Failed Communications in the Medical Office Lead to an “Alleged Delay in Treatment”

The Case

A young woman with a long history of migraine headaches, sickle-cell trait and several first trimester miscarriages finally had a normal delivery of a full term healthy infant. Her pregnancy was complicated by pregnancy induced hypertension (PIH), and possibly pre-eclampsia. She remained under the care of her obstetrician, and continued to have high blood pressure readings. No blood pressure medications were prescribed. At five weeks post-partum she went to her primary care physician (PCP) with complaints of chest pain, cough, shortness of breath and dizziness. She was diagnosed with bronchitis and prescribed antibiotics, prednisone and inhalers. A month later, she returned to her PCP with complaints of bilateral feet swelling; she had 2+ peripheral edema. Two months later, she returned with similar complaints and also complained of congestion, wheezing and flu-like symptoms. She had no fever or chills. On physical exam, she had no heart murmur or gallop; her chest x-ray showed left ventricular cardiac enlargement, but was otherwise unremarkable. Ten days later her PCP noted new findings: she had gained ten pounds, had swelling in her lower extremities (3+ edema) and abdomen and a S3 heart gallop. The PCP diagnosed congestive heart failure (CHF), and contacted a cardiologist.

In his deposition, the PCP testified that he spoke to the on-call cardiologist, and discussed the patient’s history and findings in detail. Also he said that he had instructed the patient to see the cardiologist in the morning (Friday) for an echocardiogram (ECHO). The primary aspect of his testimony that implicated the cardiologist was that the PCP asked her to call the patient the following day to arrange for the ECHO. In fact, he documented in the medical record that the cardiologist was given the patient’s name and number, agreed the patient needed the ECHO, and that she (cardiologist) would have her staff call the patient the following day. This information was also written on a referral sheet, but the referral sheet never reached the cardiologist’s office.

As instructed, the patient called the cardiology office, and was told that there were no appointment openings, and that the office did not perform ECHOs on Fridays. The cardiology scheduling secretary further advised the patient that there was no urgency and that she could be seen on Tuesday the following week. The patient called her PCP’s office for assistance. An employee in that office told her to come back and see the PCP in two days if she did not feel better.

On Sunday, the patient presented to the hospital emergency department (ED) with an inability to speak and a right-sided hemiplegia. A CT showed a large evolving left-sided cardio-embolic stroke. She was also diagnosed with post partum cardiomyopathy. The patient was eventually discharged to a rehabilitation center. At discharge from the rehabilitation center, she continued to have limitations, and was unable to care for her baby.

Disposition

The claim settled for a moderate dollar amount.

Allegation/s

The patient should have been sent to the ED and admitted to the hospital for urgent treatment of her congestive heart failure, which would have averted her postpartum stroke.

Clinical/Risk Management Commentary

The experts gave good causation arguments that, even if the patient had seen our insured cardiologist and/or had been admitted to the hospital, it is unlikely that her outcome would have been different. After the patient suffered the stroke, an ECHO was performed in the hospital setting and indicated no thrombus was present in the left ventricle. The cardiologist also performed a transesophageal echocardiogram (TEE). It revealed a left ventricle thrombus. It was unlikely that anti-coagulation would have helped her, given the timing of the event.

However, the standard of care argument remained a challenge. Experts opined that once the referral was made to the cardiologist, it was the cardiologist’s responsibility to assess the patient and make the determination on what course of treatment should be pursued, and the timing of it. Given this position, the experts opined that although the guidelines don’t necessarily require immediate hospitalization for CHF, once the cardiologist was informed that the patient was postpartum with suspected CHF, she should have immediately admitted her to the hospital as for an “urgent” ECHO and further evaluation. To do otherwise was a breach of the standard of care by the cardiologist.

From a risk management perspective, had there been better communication systems in place in both the PCP and Cardiology offices, the office staffs would have been better able to ensure that if the original plan of care agreed upon by both physicians was not practical according to scheduling constraints, an immediate, but appropriate alternate plan could have been devised.

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