Risk Management

Inadequate Hand-offs Between Physicians Delays Treatment of Endophthalmitis

By Ryan Bucsi, OMIC Senior Claims Associate

Digest, Spring 2006

ALLEGATION Failure to timely diagnose and treat endogenous endophthalmitis.

DISPOSITION Settled at mediation for $45,000. Primary care physician (PCP) and hospital contributed $25,000, OMIC insured con- tributed $15,000, and on-call physician for the PCP contributed $5,000. On- call ophthalmologist was not named in the lawsuit.

Case Summary

An elderly female patient telephoned the OMIC insured’s office complaining of blurred vision and floaters. The insured was out of town, so the patient was referred to the on-call ophthalmologist, who scheduled a same day appointment. The appointment was cancelled, however, because later that day, the patient was hospi- talized by the physician on-call for the patient’s primary care physician (PCP) for treatment of a systemic infection. Four days later, at the request of the PCP, the hospital contacted the OMIC insured’s office to request a consultation and was informed that he would not be returning to the office for two days. When the insured returned, he contacted the hospital and was told by a nurse that the patient had been diagnosed with conjunctivitis. The following morning, he went to the hospital for his sole examination of this patient. The patient’s left eye was red and painful with an intraocular pressure of 53 and visual acuity of light perception. A slit lamp exam revealed a 30% hypopyon with 4+ cells and flare in the remainder of the anterior chamber. There was no red reflex in the left eye with the ophthalmoscope on the highest setting. The B-scan displayed moderate debris in the vitreous with an attached retina. The insured diagnosed probable endogenous endophthalmitis secondary to E-coli and referred the patient to a retina specialist. The retinal specialist treated the patient in the hospital for two weeks, but after a total retinal detachment, the patient suffered complete loss of vision in the left eye.

Analysis

Multiple opportunities to intervene in a more timely manner in the infectious process were lost because of inadequate “hand-offs” between the attending physicians and their call partners. Instead of cancelling the scheduled office visit with the on-call ophthalmologist, the on-call PCP should have arranged an in-hospital consultation. The on-call ophthalmologist never informed the insured about the patient’s call, cancelled appointment, or hospital admission. Thus, when the insured did finally speak to the hospital nurse, he relied upon the diagnosis of conjunctivitis and did not clarify the patient’s symptoms or recognize the urgency of the situation.

Defense experts noted that a consulting physician should generally see the patient within a couple of days for a non-emergent consultation. They pointed out that the one day delay in treatment would not have improved the outcome of an E-coli infection. The defense was complicated, however, by the hospital consultation request, which identified the reason for the patient’s admission as bacteremia. Arguably, this diagnosis and a report of red eye should have alerted the insured to the possibility of endophthalmitis. The nurse was expected to testify on behalf of the hospital that the complaint of pain and poor vision was communicated to the insured. Given these troubling issues, mediation was arranged and the case was settled.

Risk Management Principles

Careful telephone screening of ophthalmic problems is perhaps the most effective patient safety and risk reduction measure ophthalmologists can take. Neither patients nor other health care providers can be relied upon to provide the information necessary to diagnose an eye condition over the phone. The ophthalmologist must, therefore, be proactive and “drive” the conversation, being sure to ask not only about ocular symptoms but also about the patient’s overall condition. OMIC has prepared sample contact forms that prompt ophthalmologists and their staff to ask about symptoms, prior surgery, medication use, and problems reported to other physicians, and to report contacts with other members of the health care team (see “ Telephone Screening of Ophthalmic Problems” at http:///www.omic.com/resources/risk_man/ recommend.cfm). Ophthalmologists going on or off call should conduct and document “hand-off” discussions and may want to devise an ophthalmic consultation form for referring physicians, including those in the emergency department, so they have the information necessary to determine the urgency of a consultation request.