Healthcare Inspection: Alleged Inadequate Airway Management at Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma.

摘要

The patient was an obese male in his 60s who presented to the facility's emergency department in May 2010 complaining of worsening shortness of breath. He presented with a low-grade fever and an oxygen saturation of 85 percent on room air. Per the patient's report, an outside facility had treated him for pneumonia 3 days prior; however, he reported feeling worse. He denied any significant past medical history, and no information was available in his EHR because he received his care at non-VA facilities. While in the emergency department, the patient was started on antibiotics and placed on supplemental oxygen via nasal cannula, which increased his oxygen saturation to 98 percent. He was admitted to the telemetry unit for treatment of pneumonia. The plan of care included antibiotics, bronchodilators, and oxygen therapy. On admission to the telemetry unit, a RN noted that the patient had labored breathing. On the morning of the first hospital day, a respiratory therapist (RT) administered a breathing treatment, noted the patient's decrease in oxygen saturation, and increased his supplemental oxygen. Shortly after administering the breathing treatment, the RT noted another decrease in the patient's oxygen saturation and placed him on a high flow nasal cannula. Throughout the day, the RT administered breathing treatments as scheduled and increased supplemental oxygen as necessary, per the physician's order. The patient's oxygen saturation continued to decrease, and the patient was placed on a Venturi mask. On the second hospital day, an RN noted that the patient had crackles (abnormal breath sounds caused by fluid in the lungs) in his upper chest. The patient's oxygen saturation continued to decrease and he was placed on a non-rebreather mask. In the evening, the RT attempted to administer another breathing treatment; however, the patient refused. The night RN noted coarse breath sounds and an oxygen saturation of 88 percent on the non-rebreather mask. The patients oxygen saturation continued to decrease further, and the RN notified the medical officer of the day (MOD). The MOD ordered an arterial blood gas and intravenous furosemide. The night RN noted the patients oxygen saturation was 90 percent. In the early morning hours of the third hospital day, the patient had an unwitnessed fall and was found face down in the bathroom. A nurse noted that he was cyanotic and had agonal respiration, with palpable pulse. A code was called, and the MOD responded and attempted endotracheal (ET) intubation unsuccessfully. The patient was then transferred to the intensive care unit accompanied by the MOD, the nursing supervisor on duty (NOD), and the RT. The NOD performed ET intubation and correct placement was confirmed by the MOD, who checked for the presence of exhaled carbon dioxide. Efforts at resuscitation were unsuccessful, and at 3:50 a.m., the patient was pronounced dead.