By Wayne Wenske, Senior Marketing Coordinator, and
Jennifer Templin, Risk Management Representative
Presentation
On June 2, a 61-year-old man came to the emergency department (ED) of a large hospital. He reported recurring, right-sided, lower abdominal pain for two days. He rated the pain as a 9 out of 10. He had a history of hypertension, for which he was taking atenolol and chlorthalidone.
The ED physician examined the patient and noted he had severe abdominal tenderness, rebound tenderness, voluntary guarding, and involuntary guarding. The patient reported loose bowel movements but denied black stools. He also denied fever, chills, nausea, and vomiting. Complete blood count (CBC) showed a white blood count of 16.4 with 88% neutrophils.
Physician action
The patient was admitted under the care of a hospitalist with a preliminary diagnosis of acute appendicitis. Further consults and tests were ordered.
A CT scan of the abdomen revealed a large, inflamed appendix consistent with acute appendicitis. The report also stated that colitis could not be ruled out. Based on these findings, the hospitalist presumed the patient needed an appendectomy and ordered a general surgery consult.
Surgeon A examined the patient and documented that she did not think the patient had appendicitis, despite the CT report. The surgeon planned to discuss the CT report and the possibility of Crohn’s disease with a gastroenterologist before pursuing surgery. She did not document her reasons for ruling out appendicitis.
The gastroenterologist saw the patient and started him on Piperacillin/Tazobactam (penicillin) to cover bacteria-related to appendicitis. An infectious disease (ID) physician saw the patient and noted he was on a liquid diet, had improved pain, and no diarrhea. The ID physician agreed with the prescription of penicillin.
On June 3, the ID physician saw the patient again and documented his impression as colitis with possible appendicitis. He reasoned that Crohn’s Disease was likely, based on the patient’s age, recurring diarrhea, and joint pain. He recommended a colonoscopy, continued penicillin, and monitoring.
The hospitalist saw the patient and reviewed the gastroenterology and surgery reports. Based on the consults, he documented that the patient might have inflammatory bowel disease (IBD) and not appendicitis. He requested an additional ID consult.
On June 4, the ID physician saw the patient again and documented the abdominal pain as improved and no diarrhea. The patient was limited to a clear liquid diet. His WBC remained elevated at 14.9. Blood and stool cultures were in progress.
The hospitalist saw the patient a few hours later and noted the cultures were positive for Clostridium difficile (C. difficile). He started the patient on oral vancomycin, to cover C. difficile colitis. The colonoscopy was postponed to allow the patient’s C. difficile to clear and to avoid risk of perforation.
The penicillin was discontinued, and the oral vancomycin continued.
Surgeon A also saw the patient on June 4, and noted his abdominal tenderness and pain as improved. She documented that the patient’s condition did not look like acute appendicitis that required surgery. She instead wanted the patient evaluated for possible Crohn’s colitis.
The ID physician returned and noted that the patient’s lower right quadrant pain had improved. He believed the leukocytosis had resolved and that the C. difficile explained the pain and elevated WBC. He agreed with the gastroenterologist’s assessment for performing a colonoscopy after a course of antibiotics, because the C. difficile could be superimposed on IBD.
On June 6, the ID physician noted that the patient had been advanced to a soft diet but was vomiting after eating. The patient’s abdominal pain and tenderness resolved, with normalization of WBC at 8.1. The ID physician believed the patient was still suffering from C. difficile and recommended continuing oral vancomycin.
Later that day, the hospitalist discharged the patient with oral vancomycin and instructions to follow up with the gastroenterologist in two to three weeks to schedule a colonoscopy. The nurses documented that the patient was still vomiting and unable to hold down food at discharge.
One week later, on June 13, the patient returned to the ED with reports of increased abdominal pain in the lower right quadrant. He was admitted under the care of the same hospitalist. A surgery consult was ordered. Surgeon B recommended urgent exploration for probable ruptured appendix.
Surgeon B attempted laparoscopic appendectomy but converted to open laparotomy. He found a ruptured appendix with severely inflamed cecum. The appendix and some adjacent cecum were removed. Bowel continuity was re-established with an ileocecectomy.
Approximately eight hours after surgery, the patient became hypotensive and went into hemorrhagic shock. Surgeon B took the patient back to surgery and found a small laceration in the liver. All surfaces were bleeding in the abdominal cavity, causing concern for disseminated intravascular coagulation.
The patient received multiple transfusions of red cells, fresh frozen plasma, platelets, and albumin. Multiple explorations were also required over the next few days for continued bleeding and severe sepsis.
The patient went into oliguric renal failure requiring dialysis. The patient later went into renal respiratory failure; vasopressors were needed for blood pressure support. The patient suffered anoxic brain injury during this time.
After a week of intensive medical care, the patient’s family decided to withdraw life support. The patient died on June 20.
Allegations
A lawsuit was filed against the hospitalist, Surgeon A, the gastroenterologist, and the infectious disease physician. The primary allegation was that, instead of diagnosing appendicitis, the physicians followed an incorrect course of treatment during the patient’s first hospitalization. Allegations also included choosing an inadequate antibiotic (vancomycin) to treat the patient.
Legal implications
Defense consultants were mixed in their evaluation of this case. One internal medicine consultant felt that the physicians should have realized that oral vancomycin was inadequate antibiotic coverage for the patient’s condition. Vancomycin is adequate for C. difficile, but does not cover infections consistent with appendicitis. This consultant also criticized the patient’s discharge on June 6 without a scheduled follow-up appointment or confirming that the patient was able to hold down meals or fluids.
Another defense consultant felt the evidence of acute appendicitis was strong, and Surgeon A was clearly in error in not taking the patient to surgery. Unfortunately, the other providers did not question Surgeon A’s judgement. In addition, the diagnosis of C. difficile clouded the judgement of all involved.
The infectious disease physician was criticized for not rejecting the C. difficile diagnosis and requiring the providers to reassess the patient. This consultant pointed to several reasons for challenging the C. difficile diagnosis, including the rarity of right-sided C. difficile disease.
Because the patient’s condition improved during his initial hospitalization, the hospitalist was noted as being within his right to rely on the advice of specialists. He was also noted as providing care within his scope of practice, training, experience, and certification.
While consultants for the plaintiff agreed the hospitalist was obliged to consider the consult opinions, they pointed out he was also obliged to form an independent opinion about the absence or presence of appendicitis. It was considered unreasonable for him to defer completely to the decisions of specialists regarding the patient’s treatment and diagnosis.
Plaintiff’s consultants also stated the hospitalist fell below the standard of care by discharging the patient before a proper diagnosis was established and when the patient was still unable to eat without vomiting.
These consultants felt that had the patient been diagnosed with appendicitis during his first hospitalization, he would have received appropriate treatment, including surgery, and his death from complications of a ruptured appendix may have been prevented.
Disposition
This case was settled on behalf of the hospitalist, Surgeon A, the gastroenterologist, and the infectious disease physician.
Risk management considerations
Ensuring that appropriate consultations are obtained and applied to a patient’s care is an important duty for the hospitalist. In this case, the first consult requested by the hospitalist was a general surgeon, due to the appendicitis diagnosis.
After her examination of the patient, the general surgeon did not document her rationale for her diagnosis of possible Crohn’s disease. Additionally, she did not address a possible differential diagnosis.
The diagnosis in her report differed from the CT scan that had been performed. While empirical findings should be properly addressed when precluding a differential diagnosis, this did not happen in this case.
When the hospitalist reviewed the surgeon’s report, he may have sought further clarification from her or requested another general surgery consult. Either way, if the hospitalist had an issue with the general surgeon’s report, he could have done more to define the patient’s condition. Documentation that reflected he took these steps may have provided the hospitalist with a stronger defense.
There are specific guidelines for a consulting medical specialist to follow that apply within a hospital setting, such as in this case. According to the U.S. National Library of Medicine Center for Biotechnology Information, a consulting specialist should adhere to the following 10 rules. 1
- Determine why you have been asked to consult. What question is the ordering physician attempting to answer?
- Establish the urgency of the consultation. Is it an emergency, urgent, or routine? The answer will determine how immediate your response should be, but all consults should be seen within 24 hours.
- Gather primary data. Do not rely too heavily on what is in the patient record. “Obtain your own history and physical—your expertise may allow you to extract overlooked information.” 2
- Communicate as briefly and concisely as appropriate. Don’t allow your findings and recommendations to be lost in a barrage of too much information. The ordering physician may be inundated with reports and other consult recommendations to parse through your report to discover your findings. “Consults are more effective when they are brief (five or fewer recommendations), are detailed, and provide contingency plans.” 2
- Make specific recommendations. Studies have shown that the more specific the recommendation, the more likely it will be followed by the ordering physician and the patient. 2
- Provide contingency plans. Anticipating problems and providing recommendations if those problems arise can save valuable time for you, your colleagues, and the patient. 2
- Understand your own role, as a consultant, in the process.
- Offer educational information, as appropriate, to the patient, requesting physician, and the other health care professionals seeing the patient.
- Communicate recommendations directly to the requesting physician. Do so verbally, to foster a more effective consulting relationship and find agreement on a plan of action. If you do not agree with the plan taken by the requesting physician, discuss your concerns at this time. Do not simply document your concerns in the patient records. 2
- Provide appropriate follow up.
In this case, the hospitalist had three differing diagnoses and should have followed up to obtain the general surgeon’s rationale for her diagnosis, so that he could have made a more informed opinion before requesting an infectious disease consult.
In addition, proper patient discharge is essential. According to the ID physician’s documentation, the patient had been advanced to a soft diet but was still vomiting after eating. The nurses had also documented that the patient was still vomiting and unable to hold down his meals. However, the hospitalist still discharged the patient with an oral antibiotic, which contributed to a post-discharge adverse outcome.
Ensuring that a patient is able to keep food and oral prescription medication down is an important step to helping prevent a readmission or adverse outcome.
Sources
1.Goldman L. MD; Lee T. MD; Rudd P. MD. Ten Commandments for Effective Consultations. JAMA Archives of Internal Medicine. Volume 143, Number 9. September 1, 1983. Available at https://pubmed.ncbi.nlm.nih.gov/6615097/. Accessed March 31, 2020.
2.Chang D. MD, FHM; Gabriel E. MD. 10 Tips for Hospitalists to Achieve an Effective Medical Consult. The Hospitalist. July 2015. Available at https://www.the-hospitalist.org/hospitalist/article/122225/10-tips-hospitalists-achieve-effective-medical-consult. Accessed March 31, 2020.
Wayne Wenske can be reached at wayne-wenske@tmlt.org.
Jennifer Templin can be reached at jennifer-templin@tmlt.org.
