Urgent Care Center Delays Transportation of Stroke Patient to Hospital

This case involves a 52-year-old woman with a history of high blood pressure who presented to an urgent care center with leg numbness. A CT was conducted and sent to an off-site radiologist for review. The radiologist reported acute cerebral infarction and suggested the patient receive an MRI to confirm. The urgent care center was closing for the evening and suggested the patient go home for the evening and come back to the urgent care center for the MRI the following morning. When she came back to the urgent care center, she received the MRI but was not seen by a doctor. The patient was discharged and told a doctor would follow up with her results in a few days. The next morning, the patient suffered a massive secondary stroke. The severity of the stroke caused permanent neurological damage to the patient. The MRI had shown a stroke in progress, which was never communicated to the patient. It was alleged that the urgent care facility should have transported the patient to a nearby hospital campus to be admitted under neurology as soon as the MRI was first recommended. An expert in emergency medicine was sought to review the facts of the case and opine on the standard of care.

Question(s) For Expert Witness

1. Please describe your background in emergency medicine.

2. What is the standard of care, in terms of treatment and imaging, when a patient presents with an acute cerebral infarct?

3. How should referral/transport to a stroke center be organized for a patient with an acute infarct?

Expert Witness Response E-080148

I am a regional emergency department director in charge of 2 emergency departments and 2 urgent care centers. I manage physicians assistants, nurse practitioners, family practice physicians, and emergency medicine physicians. Approximately 60% of my time is clinical and I work clinically in the urgent care centers, in 2 inner-city community hospitals, and in a large academic center. Because of my position, I am directly responsible for quality and peer review committees. I am involved in quality and peer review committees for all the hospitals as well as system-wide, 14 hospital risk management. I see many cases involving stroke care and am familiar with the standard of care in the emergency department. I have reviewed many missed stroke cases. For a patient presenting with acute cerebral infarct, the standard of care is admission to the hospital within 48 hours due to increased risk of stroke. MRI of the brain with imaging of neck arteries (either CTA, MRA, or carotid doppler) should be completed upon admission. Cardiac echo should also be done as soon as possible. In a patient with acute infarct, referral/transport to a stroke center should be in an ambulance.