Eighty-four-year-old Bernard Travaglini was admitted to Ingalls Memorial Hospital in Harvey, Illinois, on February 22, 2002. He had a history of strokes that had resulted in difficulty swallowing. He would choke if he didn't eat slowly enough, so his wife always assisted him while he ate. She cut his food into small pieces and made sure that he ate slowly, monitoring him to ensure that he only ingested one piece of food at a time.
On admission to the hospital, his admitting physician, Harish Bhatia, placed a written order in the medical record to monitor Mr. Travaglini while he was eating and to assist him with his food. Dr. Bhatia also had a conversation with Mr. Travaglini's nurse, advising her of this concern. At approximately 10 pm on the night of Mr. Travaglini's admission, Dr. Bhatia was notified that Mr. Travaglini had died.
The day before his funeral, the family received a telephone call from the mother of Lamont Carrel, Mr. Travaglini's hospital roommate. Mr. Carrel informed the family that the night Mr. Travaglini died, he and Mr. Travaglini had been engaged in conversation when a nursing attendant brought a sandwich to Mr. Travaglini and left the room. Mr. Carrel told the family that he had witnessed Mr. Travaglini choking on the sandwich. As a result of that telephone call, the family retained a pathologist, James Bryant, to perform an autopsy. The autopsy findings included food particles in the most distal parts of the tracheobronchial tree and similar food particles in the esophagus.
THE PLAINTIFF'S CASE
Clara Travaglini, Mr. Travaglini's widow, brought a wrongful death lawsuit against the hospital, alleging nursing negligence. To prevail in her case, Mrs. Travaglini needed to demonstrate that the nurses owed a duty to Bernard Travaglini (the duty of reasonable care); that they breached that duty (by departing from the standards of practice); that the departure from standards was a cause of Mr. Travaglini's injury; and that he, in fact, suffered actual harm.
At trial, Mr. Carrel testified1:
"Then we was talking, like, all of a sudden, like, I didn't really hear him talking no more and I hear him-I heard a struggle like he was choking. He was choking. I asked him was he all right, he was not responding, so he got violent. He got really violent. He was choking. He was struggling in the bed, so I started pressing the button for the nurse[horizontal ellipsis]. I heard him-I seen him choking. He was moving violent. He was struggling. He was trying to get out and sit up all the way. He was choking[horizontal ellipsis]. [In response to counsel's question regarding whether the decedent was making any sounds] Yes. Choking noise, violent-violent motions and he was choking. He was leaning into it, like his neck, he was choking."
Mr. Carrel also testified that he had pushed the emergency button and a nurse came into the room "within several minutes."1 He stated that he'd said to her, "The guy next to me is choking" and that the nurse ran out of the room. Several other hospital personnel came in and worked on Mr. Travaglini, but he didn't survive.
Dr. Bryant, the pathologist who performed the autopsy, testified at the trial that he had seen foreign particles in the most distal parts of the decedent's tracheobronchial tree that were consistent with his finding of food particles higher up in the lungs. He testified that Mr. Travaglini must have breathed these particles into his lungs and that they couldn't have been driven there by resuscitation efforts. He concluded that Mr. Travaglini had been alive when those foreign particles entered his lungs and that the cause of death was acute aspiration of partially digested food particles. Dr. Bryant also testified that the medical records revealed that a food bolus had been removed during resuscitation efforts.
Daniel M. Derman, a specialist in internal medicine and another medical expert for the plaintiff, testified that Mr. Travaglini had been eating a turkey sandwich. During resuscitation, two efforts to intubate him were unsuccessful because the airway was blocked by food. Several attempts to perform the Heimlich maneuver were also unsuccessful. Large particles of food were suctioned and the trachea became patent after the food was dislodged, but 14 minutes had elapsed during attempts to establish an airway. It was Dr. Derman's opinion that Mr. Travaglini died because his trachea was blocked by portions of the turkey sandwich, which had caused respiratory failure. It was also his opinion that the death would have been prevented if Mr. Travaglini had been monitored while eating.
Pamela Collins, the plaintiff's expert nursing witness, testified that the nurse's role is to supervise and manage the care of a patient such as Mr. Travaglini. Nursing attendants act under the direct supervision of the nurse. The nurse can delegate certain activities, such as supportive care, bathing, and feeding, to a nursing attendant but only after determining that the patient's condition is stable and that it would be appropriate for the nursing attendant to perform such duties. Because Mr. Travaglini had a documented swallowing disorder, delegation of feeding to a nursing attendant would only be appropriate if the nurse assessed the aide's level of experience and only after determining that the attendant was qualified to perform that task.
Ms. Collins further testified that there had been an order to monitor Mr. Travaglini while he was eating. It was her understanding that the nurse delegated this monitoring to the nursing attendant without first determining whether the attendant was qualified to do so. She testified that, in her opinion, this was a departure from nursing care standards of practice. It was the expert's opinion that the nurse should have monitored the patient herself, rather than delegating that task to a nursing attendant. And it was her opinion that leaving the room after giving the patient a sandwich, as the assistant did, was also a departure from acceptable standards of practice.
THE DEFENSE
The nurse caring for Mr. Travaglini admitted that failure to monitor him while eating would have been a departure from the standards of practice had there been an order to do so, but the hospital admission notes didn't contain instructions to assist him while eating. She also denied that Dr. Bhatia had provided those instructions verbally. She also stated, however, that Mr. Travaglini's wife did speak with her about his eating and swallowing problems, which was why she instructed the nursing assistant to monitor Mr. Travaglini while he ate, and she agreed that the hospital record indicated that a large amount of food was removed from his trachea during resuscitation.
Jay Goldstein testified as an expert in gastroenterology and internal medicine. He disagreed with the plaintiff's expert that the cause of death was choking. It was his opinion that Mr. Travaglini did not choke on the sandwich but that he vomited and aspirated the vomitus into his lungs. That caused a blockage of the airways, according to Dr. Goldstein, and he died from a resultant cardiac arrest caused by his inability to breathe.
A clinical pathologist, Nancy Jones, testified as an expert for the defense and disagreed with Dr. Derman. It was her opinion that the food particles found in Mr. Travaglini's lungs had traveled there from his stomach via agonal aspiration-labored, gasping breaths produced in the process of death-or had been forced into the lungs during resuscitation. She didn't find any indication that Mr. Travaglini was alive when the food entered his lungs. She also didn't believe that he had choked on the sandwich.
It was the opinion of a nursing expert for the defense, MariJo Letizia, that the nurse didn't depart from the standards of practice. She testified that there was nothing in the medical record to indicate that Mr. Travaglini had difficulty swallowing. She disagreed with the plaintiff's expert nursing witness that the nurse should have personally monitored him while he ate. She did agree that the nursing attendant should have remained with him and monitored him while he ate. She also admitted that the nurse had documented in the medical record that Mr. Travaglini's wife had requested such monitoring.
THE OUTCOME
After hearing the testimony, the jury deliberated and returned a verdict in favor of the plaintiff for $500,000. The defense appealed. On appeal, the court noted that the treating nurse had admitted that failure to monitor Mr. Travaglini while eating would have been a departure from the standard of care if there had been an order to do so. The court also noted that Dr. Bhatia had testified that he had given such an order. And the court noted that the nurse had documented the wife's request for monitoring while her husband ate because of swallowing difficulties. Despite the conflicting expert testimony regarding the cause of death (choking versus aspiration), the complaint was not based on whether or not Mr. Travaglini had choked on his food. It was based on the failure to monitor him while he ate. The defense appeal failed, and the court upheld the jury verdict.
LESSONS TO BE LEARNED FROM THIS CASE
* The medical record needs to provide evidence that the standards of nursing practice are followed. In this case, the chart needed to clearly demonstrate that nurses were monitoring for foreseeable complications. Because swallowing difficulty can foreseeably cause choking, particularly in a patient with such a history, aspiration precautions and compliance with physician's orders (in this case monitoring and assisting the patient while he's eating) must be demonstrated through medical record entries.
* When patients do have complications, the medical record must clearly reveal which specific physician was notified of which specific findings at precisely what time. Conversations with other providers regarding the management of a patient must be memorialized in the record. Additionally, nursing entries in the record must reflect that the chain of command was engaged and that nurses pursued their concerns to resolution.
* A nurse should stay at the bedside of a patient who is in trouble and call for help. In this case, according to witness testimony, a nurse "ran out of the room" during an airway crisis-a departure from the standards of practice.
* It's the nurse's responsibility to make certain those to whom safety measures are delegated understand what specific actions are required. In this case, according to a witness, a nursing attendant delivered a sandwich to an unattended patient on aspiration precautions. Professional nurses may be held responsible for failing to adequately instruct and monitor nursing attendants. All members of the team must understand the care plan, and nursing attendants function under the direct supervision of the licensed nurse.
* The organization should have documentation of the training unlicensed personnel have received for duties to which they will be assigned. Nurses who have concerns about a nursing attendant's abilities should document such concerns in writing so management can address any deficiencies.
* Nurses should listen carefully to family members. In this case, Ms. Travaglini explained her husband's risk of choking to the nursing staff explicitly enough that aspiration precautions and assistance and supervision during eating were indicated even in the absence of such orders.
* All nurses should maintain professional liability insurance. Cases such as this can also lead to nursing board investigations and discipline.
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