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DB was a 20-year-old woman who presented to her primary care physician (PCP) with fever and myalgias. Her past medical history was significant for open heart surgery 3 years earlier for ventricular myxoma and aortic valve repair. Her temperature in the office was 39.1 C. Her examination was otherwise unremarkable. An influenza swab was negative. Cultures were drawn and DB was sent home with instructions to increase her fluids and use acetaminophen and ibuprofen as needed. Two days later, 2 out of 2 preliminary blood cultures were reported positive for coagulase-negative, gram positive cocci in clusters. DB was referred to the hospital where she was admitted by Dr. Hospitalist.
Dr. Hospitalist performed a history and physical and noted an impression of sepsis from subacute bacterial endocarditis. He initiated intravenous vancomycin and ceftriaxone, repeated blood cultures, ordered an echocardiogram, and obtained an infectious disease (ID) consult. On hospital day 2, the ID consultant documented that DB had positive blood cultures for coagulase-negative staphylococci but no true evidence of sepsis. She was noted to be afebrile with a normal white blood cell count. Although the echocardiogram was pending, the ID consultant recommended that intravenous antibiotics be discontinued and that she was safe to be discharged home with follow-up blood cultures in 1 week. Later that day, the echocardiogram found a thickened aortic valve with an increased density that suggested possible vegetation.
On the morning of hospital day 3, DB had a Tmax (time to maximum plasma concentration) of 38.8 C overnight. The repeat blood cultures drawn on admission showed no growth to date. Dr. Hospitalist stopped the intravenous antibiotics and discharged DB to home. Unknown to Dr. Hospitalist at the time, the original cultures drawn at the PCP’s office were finalized as Staphylococcus lugdunensis.
One week later, DB followed up with her PCP. She continued to have fevers, myalgias, and fatigue. Blood cultures were obtained and reported the following day as 2 out of 2 positive for S. lugdunensis. DB once again returned to the hospital and was started on intravenous antibiotics. Two days into her second hospital stay, DB complained of feeling hot. She sat up in the bed and then went unconscious. After almost 2 hours of resuscitation, DB was pronounced dead. An autopsy was performed and identified the cause of death as bacterial endocarditis (S. lugdunensis) with massive vegetations and aortic valve rupture.
Complaint
DB’s mother immediately brought a claim against Dr. Hospitalist and the ID consultant from the first hospital stay. The complaint alleged that DB was inappropriately discharged from the first hospitalization without ongoing intravenous antibiotic therapy. As a result, DB missed 8 days of antibiotic treatment allowing her untreated infection to irreversibly damage her heart. The complaint further alleged that this gap in treatment was the proximate cause of DB’s death.
Scientific principles
Staphylococcus lugdunensis is a coagulase-negative staphylococcus (CNS). Like other CNS, S. lugdunensis in humans ranges from a harmless skin commensal to a life-threatening pathogen (as with infective endocarditis). Unlike other CNS, however, S. lugdunensis can cause severe disease reminiscent of the virulent infections frequently attributable to S. aureus. S. lugdunensis endocarditis is an aggressive infection that affects native valves with greater frequency than prosthetic valves in contrast to other CNS. S. lugdunensis native valve endocarditis is typically community acquired and is associated with a high rate of complications and death.
Complaint rebuttal and discussion
The only defense that Dr. Hospitalist offered was that he relied on his subspecialty consultant. Dr. Hospitalist argued that he was a generalist and not an expert in endocarditis or CNS. As a result, he followed the recommendations of the ID consultant and he further argued that he had the right to do so.
The plaintiff countered essentially countered with "Would you jump off the roof of a building just because someone told you to?" argument. In this case, the positive blood cultures, the history of aortic valve repair, and the suggestive echocardiogram were indisputable facts. Discovery in this case confirmed that Dr. Hospitalist never spoke with the ID consultant at any point during the first hospital stay.
Plaintiff experts argued that Dr. Hospitalist was a board-certified internist practicing hospital-based internal medicine and as such, he had or should have had the requisite knowledge, skills, and attitudes to evaluate, diagnose, and treat endocarditis. In this case, it appeared that Dr. Hospitalist "blindly" followed the recommendations of the ID consultant without considering all the evidence at hand. Plaintiff experts argued that in this situation, the standard of care required that Dr. Hospitalist question the plan of care outlined by his consultant. Had he done so, it is likely that both Dr. Hospitalist and the infectious disease consultant would have learned that the original blood cultures grew S. lugdunensis and antibiotics would never have been discontinued.
Conclusion
As the attending physicians of record, hospitalists carry the ultimate responsibility for the discharge decision. It is common to ask subspecialty consultants their opinion regarding stability for discharge and/or the need for ongoing hospital therapy. Yet, it is important for all hospitalists to remember that the consultant recommendations are just opinions that must be weighed against all the other evidence currently available. It is also helpful to have and document verbal discussions with consultants when discharge decisions are being made (and partially relied upon) with their subspecialty input.
The ID consultant in this case settled almost immediately with DB’s family. Dr. Hospitalist defended himself a little longer, but ultimately settled this case with the plaintiff for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.
Story
DB was a 20-year-old woman who presented to her primary care physician (PCP) with fever and myalgias. Her past medical history was significant for open heart surgery 3 years earlier for ventricular myxoma and aortic valve repair. Her temperature in the office was 39.1 C. Her examination was otherwise unremarkable. An influenza swab was negative. Cultures were drawn and DB was sent home with instructions to increase her fluids and use acetaminophen and ibuprofen as needed. Two days later, 2 out of 2 preliminary blood cultures were reported positive for coagulase-negative, gram positive cocci in clusters. DB was referred to the hospital where she was admitted by Dr. Hospitalist.
Dr. Hospitalist performed a history and physical and noted an impression of sepsis from subacute bacterial endocarditis. He initiated intravenous vancomycin and ceftriaxone, repeated blood cultures, ordered an echocardiogram, and obtained an infectious disease (ID) consult. On hospital day 2, the ID consultant documented that DB had positive blood cultures for coagulase-negative staphylococci but no true evidence of sepsis. She was noted to be afebrile with a normal white blood cell count. Although the echocardiogram was pending, the ID consultant recommended that intravenous antibiotics be discontinued and that she was safe to be discharged home with follow-up blood cultures in 1 week. Later that day, the echocardiogram found a thickened aortic valve with an increased density that suggested possible vegetation.
On the morning of hospital day 3, DB had a Tmax (time to maximum plasma concentration) of 38.8 C overnight. The repeat blood cultures drawn on admission showed no growth to date. Dr. Hospitalist stopped the intravenous antibiotics and discharged DB to home. Unknown to Dr. Hospitalist at the time, the original cultures drawn at the PCP’s office were finalized as Staphylococcus lugdunensis.
One week later, DB followed up with her PCP. She continued to have fevers, myalgias, and fatigue. Blood cultures were obtained and reported the following day as 2 out of 2 positive for S. lugdunensis. DB once again returned to the hospital and was started on intravenous antibiotics. Two days into her second hospital stay, DB complained of feeling hot. She sat up in the bed and then went unconscious. After almost 2 hours of resuscitation, DB was pronounced dead. An autopsy was performed and identified the cause of death as bacterial endocarditis (S. lugdunensis) with massive vegetations and aortic valve rupture.
Complaint
DB’s mother immediately brought a claim against Dr. Hospitalist and the ID consultant from the first hospital stay. The complaint alleged that DB was inappropriately discharged from the first hospitalization without ongoing intravenous antibiotic therapy. As a result, DB missed 8 days of antibiotic treatment allowing her untreated infection to irreversibly damage her heart. The complaint further alleged that this gap in treatment was the proximate cause of DB’s death.
Scientific principles
Staphylococcus lugdunensis is a coagulase-negative staphylococcus (CNS). Like other CNS, S. lugdunensis in humans ranges from a harmless skin commensal to a life-threatening pathogen (as with infective endocarditis). Unlike other CNS, however, S. lugdunensis can cause severe disease reminiscent of the virulent infections frequently attributable to S. aureus. S. lugdunensis endocarditis is an aggressive infection that affects native valves with greater frequency than prosthetic valves in contrast to other CNS. S. lugdunensis native valve endocarditis is typically community acquired and is associated with a high rate of complications and death.
Complaint rebuttal and discussion
The only defense that Dr. Hospitalist offered was that he relied on his subspecialty consultant. Dr. Hospitalist argued that he was a generalist and not an expert in endocarditis or CNS. As a result, he followed the recommendations of the ID consultant and he further argued that he had the right to do so.
The plaintiff countered essentially countered with "Would you jump off the roof of a building just because someone told you to?" argument. In this case, the positive blood cultures, the history of aortic valve repair, and the suggestive echocardiogram were indisputable facts. Discovery in this case confirmed that Dr. Hospitalist never spoke with the ID consultant at any point during the first hospital stay.
Plaintiff experts argued that Dr. Hospitalist was a board-certified internist practicing hospital-based internal medicine and as such, he had or should have had the requisite knowledge, skills, and attitudes to evaluate, diagnose, and treat endocarditis. In this case, it appeared that Dr. Hospitalist "blindly" followed the recommendations of the ID consultant without considering all the evidence at hand. Plaintiff experts argued that in this situation, the standard of care required that Dr. Hospitalist question the plan of care outlined by his consultant. Had he done so, it is likely that both Dr. Hospitalist and the infectious disease consultant would have learned that the original blood cultures grew S. lugdunensis and antibiotics would never have been discontinued.
Conclusion
As the attending physicians of record, hospitalists carry the ultimate responsibility for the discharge decision. It is common to ask subspecialty consultants their opinion regarding stability for discharge and/or the need for ongoing hospital therapy. Yet, it is important for all hospitalists to remember that the consultant recommendations are just opinions that must be weighed against all the other evidence currently available. It is also helpful to have and document verbal discussions with consultants when discharge decisions are being made (and partially relied upon) with their subspecialty input.
The ID consultant in this case settled almost immediately with DB’s family. Dr. Hospitalist defended himself a little longer, but ultimately settled this case with the plaintiff for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.
Story
DB was a 20-year-old woman who presented to her primary care physician (PCP) with fever and myalgias. Her past medical history was significant for open heart surgery 3 years earlier for ventricular myxoma and aortic valve repair. Her temperature in the office was 39.1 C. Her examination was otherwise unremarkable. An influenza swab was negative. Cultures were drawn and DB was sent home with instructions to increase her fluids and use acetaminophen and ibuprofen as needed. Two days later, 2 out of 2 preliminary blood cultures were reported positive for coagulase-negative, gram positive cocci in clusters. DB was referred to the hospital where she was admitted by Dr. Hospitalist.
Dr. Hospitalist performed a history and physical and noted an impression of sepsis from subacute bacterial endocarditis. He initiated intravenous vancomycin and ceftriaxone, repeated blood cultures, ordered an echocardiogram, and obtained an infectious disease (ID) consult. On hospital day 2, the ID consultant documented that DB had positive blood cultures for coagulase-negative staphylococci but no true evidence of sepsis. She was noted to be afebrile with a normal white blood cell count. Although the echocardiogram was pending, the ID consultant recommended that intravenous antibiotics be discontinued and that she was safe to be discharged home with follow-up blood cultures in 1 week. Later that day, the echocardiogram found a thickened aortic valve with an increased density that suggested possible vegetation.
On the morning of hospital day 3, DB had a Tmax (time to maximum plasma concentration) of 38.8 C overnight. The repeat blood cultures drawn on admission showed no growth to date. Dr. Hospitalist stopped the intravenous antibiotics and discharged DB to home. Unknown to Dr. Hospitalist at the time, the original cultures drawn at the PCP’s office were finalized as Staphylococcus lugdunensis.
One week later, DB followed up with her PCP. She continued to have fevers, myalgias, and fatigue. Blood cultures were obtained and reported the following day as 2 out of 2 positive for S. lugdunensis. DB once again returned to the hospital and was started on intravenous antibiotics. Two days into her second hospital stay, DB complained of feeling hot. She sat up in the bed and then went unconscious. After almost 2 hours of resuscitation, DB was pronounced dead. An autopsy was performed and identified the cause of death as bacterial endocarditis (S. lugdunensis) with massive vegetations and aortic valve rupture.
Complaint
DB’s mother immediately brought a claim against Dr. Hospitalist and the ID consultant from the first hospital stay. The complaint alleged that DB was inappropriately discharged from the first hospitalization without ongoing intravenous antibiotic therapy. As a result, DB missed 8 days of antibiotic treatment allowing her untreated infection to irreversibly damage her heart. The complaint further alleged that this gap in treatment was the proximate cause of DB’s death.
Scientific principles
Staphylococcus lugdunensis is a coagulase-negative staphylococcus (CNS). Like other CNS, S. lugdunensis in humans ranges from a harmless skin commensal to a life-threatening pathogen (as with infective endocarditis). Unlike other CNS, however, S. lugdunensis can cause severe disease reminiscent of the virulent infections frequently attributable to S. aureus. S. lugdunensis endocarditis is an aggressive infection that affects native valves with greater frequency than prosthetic valves in contrast to other CNS. S. lugdunensis native valve endocarditis is typically community acquired and is associated with a high rate of complications and death.
Complaint rebuttal and discussion
The only defense that Dr. Hospitalist offered was that he relied on his subspecialty consultant. Dr. Hospitalist argued that he was a generalist and not an expert in endocarditis or CNS. As a result, he followed the recommendations of the ID consultant and he further argued that he had the right to do so.
The plaintiff countered essentially countered with "Would you jump off the roof of a building just because someone told you to?" argument. In this case, the positive blood cultures, the history of aortic valve repair, and the suggestive echocardiogram were indisputable facts. Discovery in this case confirmed that Dr. Hospitalist never spoke with the ID consultant at any point during the first hospital stay.
Plaintiff experts argued that Dr. Hospitalist was a board-certified internist practicing hospital-based internal medicine and as such, he had or should have had the requisite knowledge, skills, and attitudes to evaluate, diagnose, and treat endocarditis. In this case, it appeared that Dr. Hospitalist "blindly" followed the recommendations of the ID consultant without considering all the evidence at hand. Plaintiff experts argued that in this situation, the standard of care required that Dr. Hospitalist question the plan of care outlined by his consultant. Had he done so, it is likely that both Dr. Hospitalist and the infectious disease consultant would have learned that the original blood cultures grew S. lugdunensis and antibiotics would never have been discontinued.
Conclusion
As the attending physicians of record, hospitalists carry the ultimate responsibility for the discharge decision. It is common to ask subspecialty consultants their opinion regarding stability for discharge and/or the need for ongoing hospital therapy. Yet, it is important for all hospitalists to remember that the consultant recommendations are just opinions that must be weighed against all the other evidence currently available. It is also helpful to have and document verbal discussions with consultants when discharge decisions are being made (and partially relied upon) with their subspecialty input.
The ID consultant in this case settled almost immediately with DB’s family. Dr. Hospitalist defended himself a little longer, but ultimately settled this case with the plaintiff for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.
