The New York Times recently reported the death of a 12-year-old boy after being discharged from a hospital emergency room.

A laboratory test report was issued three hours after the boy left the emergency room, with results that may suggest high possibility of bacterial infection.  However, the report did not get the attention of emergency physicians and nurses, and never reached the boy's primary care physician or his family.  The boy died 3 days later of septic shock resulting from bacterial bloodstream infection.

Three and half months after the incident, the hospital announced a significant change of procedures that requires emergency physicians and nurses be immediately notified of certain lab results, and developed a new checklist before the patient is discharged.

The story is heartbreaking.  It’s also a solemn reminder of the commitment I made when joining Axial Exchange - that I will use my expertise as software engineer to make a difference and hopefully help hospitals and patients avoid these kinds of situations in the future.  At Axial Exchange, we are keenly aware that when patients transition from the doctor's office to the emergency room to home, it can easily result in a lack of communication and coordination between the parties involved in the patient's care.  Sadly, in this case, it turned tragic.  For those of you that might think this was an unusual occurrence that he was released before his tests came back; know that 40% of the time patients are discharged from the Emergency Room with tests pending, according to AHRQ1.

At Axial, we strive for a solution to improve these situations, and we believe part of the answer lies in technology that improves timely, important communication amongst healthcare professionals and the education of patients and their caregivers.  Our suite of software, based on open source technology, can help hospitals and acute care providers by following the patient, and can improve the all-too-common communication lapses inherent in this sad story, and avoid others going forward.

Our product, Axial Provider, listens in to a hospital's system, and can detect when a lab report is issued, and will notify the primary care physician instantly via email and text message.   Not involving the pediatrician seemed to be a major lapse in this particular case.  While overloaded emergency rooms may be a sad reality that can't be changed in months or years, primary care physicians can afford much more attention to his/her patients during and after their visit.  The technology in Axial Provider automates involvement of the primary care physician, without adding any burden to existing hospital system or personnel.  In addition, Axial Provider goes beyond mere delivery of information by making access to critical information easy.  Upon receiving the email or text alert, the pediatrician would only need to click the embedded link, login and immediately see the critical lab report.

Another product, Axial Patient, might have helped here as well.  Its focus is on the patient discharge process, which fits nicely with the discharge checklist policy announced by that hospital.  It not only reminds nurses of critical steps during discharge, but also helps to inform the patient and their caregivers.  Using Axial Patient, the discharge nurse could be reminded to tell the boy's parent of the lab test that's been ordered.

In the NYT story, it depicted the boy's parents feeling helpless while observing their boy's apparently unusual symptoms.  One cannot help wondering if anything might have been different if clinical information and resources had been put in the hands of the parents.  At Axial, our software accesses the education modules and material from The Mayo Clinic to help educate and explain the condition and risks to the patient and their family.  After all, family or caregivers are the ones who dedicate the most time to the patient's care post discharge, and empowering them with the right knowledge will only contribute to the best outcomes over time. In this case, the diagnosis was incorrect, so the patient’s family might not have known what to read, but they perhaps might have seen that their son’s ensuing symptoms didn’t match his diagnosis. 

It’s human nature to want to point the finger at someone, but the truth is that health care is complex, and only through consistent, improved timely communication amongst all the professionals, not just those at the hospital, and the education of patients and their caregivers, can things change.  I will remember this story for a long time, as it will serve as a reminder of how our work at Axial can change things.


1. http://psnet.ahrq.gov/primer.aspx?primerID=11

Topics: Axial Patient

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