In addition to my roles as a pediatric emergency nurse and an instructor for a major school of nursing, I’ve taken on the role of pediatric expert nurse witness for several emergency department medical-legal cases in the past five years. Many of them involve similar issues which raise common questions, and many also require the same documents to be produced. This is a summary of some of the key themes I have found in reviewing pediatric emergency cases. Real examples (without patient identifiers) are provided for each theme, with a brief rationale for each point. Knowledge of these common themes and questions can help you understand and prepare for future cases which involve ED care. Moreover, this will ultimately save you time and money.
The references used for some of the rationales are based upon the Emergency Severity Index (ESI) Handbook2 and the Emergency Nurse Pediatric Course3, both of which serve as major resources for many emergency departments. While the triage/acuity rating system and required staff education are hospital-specific, the five-level ESI is a triage/acuity rating system recommended by the Emergency Nurses Association and the American College of Emergency Physicians (ACEP)1 and is utilized by many U.S. EDs. Emergency Nursing Pediatric Course is one of the major pediatric emergency nursing courses required by many emergency department nurses who care for children.
Knowing the institution’s ED triage/acuity rating system, vital signs, assessment/reassessment policy, and mandatory ED nursing education is a great starting point for any expert nurse review of an ED case and can help serve as the basis for their review. Therefore, the ESI algorithm and full handbook is available online, free of charge, at the Agency for Healthcare Research and Quality website.
1. Missing or Insufficient Documentation in Relation to Patient Status or Acuity Level
Take, for example, the case of a child who came to a pediatric ER for a respiratory complaint who eventually passed away in the hospital. Upon her arrival, no pulse oximetry was recorded. This is not standard practice, as “Patients with mild to moderate distress should be further evaluated for respiratory rate and pulse oximetry to determine whether they should be categorized ESI level 2” (urgent acuity status).2
No continuous vital sign monitoring was recorded as being performed in the ED for a child whom EMS reported had O2 saturation rate (pulse oximetry reading) in the 80’s. Until she coded 8 hours later. Continuous vital sign monitoring and documentation of that monitoring as well as the vital signs produced would be considered a standard of care for a child with a validated pulse oximetry reading in the 80s, a level which indicates the child has moderate to severe respiratory compromise. The order for continuous monitoring must typically come from a medical provider (MD, PA, or NP.) while documentation of the vital signs would be recorded by ED nursing staff.
No documentation of provider notification for changes in patient status (which includes changes in mental status/behavior). Documentation of major changes in patient status would be considered a standard of care for both the patient’s primary nurse and any provider who was notified to assess the patient.
2. No Proof That Anyone Actually Touched the Patient
Vital signs alone are not a full assessment; they are simply a tool to aid in the assessment. Very sick patients (especially children) can sometimes compensate for a long time before their vital signs tank. Look for the full nursing assessment documented by the patient’s nurse, and compare it to the patient’s presenting complaint/symptoms. If the patient presented in respiratory distress, are there breath sounds documented in the nurse assessment? If the patient presented with cardiac complaints, are there heart sounds documented? While documentation standards vary by institution, this is an example of where nursing judgment and standard of care are considered.
3. Delayed Intravenous (IV) Access
In today’s healthcare environment, there is no excuse for multi-hour delays in IV access. In one case I reviewed, a very dehydrated child went 6 hours with no access (IV and central line attempts were unsuccessful). She compensated until she couldn’t anymore. If she had received IV (or I/O) fluids just hours earlier she likely would have survived her illness. Intraosseous (I/O) access is widely available, relatively easy and can be life-saving. It is performed every day in ambulances, by medical providers and now by many nurses depending on the institution, when IV access is unsuccessful. Ask for the institution’s IV access and/or I/O protocols- many give specific “acceptable” time frames for attempted IV access prior to starting an I/O.
4. Assuming Changes in Behavior are Behavioral in Nature
Consequently, the lesson here is, healthcare providers including nurses should always ASSESS, never ASSUME. In one case I reviewed, a nurse documented the patient’s “unusual, combative” behavior four hours before the child went into respiratory arrest and died. The physician documented being called for “patient’s dramatic events”. In hindsight, this behavior change was almost certainly secondary to impending respiratory failure. Everyone assumed it was behavioral in nature. Yes, kids, teenagers and even adults can be anxious, dramatic, and even combative. But if there is a change in behavior or mental status, don’t assume it is behavioral. In a pediatric patient, any change in mental status should be considered to be a result of hypoxia until proven otherwise3
1. American College of Emergency Physicians (2010). ACEP policy statements: Triage scale standardization. Dallas, TX: American College of Emergency Physicians. Retrieved September 5, 2016, from http://www.acep.org/Content.aspx?id=29828&terms=triage%scale.
2. Gilboy, N., Tanabe, T., Travers, D., Rosenau, A.M., Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality.
3. Emergency Nurses Association (2012), Emergency Nursing Pediatric Course. Emergency Nurses Association, Des Plaines, Ill.
Expert Witness Bio
This highly qualified Pediatric Emergency Medicine and Triage Nursing expert received her Masters in Nursing from the highly regarded University of North Carolina. She is a Certified Pediatric Emergency Nurse. She holds an Emergency Nurse Pediatric Course certificate. She is a member of several professional organizations including the Emergency Nurses Association. An authority in her field, this expert has received numerous awards in recognition of her contributions. She is a recipient of the North Carolina State Council Emergency Nurses’ Association Nursing Practice and Professionalism Award. This expert is a co-author of the “Best practices for improving flow and care of pediatric patients in the emergency department”, an American Academy of Pediatrics Technical Report. She has published numerous articles in the Journal of Emergency Nursing (e.g. “Conducting triage research: lessons learned in a pediatric emergency department”) and serves as a peer-reviewer for the publication. She previously served as a Research Nurse for the University of North Carolina’s Pediatric Emergency Severity Index (ESI) Research Project. This research project informed the creation of a pediatric chapter within the “Emergency Severity Index Handbook. She currently holds clinical, academic and administrative at a top-ranked institution.
BS, East Carolina University
ADN, Nursing, Durham Technical Community College
MSN, Nursing, University of North Carolina at Chapel-Hill
Certification, Certified Pediatric Emergency Nurse (CPEN)
Certification, Emergency Nurse Pediatric Course (ENPC)
Certification, Pediatric Advanced Life Support (PALS)
Certification, Trauma Nurse Certification Course (TNCC)
Member, Emergency Nurses Association
Member, National League of Nurses
Member, (Hospital’s) Research and Innovation Council
Honor, Nursing Practice and Professionalism Award, Emergency Nurse’s Association
Authored, best practices guidelines, American Academy of Pediatrics Technical Report
Published, multiple peer-reviewed journal articles in pediatric emergency nursing
Lectures, “Red Flags of Pediatric Triage”, “Case Studies in Pediatric Triage”, “Pediatric Head Injury Assessment”, Emergency Nurses Association National Conferences
Reviewer, Journal of Emergency Nursing
Former, Nursing Teaching Assistant, University of North Carolina at Chapel Hill
Former, Author, Emergency Nurses Association
Former, Research Nurse, University of North Carolina at Chapel Hill
Former, Pediatric Triage Consultant to the The Emergency Severity Index Triage Research Team
Current, Pediatric Emergency Medicine Nurse, major healthcare system
Current, Clinical Faculty, School of Nursing, top university