Stroke patient dies after 90-minute wait in ER

A patient died after he waited about 90 minutes to receive treatment for a stroke at St. John's Hospital in Maplewood, according to an investigation by the Minnesota Department of Health.

A family member brought the man to the emergency room on April 1, 2007 at about 11:50 a.m., and told staff she thought the patient was having a stroke. The man's symptoms included impaired peripheral vision and facial numbness.

A nurse evaluated the patient at 11:53 a.m., and gave him an "emergency severity index" classification of 2. The emergency room staff rate patients on a scale of 1-5, with 1 being the most urgent cases and 5 being least urgent.

The nurse documented that the patient's symptoms started at about 8 a.m., when he complained of visual problems, a headache, and expressive aphasia. A family member also told the nurse that the patient had a history of alcohol use and recently "fell off the wagon," according to the MDH report.

Hospital policy requires that staff reassess waiting patients every 30 minutes. Instead, the nurse did not conduct a formal reassessment for 75 minutes. A nurse did take the patient's vital signs at 11:53 a.m. and 12 p.m. The tests indicated that the patient was suffering from hypertension.

Staff did not bring the patient into a treatment room until 1:15 p.m. Within five minutes, the patient began seizing.

A nurse immediately notified a doctor of his condition, but the patient declined rapidly. He was put on a ventilator and transferred to the ICU.

A CT scan conducted the following day revealed that the patient suffered a stroke. The patient remained unresponsive over the next several days, and was dependent on the ventilator.

His family decided to remove the ventilator and he died soon afterward, on April 5, 2007.

A subsequent MDH investigation found that the hospital was not in compliance with established hospital policies governing the reassessment of patients in the emergency department.

"The nurse involved in this incident has been reminded of her obligation to follow established clinical pathways and procedures regarding patient assessment/reassessment," the report said.

Hospital officials declined to comment on whether disciplinary action has been taken against the nurse involved in the incident.

In response to the incident, the hospital has increased nursing staff in the triage area during peak times, conducted staff training on stroke recognition, and provided additional training on reassessment policies, hospital officials said.

The hospital also added an area next to the triage station, where waiting patients can lie down and be under closer visual observation.

John Kvasnicka, medical director of St. John's Hospital, said the hospital's stroke steering committee has been working to improve care for stroke patients.

"A lot of that work is around this front-end process of recognizing and identifying patients and getting them into the physician evaluation, the neurological consultation, and the CT scan more quickly," Kvasnicka said.

The hospital measures the amount of time between a stroke patient's arrival in the emergency room until a CT scan is performed to confirm the stroke. The clinical director told MDH that the mean time for fiscal year 2008 was 21 minutes.

Hospitals officials declined to comment on why the patient who died did not receive a CT scan until the day after he presented to the ER.