Failure to honor a patient's request for a specialist
On September 27, a 61-year-old woman came to an urgent care clinic reporting stomach pain, bloating, and loss of appetite for two days. She had a history of digestive issues, including diverticulitis.
Failure to honor a patient's request for a specialist
On September 27, a 61-year-old woman came to an urgent care clinic reporting stomach pain, bloating, and loss of appetite for two days. She had a history of digestive issues, including diverticulitis.
Presentation
OnSeptember 27, a 61-year-old woman came to an urgent care clinic reporting stomach pain, bloating, and loss of appetite for two days. She had a history of digestive issues, including diverticulitis.
Physician action
Upon examination and review of abdominal CT imaging, Physician Assistant A diagnosed the patient with mild to moderate diverticulitis and prescribed antibiotics and pain relievers.
The patient returned the next day reporting new symptoms: more severe pain, very loose stools, feelings of constipation, and elevated blood pressure. PhysicianAssistant A ordered another CT which showed the patient had developed a micro-perforation and more complicated diverticulitis.
The patient was transferred to Hospital A and admitted under the care of Internal Medicine(IM) Physician A.
During her initial examination with IM Physician A, the patient asked to see a gastroenterologist. IM Physician A told her a consultation was not medically indicated and that she required IV antibiotics, pain control, IV hydration, and monitoring. The patient acquiesced. This conversation was not documented.
Overnight, the nursing staff noted the patient made several requests to see a gastroenterologist. The next day, September 29, the patient’s care was transferred to IM Physician B who examined the patient and documented: “Acute diverticulitis. Responding well to metronidazole and ceftriaxone. Ensure adequate pain control with opiates … Anticipate improvement within 48 hours.Will likely be discharged with oral antibiotics with GI follow up.”
IM Physician B later noted an addendum: “Patient continues to have discomfort. She insists on not using opiate medication and seeing GI, despite being counseled on the dangers of colonoscopy while having active diverticulitis infection. GI has been consulted.”
At 3:50p.m., IM Physician B examined the patient and noted no rebound tenderness “however, she has already received 50 mcg of fentanyl in addition to PRN morphine.” X-ray showed mildly distended bowel loops. A nasogastric tube with intermittent suction was ordered.
On September 30, IM Physician B consulted with a gastroenterologist and a general surgeon and discussed his concerns about potential worsening of the micro-perforation. The consults found that the patient’s micro-perforation had grown into a frank perforation and the patient was experiencing fecal peritonitis.
During emergency surgery, the general surgeon diagnosed the patient with sigmoid diverticulitis with perforation. A colectomy was performed and an ostomy required. During surgery, the perforation was located and the perforated section of colon was removed.
Allegations
A lawsuit was filed against IM Physicians A and B for failure to consult with a gastroenterologist and/or a general surgeon in a timely manner. This failure resulted in the patient experiencing a perforation of the colon, subsequent surgery, and a colostomy bag for three months.
Legal implications
Expert consultants for the defense and the plaintiffs were mostly critical in their evaluation of the case. One intensivist stated that neither IM Physician A nor B met the standard of care in this case due to their failure to:
- recognize the complications of diverticulitis;
- consider worsening of the micro-perforation;
- consider peritonitis; and
- request aspecialist evaluation to more closely monitor the patient’s condition.
This physician felt that without closer monitoring, the micro-perforation worsened and led to abscess formation, fecal peritonitis, prolonged hospitalization, and further complications.
An internal medicine physician stated that consultation with a gastroenterologist was not medically indicated until September 30, when the patient developed symptoms of peritonitis and the consult obtained. This consultant also suggested that progress notes seemed to be copied from one day to the next by IM Physician B, suggesting a lack of attention to the patient’s worsening symptoms.
A general surgery consultant said the care initially provided to the patient for diverticulitis was appropriate and that time was needed (48 hours) to give the antibiotics a chance to work. He stated that surgical or gastroenterology consults were not indicated or required earlier, as localized perforations have an extremely high cure rate with antibiotics alone, and rarely progress to the point of needing surgery.
This consultant also felt that, even if a surgical consult happened earlier, it was likely the patient would have received the same care — including the surgery and colostomy — and the same outcome.
A hospitalist who reviewed the case stated that the nurses should have communicated the patient’s pain, nausea, and requests to see a gastroenterologist to the physicians. There was no documentation that the nurses contacted the physicians about the patient’s condition or requests. The hospitalist also felt the patient’s request for a specialist (or possible second opinion) should have been honored.
Disposition
This case was settled on behalf of IM Physician A and B.
Risk management for hospitalists
About improper performance
Disclaimer
Presentation
OnSeptember 27, a 61-year-old woman came to an urgent care clinic reporting stomach pain, bloating, and loss of appetite for two days. She had a history of digestive issues, including diverticulitis.
Physician action
Upon examination and review of abdominal CT imaging, Physician Assistant A diagnosed the patient with mild to moderate diverticulitis and prescribed antibiotics and pain relievers.
The patient returned the next day reporting new symptoms: more severe pain, very loose stools, feelings of constipation, and elevated blood pressure. PhysicianAssistant A ordered another CT which showed the patient had developed a micro-perforation and more complicated diverticulitis.
The patient was transferred to Hospital A and admitted under the care of Internal Medicine(IM) Physician A.
During her initial examination with IM Physician A, the patient asked to see a gastroenterologist. IM Physician A told her a consultation was not medically indicated and that she required IV antibiotics, pain control, IV hydration, and monitoring. The patient acquiesced. This conversation was not documented.
Overnight, the nursing staff noted the patient made several requests to see a gastroenterologist. The next day, September 29, the patient’s care was transferred to IM Physician B who examined the patient and documented: “Acute diverticulitis. Responding well to metronidazole and ceftriaxone. Ensure adequate pain control with opiates … Anticipate improvement within 48 hours.Will likely be discharged with oral antibiotics with GI follow up.”
IM Physician B later noted an addendum: “Patient continues to have discomfort. She insists on not using opiate medication and seeing GI, despite being counseled on the dangers of colonoscopy while having active diverticulitis infection. GI has been consulted.”
At 3:50p.m., IM Physician B examined the patient and noted no rebound tenderness “however, she has already received 50 mcg of fentanyl in addition to PRN morphine.” X-ray showed mildly distended bowel loops. A nasogastric tube with intermittent suction was ordered.
On September 30, IM Physician B consulted with a gastroenterologist and a general surgeon and discussed his concerns about potential worsening of the micro-perforation. The consults found that the patient’s micro-perforation had grown into a frank perforation and the patient was experiencing fecal peritonitis.
During emergency surgery, the general surgeon diagnosed the patient with sigmoid diverticulitis with perforation. A colectomy was performed and an ostomy required. During surgery, the perforation was located and the perforated section of colon was removed.
Allegations
A lawsuit was filed against IM Physicians A and B for failure to consult with a gastroenterologist and/or a general surgeon in a timely manner. This failure resulted in the patient experiencing a perforation of the colon, subsequent surgery, and a colostomy bag for three months.
Legal implications
Expert consultants for the defense and the plaintiffs were mostly critical in their evaluation of the case. One intensivist stated that neither IM Physician A nor B met the standard of care in this case due to their failure to:
- recognize the complications of diverticulitis;
- consider worsening of the micro-perforation;
- consider peritonitis; and
- request aspecialist evaluation to more closely monitor the patient’s condition.
This physician felt that without closer monitoring, the micro-perforation worsened and led to abscess formation, fecal peritonitis, prolonged hospitalization, and further complications.
An internal medicine physician stated that consultation with a gastroenterologist was not medically indicated until September 30, when the patient developed symptoms of peritonitis and the consult obtained. This consultant also suggested that progress notes seemed to be copied from one day to the next by IM Physician B, suggesting a lack of attention to the patient’s worsening symptoms.
A general surgery consultant said the care initially provided to the patient for diverticulitis was appropriate and that time was needed (48 hours) to give the antibiotics a chance to work. He stated that surgical or gastroenterology consults were not indicated or required earlier, as localized perforations have an extremely high cure rate with antibiotics alone, and rarely progress to the point of needing surgery.
This consultant also felt that, even if a surgical consult happened earlier, it was likely the patient would have received the same care — including the surgery and colostomy — and the same outcome.
A hospitalist who reviewed the case stated that the nurses should have communicated the patient’s pain, nausea, and requests to see a gastroenterologist to the physicians. There was no documentation that the nurses contacted the physicians about the patient’s condition or requests. The hospitalist also felt the patient’s request for a specialist (or possible second opinion) should have been honored.
Disposition
This case was settled on behalf of IM Physician A and B.
Risk management for hospitalists
About improper performance
Disclaimer
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