Infectious Disease Malpractice: The $1.2 Million Miscommunication
By Joseph Patterson, MD, Emergency Medicine Residency, Madigan Army Medical Center, Tacoma, WA; Cyril Fider, MD, Madigan Army Medical Center, Tacoma, WA; and Gregory Moore, MD, Emergency Medicine Residency Director,Madigan Army Medical Center, Tacoma, WA
The authors report no financial relationships in this field of study.
Infectious diseases account for a significant percentage of emergency department (ED) visits each year and are frequent sources of litigation. A plaintiff verdict or settlement is usually based on a delay in diagnosis and subsequent substandard treatment. It is important to recognize specific infectious entities early to avoid medical-legal exposure.
In Anonymous Woman v. Anonymous Physician and Anonymous Nurse, a 40-year-old female was referred from her primary care physician to the ED after presenting with five days of headache, fever, and body aches. An initial evaluation consisting of a lumbar puncture, urinalysis, and blood cultures was performed, and she was discharged with blood cultures pending after the other tests were negative. Two days later, the blood cultures grew group B streptococcus. A nurse was instructed to call the patient back, but was unsuccessful after two attempts at the home number on different days — no attempt was made to contact the primary care doctor who referred the patient. The physician stated that the nurse was instructed to call the patient back for treatment, while the nurse stated that the culture results were thought to be a contaminant and the call was meant to see how the patient was doing. The patient returned six days after the initial visit with worsening symptoms and was admitted for treatment of endocarditis. The patient was also found to have aortic regurgitation and valvular disease, expected to require a valve replacement. The defense claimed that the damage was pre-existing and not worsened by the delay in diagnosis and treatment, but a $1.2 million settlement was reached.1
Infective endocarditis is an inflammation of the lining of the heart or its valves with an infectious agent, usually bacteria. Diagnosis is challenging, and untreated disease is associated with significant complications and a mortality rate approaching 100%.2 The above case illustrates two excellent points. The first concerns follow-up. The follow-up call was delegated to a nurse, and the physician and nurse gave conflicting statements on the purpose of the calls. Additionally, the primary care doctor was not contacted as another means of reaching the patient. In the end, the patient was never reached with the results and it would be difficult to say that every effort had been made to contact the patient.
There are a plethora of cases in which blood culture results were inadequately communicated. These cases universally result in court settlements or payouts. It is imperative that the ED have a follow-up protocol that is 100% compliant. Interestingly, the defense argument was that the damage was already done, not that the delay was the patient’s fault for not giving a reliable phone number or checking her messages.
The second point is that infective endocarditis bears special consideration as a diagnosis that is both difficult to make and dangerous to miss. Patients typically present with vague constitutional symptoms and fevers. The median age of onset is 67, although this can occur at much younger ages based on other co-morbidities or IV drug abuse,3and the median time from symptom onset to diagnosis is eight days.4
Diagnosis has been standardized with the Duke criteria, which are quoted at approximately 90% sensitivity. They consist of two major and six minor criteria. The major criteria are blood cultures (the presence of typical bacteria from two separate blood cultures or in persistently positive blood cultures) and evidence of echocardiographic involvement. The minor criteria are a predisposition to the disease, fever (> 38° C), vascular phenomena, immunologic phenomena, suggestive echocardiogram, and suggestive microbiologic findings.5 In 2000, these criteria were modified to drop suggestive echocardiogram findings as a minor criterion and divide cases into one of three categories — definite infective endocarditis (two major criteria; one major and three minor; or five minor), possible (one major and one minor; or three minor), or rejected (due to a firm alternative diagnosis, resolution of the syndrome with four or less days of antibiotics, no pathologic evidence on autopsy or surgery, or not meeting the criteria above).6
While most of the criteria are self evident, one deserves additional discussion. Predisposition to the disease is anything that allows bacteria to accumulate on the endocardium and is generally due to an anatomic valvular defect, causing turbulent flow that injures the endothelium, a foreign object such as a mechanical valve, or injection drug use. A thorough history or review of records can provide one of the criteria, along with raising the clinician’s index of suspicion. Along with the formal diagnostic criteria, lab findings of anemia, hematuria, and elevated ESR, CRP, or procalcitonin have been identified as being strongly associated with the disease but nonspecific.2
As noted above, patients are at risk of significant morbidity and mortality if the disease is not identified and treated with a prolonged course of antibiotics. Along with the ill effects of prolonged bacteremia, the disease process can result in direct damage to the heart or valves, with heart failure or arrhythmias as a result. Additionally, fragments of the bacteria and clot that cling to the heart valve can break off and embolize, causing infarction or abscess in any area of the body, including the lungs, the mesentery, the eyes, and the brain, with the most common CNS complication being a middle cerebral artery embolic stroke.2,3These devastating complications can be minimized or avoided with admission for IV antibiotics as well as early surgical removal of the bacterial vegetation in higher risk cases.
References
- Medical Malpractice Verdicts and Settlements 2010;26:13.
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed. New York: McGraw-Hill; 2011.
- Murdoch DR, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: The International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med 2009;169:463473.
- Hill EE, et al. Infective endocarditis: Changing epidemiology and predictors of 6-month mortality: A prospective cohort study. Eur Heart J 2007;28:196203.
- Durack DT, et al. New criteria for diagnosis of infective endocarditis: Utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med 1994;96:200209.
- Li JS, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000;30:633638.
