultants (LNC) play an important role in personal injury and medical malpractice cases by reviewing and analyzing the client/patient's medical records. Due to their extensive educational background and great practical experience in hospital and medical settings, LNC's are able to review records and put together a comprehensive medical picture of the client's case. This picture helps the lawyer deal with the medical issues and interact effectively with treating doctors, expert medical witnesses and the opinions of the medical witnesses hired by the opposing side.
The Perfect Storm:
Reducing Waiting Times in Emergency Departments and Diagnosing Heart Attacks
by Jean M. Klingenberger, MBA/MHA, BSN, RN of Aurora Nurse Consulting, PLLC
More than 1 million people per year in the US have heart attacks. Heart disease is the leading cause of death in both American men and women. Heart attacks, or myocardial infarctions, cause permanent damage to the heart muscle. “Myo” means muscle, “cardial” refers to the heart, and “infarction” means death of tissue caused by lack of blood supply. If the heart damage is extensive, one’s health and quality of life can be severely impaired since the heart pumps blood to the rest of the body.
The heart has a network of arteries in the heart wall that supplies blood and oxygen to the heart muscle, allowing the heart to continue to pump effectively. Build-up of plaque and other blood products, such as clots, can severely narrow or completely clog a coronary artery, cutting off the supply of blood to that area of the heart muscle. Without restoring the blood flow to that area, the affected heart muscle will die.
Medical treatment for acute myocardial infarctions (AMI) is aimed at returning this flow of blood by using medications and/or medical procedures. Time is critical in restoring this blood flow. The American College of Cardiology and the American Heart Association joint guidelines for AMI care state that the goal for treatment is 90 minutes from time of patient presentation (to emergency department) to the medical procedure (angioplasty). For health care organizations using “clot-busting” medication, that time is narrowed to 30 minutes from time of patient presentation to giving the clot-busting medication.
Recent estimates are that between 2 and 8% of AMI patients are erroneously sent home from emergency departments. How does this happen? One probable cause is that patients may not exhibit the classic symptoms of a heart attack. Typical symptoms of AMI include:
- • Any abnormal sensation such as squeezing, pressure, burning, or pain in the center of the chest, which sometimes moves or radiates to the shoulder(s), neck, jaw, arms, or upper back;
- • Shortness of breath;
- • Sweating;
- • Palpitations (fluttering in chest);
- • Fatigue.
However, a moderate percentage of people experience non-typical or “atypical” symptoms with or without the usual ones listed above. These atypical symptoms include:
- • Faintness or lightheadedness;
- • Nausea and vomiting;
- • Abdominal pain.
It is people who present with these atypical symptoms that pose the highest risk of not being correctly diagnosed as having an AMI. Women under the age of 55, nonwhite persons, and those who reported shortness of breath as their main symptom were most likely to be discharged from an emergency department prior to the correct diagnosis of AMI.
Another possible cause may be emergency department sensitivity drift. Of all of the patients coming into emergency departments complaining of chest pain, only about 15% of them are actually having an AMI. This leads to a skepticism shown to patients presenting with chest pain, since roughly 85% are not having AMIs. Emergency department personnel are much more likely to drop everything and run for a gunshot wound patient than for a chest pain patient, even though the consequences of responding slowly in either case could be devastating.
Emergency departments have been pressured over the past few years to improve patient satisfaction and reduce waiting time. This has led to a tremendous amount of work being done across the country’s emergency departments to improve processes to move patients through in shorter periods of time. When factoring the complexity of diagnosing patients with atypical symptoms and efforts to improve work flow processes within emergency departments to reduce time, the result is missing the diagnosis of AMI.
Time gained for emergency department process improvement goals can result in some people dropping through the cracks and not receiving timely medical care to prevent losing heart muscle function. Loss of good heart pumping leads to less blood nourishment of all the organs in the body. Not only can this affect the way we feel physically, but can reduce our ability to perform our activities of daily living. This loss of ability can affect our families, jobs, and emotional well-being. Financially, the costs of impaired heart function can be substantial to pay for physicians, tests, and medications.
How do we weather this perfect storm? The best way is to know all of the typical and atypical symptoms of an AMI. Know that tests such as electrocardiograms (EKGs) and blood tests should be performed at least twice and compared to each other for change, indicating possible heart damage. This time frame should be no shorter than 4 or 5 hours. Insist on being heard by the emergency department staff. Patients often know when “something is not right,” and communicate that clearly. Being informed and being heard are keys to accurate diagnosis and effective care during a heart attack.
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