News: In March 2013, a middle-aged man presented to a hospital for treatment of chest pain. After consulting with a cardiologist, the patient underwent multiple ECGs, which revealed an infarction. The patient was discharged with instructions to follow up with his general physician based on a determination that his symptoms were noncardiac-based. Several months passed and the patient did not seek a general physician for diagnosis or treatment. The patient eventually passed away due to a heart attack.

The patient’s widow sued the cardiologist and multiple healthcare entities, alleging medical malpractice and wrongful death claims. The case proceeded to trial where the jury awarded the plaintiff more than $2.5 million.

Background: On March 30, 2013, a 66-year-old journalism professor presented to an ED with acute chest pain lasting two weeks and made worse with activity. A cardiologist treated the patient and performed a series of ECGs.

An ECG performed on the patient at 10:41 a.m. was described as abnormal with a possible interior infarct. Another ECG performed nine hours later confirmed the interior infarct. The assessment provided by the cardiologist referenced an “unstable angina,” and the next day, at approximately 10:00 a.m., a stress test was completed. The same day, the cardiologist determined that the patient’s symptoms were noncardiac and discharged the patient with a recommendation of a noncardiac follow-up. However, the patient failed to seek the recommended follow-up appointment, and on Oct. 17, 2013, he died because of a ruptured myocardial infarction.

The patient’s widow filed a medical malpractice action on Dec.16, 2014, against the cardiologist, the hospital, and a physician management company. The plaintiff claimed that the cardiologist was negligent in failing to provide the appropriate cardiac follow-up care, failing to order a cardiac catheterization, and failing to appropriately diagnose the patient’s chest pain. The plaintiff’s claim against the hospital and physician management company were based on a vicarious liability theory.

The plaintiff sought damages for past and future loss of earnings, loss of net accumulations, medical and funeral expenses, past and future loss of support and services, loss of the decedent’s parental and spousal companionship, parental instruction and guidance, spousal protection, and for spousal and parental mental pain and suffering. The plaintiff identified five experts who were intended to testify regarding cardiology, interventional cardiology, economic damages, autopsy findings and the patient’s cardiovascular system as it related to his cause of death, and the psychological care and treatment of the surviving widow.

The jury found the cardiologist 95% negligent and the patient 5% negligent and awarded the plaintiff $31,000 for past medical expenses and $383,000 for loss of support and services, and the jury awarded the patient’s minor surviving son $22,500 for loss of support and services and $2 million in noneconomic damages. The court entered a final judgment holding the cardiologist, the hospital, and the physician management company jointly and severally liable for the jury verdict.

The defendants filed multiple post-trial motions, including a motion for new trial (which the court denied) and a motion for setoff and remittitur (which, as of press time, remains pending). The defendant’s theory for setoff is that the past medical expenses should be reduced to the amount paid by the plaintiff, and that the loss of support and services damages should be reduced to present value.

What this means to you: This case demonstrates the need for physicians to create and adhere to adequate follow-up procedures. It is imperative for hospitals and medical professionals to review and update such procedures to ensure they have not become outdated with changing technology and best practices. A study published in the Annals of Family Medicine found that the optimum follow-up time frame on average is seven days. Example follow-up procedures include emails, a brief satisfaction survey, periodic emails that educate patients on diseases and medical regimes, phone calls by staff, automated phone calling services, and post mail. Hospitals should consider who will be following up with patients, the time frame of the follow-ups, how follow-ups will be accomplished and scheduled, and how to monitor and evaluate the procedures for efficiency and value.

These follow-up procedures must be more than merely administrative. Follow-ups can be used to evaluate medication efficacy and side effects, monitor and track changes in patient health, reinforce knowledge and action plans, confirm medical regimes, schedule new appointments, verify follow-through on referrals, and discuss lab results. A follow-up appointment that fails to accomplish these goals results in a waste of hospital resources and patients’ time, and does nothing to meaningfully mitigate risk. Specific, objective goals should be established for these return appointments. To obtain meaningful benefit from follow-ups and to preserve medical records, patients should be encouraged to truthfully track their compliance with post-discharge actions.

Whenever new procedures are implemented in a hospital, such as new follow-up procedures, hospitals should plan for and evaluate medical professional buy-in. Many hospitals already have implemented procedures for following up with patients, but medical professionals may not adhere to those policies. When rolling out new procedures, hospitals should, at a minimum, ensure the following are established: a full understanding of the new procedure and its purpose to reduce the risk of resistance to change, an understanding of the medical professionals’ roles in the procedure to avoid miscommunication, an understanding of the connection between the new procedure and higher-quality medical care, an identification of potential barriers to the implementation and a strategy for overcoming those barriers, and a plan to engage with staff to ensure and encourage compliance. Hospitals should consider creating an implementation team tasked with overseeing effective implementation.

Experts are critical in any medical malpractice case as they are required to discuss the standard of care and what physicians should do under the same or similar circumstances. In this case, experts opined about the cardiologist’s failure to order a cardiac catheterization. The defendant’s own expert indicated that he would have ordered a cardiac catheterization given the infarction showed by the second ECG. Cardiac catheterization is a useful tool to determine whether a patient suffers from heart disease, and the failure to use such an effective procedure when circumstances justify its use may fall below the standard of care.

Treatment always must be tied to each specific patient’s symptoms and conditions, yet a wide variety of methods may be available to treat a single condition. Myocardial infarctions, which caused the death in this case, often are caused by heart disease. In treating heart disease, physicians have multiple options, including angioplasty with or without stent placement, closing holes in the heart and addressing congenital defects, repairing or replacing heart valves, or using balloon valvuloplasty. In this case, the first ECG result was enough to indicate that further observation and testing was urgently needed. An ECG would indicate abnormalities in the structure of the heart and heart valves and the ejection fraction or ability of the heart to pump blood, which would diminish following damage to heart muscle after an infarct. To make a diagnosis of unstable angina and discharge the patient with a noncardiac diagnosis likely does not satisfy the applicable standard of care. Unstable angina is a cardiac diagnosis that requires treatment with medication designed to prevent constriction of the cardiac arteries that supply blood to the walls of the heart. Without using these critical and readily available diagnostic tools, this patient was not afforded the appropriate standard of care that he deserved.

REFERENCE

Decided on March 21, 2017, in the Florida Circuit Court, Sixth Judicial Circuit, Pinellas County; Case No. 14-009201-CI.