Renal Failure Patient Is Given Delayed Emergency Room Treatment

This case involves a 63-year old female patient with a past medical history of high blood pressure, high cholesterol, and coronary artery disease. She presented to the emergency room around 10 am with a chief complaint of pain in her extremities but was not seen until around 3 pm. By the time the patient was seen, her glomerular filtration rate was extremely low. The patient was admitted for acute renal failure but the transfer was not completed for another 3 hours. When admitted, the patient was not immediately seen by any physician. Her intake was not monitored and she was not put into a telemetry unit. Eventually, a nurse practitioner examined the patient and noted necrosis, swelling, and tenderness in the toes of her foot. No followup action was taken. Around 11 pm, the patient developed respiratory distress went into V-Tach. A code blue was called but the patient could not be resuscitated. It was alleged that the emergency room nurses failed to administer the appropriate level of care to the patient in a timely manner.

Question(s) For Expert Witness

1. How often do you take care of patients with hyperkalemia?

2. In the presence of a high potassium level, should a nurse evaluate the condition and communicate with the physician?

3. If ordered by a physician, how fast should a nurse administer IV fluids?

Expert Witness Response E-006392

The patient was at risk for ventricular and lethal dysrrhythmias due to an elevated potassium and renal failure. The renal failure placed her at significant risk for worsening electrolyte and fluid imbalance and therefore such life threats as hyperkalemia and pulmonary edema. Nurses are taught in first year nursing school and therefore have a reason to know that a risk of hyperkalemia is cardiac arrest due, most often from ventricular fibrillation. Hyperkalemia cardiac arrests are most difficult to resuscitate due to the hyperkalemia must first be reversed. The nurses had a duty to know that this patient was at risk for sudden death and the standard of care was to pursue the doctor for repeat serum chemistry labs and continuous telemetry. The standard of care was to place this patient on a unit such as the ICU or step down unit that could provide a level of care allowing for continuous electronic monitoring by telemetry and frequent nursing reassessment. It is difficult to ascertain without reviewing the records, however, the patient may have had necrotizing fascitis or severe sepsis which would have made the standard of care to place her on an ICU unit. Nurses must advocate for a higher level of care by informing the physician if their unit is not able to provide the level of care the patient requires. Emergency room nurses must also be able to recognize when a patient is being admitted to a unit that cannot provide the level of care needed and therefore advocate by approaching the doctor to provide appropriate orders. Emergency room nurses have frequent occasion to access their chain of command and contact physicians when the patient's needs are not being sufficiently addressed in the inpatient orders. Nurses also have a duty to know the level of care their unit or the unit the patient is being sent to can provide according to hospital policy. Most hospitals have policies that require any patient with a potassium above 5 be admitted to ICU or telemetry.