Legal Review & Commentary: Failure to diagnose staph infection: $5.45M verdict
Legal Review & Commentary
Failure to diagnose staph infection: $5.45M verdict
News: A 30-year-old man presented to an ED with complaints of fever, joint pain, a severe headache, and shaking chills. The ED physician further determined that the man was suffering from a rapid heart rate and some paresthesia. The man did not undergo any further testing and was sent home with instructions to take acetaminophen and drink fluids. A follow-up appointment was set. A few days later, the man returned to the ED with the same complaints. A blood test was performed, and the man was found to have bacterial endocarditis that had entered his heart and arteries. The man sued the hospital.
Background: A 30-year-old assistant director of a visiting home nursing service went to the ED with complaints that he felt "deathly ill" and was suffering from a fever, joint pain, a severe headache, and shaking chills. He was also diagnosed to be suffering from a rapid heart rate and paresthesia in his fingers and hands. While the man was examined by the ED physician, no blood or urine was taken. A notation was made in his chart that he was suffering from "probable viral syndrome" or the flu. The ED physician sent the man home with instructions to take acetaminophen and drink fluids. An appointment was scheduled for a week later.
Four days later, in advance of his scheduled appointment, the man returned to the ED complaining of the same symptoms but asserting that they had become increasingly worse. A blood test was performed, and the man was found to be suffering from bacterial endocarditis (a.k.a., infective endocarditis), which was found to have entered his heart and arteries. Infective endocarditis occurs when bacteria in the bloodstream lodge on abnormal heart valves or other damaged heart tissue. Two days later, doctors performed heart surgery to replace one of the man's valves. Afterward, the doctor told him he "was 30 minutes from death."
The man sued the hospital alleging that it had failed to properly and timely diagnose his condition and failed to timely perform tests. The man relied on the fact that his initial symptoms suggested a bacterial infection and, therefore, a urinalysis and blood work-up were warranted. The man's expert testified that had a complete blood count been conducted, the white blood cell count would have been elevated and the ratio of granulocytes to lymphocytes would have demonstrated a bacterial infection. The expert further contended that a urinalysis would have confirmed a bacterial infection and may have led to further testing. On cross-examination, the expert conceded that a urinalysis cannot definitely confirm a bacterial infection in this setting.
The man claimed that the hospital's failure to perform these tests caused the spread of the infection and the subsequent damage to the mitral valve in his heart and his arteries. The man also underwent two surgical procedures to correct an aneurysm and a pseudoaneurysm. If his condition had been diagnosed early on, he could have been provided with an antibiotics IV for approximately one week, which would have allowed him to recover.
The man's mother and previous girlfriend also testified in the case that the man's condition worsened in the days following his initial discharge. While the girlfriend became concerned, the man did not return to the ED because he said he had been told that "things would get worse before they got better." The man stated that this information had caused him to wait until four days after the initial visit. The expert testified that if he had returned within 48 hours of his discharge, all the surgeries and resulting complications could have been avoided.
The defendant hospital countered the man's claim and contended that the signs and symptoms did not warrant further testing and suggested that the man was only suffering from a normal virus. The infectious disease expert employed by the hospital testified that a blood test would not have shown any signs of a bacterial infection at that time. The defense expert addressed the plaintiff's expert, claiming that a retrospective look at test results was speculative and relied improperly on hindsight thinking. Furthermore, the hospital denied the man's contention that anyone at the hospital ever said that things would "get worse before they got better." It argued that this kind of language is inconsistent with the discharge planning instructions, which requested the man to return immediately if his condition worsened or if new symptoms arose. Defendant also claimed that the man was partly liable for his failure to return to the hospital at the time the condition worsened.
In calculating proposed damages, the man stated that as a result of his injuries, he was required to be on warfarin, a blood thinner, for life and that he was unable to perform in triathlons as he had done for many years. The man asked the jury for a total of $15.85 million but was awarded only $5.45 million.
What this means to you: When an otherwise healthy 30-year-old presents to an ED with complaints of feeling "deathly ill," experiencing fever, joint pain, chills, a severe headache, rapid heart rate, and paresthesia in his fingers and hands, a thorough assessment must be performed in order to determine the patient's care needs and treatment. The Joint Commission defines assessment as "an objective evaluation or appraisal of an individual's health status, including acute and chronic conditions. The assessment gathers information through data, observation, and physical examination." In its introduction to Standard PC.01.02.01, the goal of such an assessment is "to determine the care, treatment, and services that will meet the patient's initial and continuing needs." This includes collecting and analyzing information regarding the patient's health history, followed by care and treatment decisions appropriate for the patient based on the information obtained.
In this case, the "objective" evaluation or appraisal would be considered incomplete given the definitions noted above. Although the patient was observed and a physical examination performed by the ED physician, no data were collected by means of diagnostic testing (such as a urinalysis or blood count) to assist the physician in determining care and treatment decisions appropriate for a 30-year-old who presents with fever of unknown origin and other acute symptoms. For example, obtaining a urinalysis could indicate a urinary tract infection with potential for subsequent sepsis. A complete blood count including a seg rate may have alerted the physician to an inflammatory or infectious process. Because the patient presented with symptoms that could describe myriad illnesses (including bacterial and viral illnesses), obtaining minimal diagnostic studies would be warranted in order to reach a substantiated decision.
Discharging an ED patient with a diagnosis of "probable viral syndrome" raises red flags from a risk/litigation viewpoint. First, the word "probable" conjures a sense of doubt or lack of knowledge regarding the root of the problem. It denotes guesswork in reaching a conclusion rather than a decision based on fact. It is subjective rather than objective. If, in the height of flu season and in light of hospital efforts to control costs, an ED physician has encountered multiple patients with similar or identical symptoms during an ED shift, it is understandable that the physician might presume this patient was another of the "walking wounded" and save costs by designating the discharge diagnosis as a viral syndrome. This, however, creates the second issue; without supportive data to justify the diagnosis decision, there is little to no defense for a diagnosis that later proves incorrect. There is no way to defend a "probable" diagnosis, especially if there are no supporting data or evidence of attempts to determine a diagnosis through diagnostic testing. It begs the question, "On what did you base your diagnosis?" While subjective information plays a role and aids the physician in seeking more information, objective information provides a rationale for the decision and, therefore, a diagnosis decision defense.
Thirdly, ED physicians are at a disadvantage, since they typically do not know their patients. It is easier for a primary care physician who is more familiar with a patient to recognize changes in his or her patient's health status. This serves as an argument for the need for an ED physician to be more prudent in seeking information in order to make a rational diagnosis on a patient he or she does not know. Often, however, ED physicians are under fire to evaluate patients as quickly and efficiently as possible, placing the ED physician at risk as well.
There is little question that had this patient, in otherwise good health (triathlon participant, health care employee), been properly diagnosed and treated with IV antibiotic therapy in a timely manner, there may have been no need for the patient's mitral valve replacement, and subsequent litigation, trial, and a $5.45 million jury verdict.
A 30-year-old man presented to an ED with complaints of fever, joint pain, a severe headache, and shaking chills. The ED physician further determined that the man was suffering from a rapid heart rate and some paresthesia. The man did not undergo any further testing and was sent home with instructions to take acetaminophen and drink fluids.Subscribe Now for Access
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