DEIB Case Study: Healthcare Bias in Acute Coronary Syndrome (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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    00:01 Hi, I'm Jacqui. Let's do a case study.

    00:04 I want you to meet Evelyn.

    00:06 Evelyn is a client who presents to the emergency department accompanied by her adult daughter after visiting an urgent care facility and then being instructed to go to the ED.

    00:17 Evelyn presents with nausea, fatigue, and shortness of breath.

    00:22 The nurse is now assessing her current vital signs while gathering her medical history.

    00:29 Take a moment and review the results of the history and physical.

    00:39 Now we're ready for the question.

    00:41 Highlight the findings on the table that should be significant to the nurse.

    00:48 Now let's see which data points should have been highlighted.

    00:51 First sex. And when I say sex.

    00:55 I mean sex and not gender identity.

    00:57 Evelyn, sex is female.

    00:59 And this is significant because females can present with slightly different symptoms for cardiac related events than males.

    01:07 The classic symptoms of a heart attack, chest pain, arm pain, jaw pain, those may not be present in the female client.

    01:16 Females may present with more vague symptoms such as fatigue.

    01:20 Hmm. The differences between males and females have to be taken into consideration when considering this disease process.

    01:28 Next, let's look at ethnicity. Everyone is African American.

    01:33 Ethnicity matters in this particular case, because of what we understand about health inequities.

    01:39 So syndromes such as hypertension and diabetes may be more likely to occur in this particular population.

    01:45 Persons of color also experience healthcare quality disparities in the presentation of coronary syndromes.

    01:52 So we have to pay attention to ethnicity in this case, because it may affect outcomes.

    01:58 Now let's talk about Evelyn's vital signs.

    02:01 These are particularly related to her presentation.

    02:04 Her respiratory rate was 24.

    02:07 This is elevated and is of particular concern because this indicates that Evelyn's body is working hard to obtain adequate oxygenation.

    02:16 The heart rate is also elevated. It's 110 beats per minute.

    02:21 And this increase is concerning because Evelyn's heart is working hard in order to compensate for the lack of oxygen.

    02:28 her blood pressure is 168/112.

    02:32 Ideally, the adult blood pressure should be around 120/80.

    02:37 Hypertension is a consistent forceful pushing of blood against the arterial walls and this can cause damage of the inner lining.

    02:44 We want to make sure we bring this blood pressure down, but right now it's elevated and so therefore it should be highlighted.

    02:51 The other vital signs are normal.

    02:55 Evelyn's past medical history -- diabetes, cholesterol, anemia, and hypertension.

    03:01 Evelyn's also taking several medications, which is significant because it lets us know that her past medical history conditions are being managed.

    03:10 When we look at her history of substance use, we find that both that and her social history are benign.

    03:17 So they're not relevant in this particular case.

    03:22 Five minutes later, Evelyn reports feeling nausea, fatigue, and shortness of breath.

    03:27 She also reports a sensation in her chest where her heart feels like it's racing, and she has aches and her shoulders and neck.

    03:34 These are the very same symptoms that occurred yesterday.

    03:39 Evelyn was actually seen yesterday in an urgent care clinic after her daughter urged her to go.

    03:45 She was told she had indigestion and stress fatigue.

    03:50 She was discharged with instructions to start a two week regimen of omeprazole and over the counter ibuprofen.

    03:57 Her daughter reports, "My mom isreally stubborn and doesn't want to be seen.

    04:02 But she hadn't gotten any better." Today, they returned to the same urgent care clinic due to those same symptoms not improving, and then they were told to come to the ED.

    04:13 It's important to note that in this particular case, Evelyn has a strong advocate in her daughter.

    04:19 Now imagine all of our other clients who might report to the urgent care facility or to the hospital without someone there to advocate and to urge them to be seen.

    04:30 Clearly, Evelyn is in some sort of distress, and this needs to be addressed.

    04:35 So in times when our clients don't have advocates, nurses, you have to be the advocate.

    04:41 Now, let's see if we can answer the next question.

    04:45 Indicate if Evelyn is at risk or not at risk from the following responses while she's receiving health care treatment in this setting.

    04:54 Here are the potential responses.

    04:57 Take a moment and identify whether you think she's at risk are not at risk.

    05:08 Now, let's go through the answers.

    05:10 We're going to look at the first two responses together because they're related.

    05:15 Minimization of symptoms related to gender, or related to being a person of color.

    05:21 As we've already discussed, research shows that persons who identify as female or persons of color are more likely to experience a minimization of symptoms in the healthcare system.

    05:32 Definitely, Evelyn is a person of color, and female.

    05:36 So she's at risk for both of these.

    05:39 Denials of medical treatment due to not having health insurance.

    05:43 Under the 1986, Emergency Medical Treatment & Labor Act You may hear this referred to as EMTALA, denying a medical screening examination when it's requested or when there is an emergency is illegal.

    05:59 So that is not something that Evelyn is at risk for, in this particular case.

    06:04 Inappropriate discharge to home.

    06:06 Well, we've already seen Evelyn be inappropriately discharged.

    06:11 So unfortunately, even though she's now in the emergency department, this is still a risk.

    06:16 And finally, excessive medical treatment due to the vagueness of complaints.

    06:21 Well, actually, Evelyn is at risk for not receiving adequate medical treatment, not excessive.

    06:28 So here's a summary of the correct answers.

    06:33 It's now been 15 minutes after Evelyn arrived in the ED.

    06:37 The healthcare provider has now written orders.

    06:40 Take a moment and review what's been prescribed.

    06:48 Now we're ready for the next question.

    06:50 We're going to drag the options to complete the following sentence.

    06:55 The nurse determines the client is most at risk for blank due to blank in the female African American population.

    07:04 Take a look at the options under option one and two, and see if you can fill in the blanks.

    07:15 Now let's look at the answers under each option.

    07:18 Under option one, misdiagnosis.

    07:21 Evelyn is certainly at risk for misdiagnosis.

    07:25 We know that the differences in clinical presentation for acute coronary syndrome is very different between males and females.

    07:33 We also know that because Evelyn is African American, her risk for experiencing health inequities is definitely present.

    07:41 So misdiagnosis might be an answer. But let's see what else.

    07:45 A decrease in quality of care. Hmm.

    07:49 Some of this we answered under misdiagnosis.

    07:52 So a decrease in quality of care sounds like more of an umbrella term, which might cover all the ways that African Americans may experience differences in how they achieve health care.

    08:03 The next option, leaving against medical advice.

    08:07 Well, Evelyn really has it left.

    08:10 She was discharged from the urgent care facility.

    08:12 She showed back up again the next day, and now she's in the ED.

    08:16 This doesn't seem appropriate in this particular situation.

    08:19 So that's not the answer.

    08:21 And nonadherence to the treatment plan.

    08:25 First of all, nonadherence to the treatment plan is usually never a good option.

    08:30 Nonadherence supplies that people don't have control or choices about their medical care.

    08:35 But it certainly hasn't happened in this case.

    08:37 Evelyn has followed every prescription and every instruction she has been given.

    08:42 So that doesn't work in this case.

    08:44 So under option one, the best answer is a decrease in quality of care.

    08:51 Now let's look for the reasons why Evelyn might be at increased risk for a decrease in the quality of care.

    08:58 We've already discussed the increased risk for health inequities that are experienced by African American persons.

    09:06 So this seems like a great answer.

    09:08 But there might be something else. So let's take a look.

    09:11 Poor communication.

    09:13 So far, we haven't had any indication that there's been poor communication between Evelyn, her daughter, and the hospital staff.

    09:21 So that doesn't seem to fit.

    09:23 Next social stigma.

    09:26 Social stigma tends to cause a delay in seeking of health care.

    09:30 Well, Evelyn went to the urgent care twice, and now she's in the ED so this doesn't seem to fit.

    09:37 And finally, lifestyle choices.

    09:40 Certainly, this is relevant in any case when we're talking about coronary artery disease.

    09:44 However, Evelyn's history, her social history, and her substance use history do not indicate any problems.

    09:51 So this would not be the correct answer.

    09:54 So, the correct answer for option two is health disparities.

    09:59 The nurse determines that Evelyn is most at risk for a decrease in quality of care due to health disparities in the female and African American population.

    10:08 Now we're ready for the next question.

    10:11 Complete the following sentence by choosing from the list of options.

    10:15 The nurse plans on overcoming the identified barriers in providing care to the client by discussing, what? So what does the nurse need to discuss? Look at the options below and see what you think.

    10:35 Now, let's discuss.

    10:37 The first option.

    10:38 Treatments received at the urgent care facility.

    10:42 While it might be important to discuss that Evelyn visited the urgent care facility, if we think about the diagnosis of indigestion and stress, we know that we have to move beyond this.

    10:53 So read discussing what happened at Urgent Care might actually elicit bias and not be helpful.

    11:00 Current concerns with the health care provider.

    11:03 This seems like an appropriate option.

    11:05 As we're discussing what's currently going on with Evelyn.

    11:08 What she is saying, what she is doing in an effort to figure out what is going on.

    11:13 Let's see what else we have.

    11:16 Modifiable risk factors with the client.

    11:19 Well, modifiable risk factors are important, but this is talking about diet and smoking.

    11:25 And we've already discussed that this is not particularly relevant in this case.

    11:29 And finally, the importance of monitoring the client during the handoff.

    11:34 Well, it seems like we've been doing a lot of monitoring for Evelyn.

    11:37 Now it's time for intervention.

    11:40 So this is probably not the best option either.

    11:43 Therefore, the answer is, the nurse plans on overcoming the identified barriers in providing care to the client by discussing current concerns with the health care provider.

    11:56 It's now 35 minutes after Evelyn arrived in the ED.

    12:00 Ondansetron and Metoprolol were administered at 17:00.

    12:04 Remember, that's about five minutes after she arrived.

    12:06 Her vital signs have improved, and she states, "I don't feel my heart racing so much anymore." She also denies the nausea and states that the aches and pains are much better.

    12:18 Evelyn is assisted to the bathroom and upon returning to the bed the nurse notes diaphoresis on her face.

    12:25 Take a look at these vital signs. What do you notice is different? Now we're ready for the question.

    12:36 What three actions by the nurse are examples of providing advocacy for equitable care while communicating the client status with the health care provider? So take a pause, and see which three actions you would choose.

    12:56 Now let's review the answers.

    12:58 We're going to pay particular attention for looking for responses that exemplify advocacy and providing equitable care.

    13:07 We want to move Evelyn's treatment plan forward and not just listen to her chief complaints over and over again.

    13:14 The nurse says, "I am concerned the symptoms could be cardiac related." This displays advocacy for equitable health care by voicing the concerns.

    13:24 Now, Evelyn has a new symptom of diaphoresis, which further indicates cardiac destabilization.

    13:32 Suggesting the need for further testing by encouraging the provider to order cardiac troponins and an electrocardiogram would also be advocacy.

    13:41 Because this means that the nurse believes that Evelyn is experiencing a coronary event and needs further testing.

    13:50 Contributing the client's worsening symptoms to anxiety.

    13:53 Hmm, this is not advocating for this client.

    13:57 The nurse must take Evelyn's symptoms seriously and be able to recognize that she could be presenting with ACS.

    14:05 The nurse says, "She has already been treated for these symptoms." So shall we check her blood sugar? Dismissing the current symptoms is not advocating for the client.

    14:15 Remember, diaphoresis also goes along with cardiac events.

    14:20 Because this client is already been diagnosed with Type 2 diabetes, The blood glucose would have likely already been done.

    14:27 And finally, she had a new onset of diaphoresis.

    14:30 This symptom is worrisome.

    14:32 The nurse is recognizing that this is further exemplification of a coronary event and is reporting exactly the correct thing.

    14:40 So in summary, options one, two, and five are correct.

    14:47 It's now 17:45. Evelyn has been in the ED for about 50 minutes.

    14:52 The nurse discusses the client's plan of care with the health care provider and additional orders are placed.

    14:58 Take a moment and review the new orders.

    15:07 So we're ready for the final question.

    15:09 which information provided by the nurses notes and the providers orders support that Evelyn is receiving equitable care? Please note that you have to have at least one item.

    15:22 Okay, let's review the answers.

    15:25 Remember, we're looking for answers that move the action forward, either to diagnosis or treatment that would be equitable care in this particular situation.

    15:36 So the answers would look like options one and two.

    15:41 Laboratory orders, CBC, CMP, Troponins, ECG and echocardiogram.

    15:49 These are correct.

    15:51 An IV with normal saline initiating an NPO diet.

    15:57 These are often standard treatments in the ED.

    15:59 So this implies more of that watching and waiting and not acting.

    16:04 So the correct answers are the first two. Great job.

    About the Lecture

    The lecture DEIB Case Study: Healthcare Bias in Acute Coronary Syndrome (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course NGN DEIB Case Studies.

    Author of lecture DEIB Case Study: Healthcare Bias in Acute Coronary Syndrome (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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