'Stat' means 'now': How hospitals bungle urgent CT and MRI orders

 

Hospitals can save lives by training their nurses to follow stat physician orders for CT and MRI scans immediately and to contact a doctor when the images are available for review

 
July 2, 2010

A doctor orders radiology studies for a patient when a physical exam suggests a preliminary diagnosis but additional information is necessary to be certain. Having the correct diagnosis is essential for selecting the correct treatment.

Frequently, a doctor orders a radiology scan, like computer aided tomography (CT or “CAT scan”) or magnetic resonance image (MRI), when he or she needs detailed information about an internal part of the body.

After the CT or MRI is ordered, a nurse or hospital administrative staff gets the order to a radiology department.

Most hospitals have a radiology department equipped with CT and MRI machines, and many of these facilities have radiology techs on site 24 hours a day who perform the scans.

Typically, a CT or MRI scan produces digital images that are available at hospital computer terminals, or even remotely, during or immediately following the scan. Officially, radiologists (doctors trained to read most types of radiology scans) and neuroradiologists (radiologists with additional training to read and interpret brain and nervous system scans) interpret the films and write a report.

Practically, though, the doctor who ordered the CT or MRI frequently reviews and interprets the digital images before the official interpretation is complete. This occurs because the doctor wants to get the correct treatment underway as soon as possible.

When a doctor orders a CT or MRI, he or she may order it as “routine,” which essentially is telling the nurse and radiology department “whenever you can get to it.” But sometimes, a doctor may order the CT or MRI as “stat.”

Most people understand that the word “stat” means “now” or “as soon as possible.”

A “stat” CT or MRI is ordered when the patient is potentially in serious danger. Shockingly, though, at some hospitals the clear sense of urgency for a “stat” order is not followed consistently by nurses.

As a Texas medical malpractice lawyer, I have seen many cases in which nurses or hospital employees mess up “stat” orders from doctors. Two cases, in particular come in mind, both of which occurred at facilities in the Houston-area Memorial Hermann Hospital System.

In the first case, I represented a teenager who had a brain infection that had been surgically drained. She initially did fine after the surgery. But about a day after the surgery, lab results showed that her serum sodium level was low (hyponatremia), and nurses and family members noticed that she was behaving oddly.

Considered together, hyponatremia and altered mental status can be life-threating to a patient with head trauma because of the potential for brain swelling. As a result, a doctor ordered a “stat” head CT. The stat order was written at 10:30 a.m. The patient was not taken to the CT room until 11:30 a.m. and the scan was not performed until 11:50 a.m. No physician interpreted the stat CT until around 2:15 p.m. Thus, in that hospital on that day, a stat CT took almost four hours.

I thought surely that must be a fluke, but I was wrong.

A few months later I was investigating the second case. My client, a middle-aged man, had hit his head in a horse-riding accident and was hospitalized. He too, developed hyponatremia during his hospitalization, and his doctor wrote an order for a “stat” head CT. He wrote the order at 9:30 a.m. The stat CT scan was not performed until 11:50 a.m., and no one interpreted the images until 2:11 p.m. So in the hospital that day, a state order took almost five hours.

These time periods for a stat CT are absurd. How could it be that the hospitals didn’t carry out what virtually every American intuitively knows? “Stat” means now.

After deposing Steven Weber, RN, the hospital’s head nurse in the first case I mentioned, I realized that the breakdown was in nursing communication. Mr. Weber explained that once a doctor gives an order for a stat scan, a hospital employee—either a nurse or unit clerk—is responsible for communicating the order to the Radiology Department and then arranging transportation of the patient to the room where the CT or MRI scan is performed.

Once the physician writes the order, he or she usually moves on to treat other patients—the doctor has passed the baton to the nursing staff to make sure the order is executed and the results are communicated back to the doctor.

For the stat CT or MRI to be useful to the doctor in terms of making treatment decisions, it must be performed timely and the results must be promptly communicated back to the doctor. To achieve this outcome, there are multiple people involved who must work in harmony: the doctor, nursing staff, unit clerks or staff, and the Radiology Department staff (radiology techs and radiologist or neuroradiologist).

In health-care jargon, there must be a “continuity of care” between each of these providers, which means seamless communication and action. Further, frequently when a stat CT or MRI order is made, the patient’s condition has changed to a more critical level, and there is an accompanying order to move the patient to a different floor with a higher level of care and monitoring.

For example, the doctor may order a patient moved from a general floor to an intermediate care unit or from an intermediate floor to an intensive care unit. In such instances, there is yet another layer of providers added to the equation. The old floor nursing staff gets the CT or MRI performed, but they never see the patient again after dropping them off in the CT or MRI scanning room. After the scan, the patient is sent to the new floor, where the new nursing staff is responsible to get the scan results and deliver those to the doctor.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recognized that this type of situation is prime territory for communication breakdown that can have devastating or even deadly results. To help reduce this risk, in 2006, JCAHO established National Patient Safety Goals, which require accredited hospitals to implement policies and procedures for executing and communicating stat CT or MRI orders.

Additionally, JCAHO mandates that hospitals train their nursing staff on “hand-off communications.” In other words, when a nurse on one floor hands off a patient to a new floor, there needs to be a detailed discussion about what treatment had been provided and what was pending. When there is a transfer following a stat radiology procedure, this “hand-off communication” should ensure that the new nursing staff knows the reasons for the procedure, to follow-up with the Radiology Department, and to notify the doctor who ordered the scans just as soon as the images are available for review.

Without these important communications, even stat orders can fall through the cracks. Because the doctor who ordered the stat CT or MRI is responsible for treating many patients, it could be hours until he or she checks for the results, unless the nursing staff do their job and communicate when the images are available.

In both of the cases I mentioned above, the nurses who received the stat orders did not ensure that the scans were performed immediately. In both cases, the patients went to a new floor after the scans and there was no evidence of a “hand-off communication.” And in both cases the nursing staff on the new floor did not follow-up with the Radiology Department or communicate availability of the images to any doctor.

Meanwhile, both patients experienced brain swelling, and their conditions deteriorated quickly—only then did someone think to check into the imaging results that were supposed to have been done stat. By then, it was too late! Permanent brain damage had already occurred. It was a tragic outcome for both of these people, because it all could have been avoided with prompt and proper communication by the nurses.

Hospitals need to take heed of the JCAHO requirements on hand-off communications and for handling stat radiology scans. Hospitals need clear policies and procedures in these areas and need to train their nurses on the importance of follow-up and communication when it comes to stat orders. The solution to this chronic problem is simple and inexpensive and, most importantly, it will save lives.

If you or a loved one has been harmed by medical errors, call 281-580-8800 to speak to the Texas medical malpractice lawyers at Painter Law Firm. There is no cost for our initial evaluation of your potential case.

Robert Painter

Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.

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