In handling a hospital transfer patient, a receiving specialist may have a new patient who has ongoing issues and is taking multiple medications. Discontinuing medications initiated prior to the transfer without probing the basis for the therapy carries significant risk.
A 47-year-old former mason visited the emergency department complaining of right hip pain and 10/10 pain. A drug screen tested positive for amphetamines, cannabis, opiates, and methamphetamine. CT images showed bilateral total hip arthroplasties and, on the right, a side plate and multiple fixation screws covering an old healing fracture of the proximal femur. A large lucent area indicated a possible loosening of the hardware or osteomyelitis.
The patient’s temperature in the ED started out as normal but rose to 102 within five hours. This prompted the ED physician to order blood cultures and request a consult by an infectious disease specialist who initiated vancomycin and cefepime. The cultures later grew out MRSA. During that time, the patient’s white blood count fluctuated between 15.4 and 8.4. At the family’s request, the patient was transferred to another facility (where his hip surgery took place) following a one-day delay. The inter-facility transfer worksheet at the new facility showed “isolation: yes. Type: MRSA – blood CX” with a primary diagnosis of “aseptic versus septic right THA loosening versus acute lumbar radiculopathy.”
Upon accepting the patient to the new facility’s orthopedic unit (where he was placed in isolation), Dr. O, an orthopedist, documented an afebrile patient with a white count of 9.2 and 10/10 pain, aggravated by movement. Dr. O’s impression was that the patient’s problems were spine-related. Working with an internist, Dr. O discontinued the patient’s antibiotics based on the absence of any apparent infection.
With no indication for surgery, Dr. O discharged the patient after two days.
When Dr. O saw the patient at his office for a scheduled visit six days later, the patient complained of constant 10/10 right knee pain radiating to his right hip and lower back. Dr. O suspected an acute herniated lumbar disc and sent the patient home while an MRI study was ordered. Dr. O did not record a temperature on that visit.
Three days later, the patient’s wife called paramedics because of her husband’s severe back pain, lethargy, and altered levels of consciousness. A toxic screening at the emergency room showed opioids and cannabis; the patient’s temperature was 101.8, and his white blood count was 19.4. The ED physician intubated the patient and ordered a STAT CT. The gentleman’s condition continued to deteriorate and he died 11 days later. The cause of death was attributed to “acute bacteremia...prosthetic joint sepsis.”
The family’s subsequent lawsuit alleged that Dr. O and the internist should have been aware of the patient’s MRSA infection based on the tests performed at the initial facility and that they were negligent in discontinuing antibiotics in a patient with hepatitis B and C, cirrhosis, and morbid obesity.
Dr. O, the internist, and the family resolved the legal matter informally.
This column frequently highlights cases in which missed communications contribute to inaction on the part of a patient’s healthcare team, leading to an injury. But sometimes a lack of communication leads to an action that is later questioned — such as a subsequent treater terminating a potent medication without fully exploring why the medication was initiated.
Gordon Ownby is general counsel for CAP. Questions or comments related to this article should be directed to gownby@CAPphysicians.com. The information in this publication should not be considered legal or medical advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.