Discharging a patient with that set of vital signs and confusion (apparently severe enough that he was refusing medical care and needed to be restrained to have the nasal swab) is definitely negligent. This patient definitely needed to be referred to the ER, preferably via ambulance. A sepsis alert with an initial dose of Ceftriaxone would have helped this man tremendously.
The lack of a sepsis alert is not the problem. (It's not unusual for patients with strep pharyngitis or pneumonia to present to UC with a HR of 90+ and a fever. It would be inappropriate to hit every one of these patients with ceftriaxone and ship them to the ED.) The problems here sound like premature closure and not recognizing the danger signs of altered mental status and inability to ambulate. I don't care what your vital signs are; AMS and can't walk are symptoms meriting an ED transfer from UC.
Excellent analysis. Patients need to be aware of the differences in the level of care they will receive from an Urgent Care clinic and a hospital's Emergency Department.
I understand that, but they still need to have a clue about when a longer wait and greater expense might be worth it. Unfortunately, the patient discussed here thought he had the flu. For that, Urgent Care would be more appropriate.
Old adage is that fever and AMS or other neurologic findings demands an LP. We don’t always follow this in practice because determining baseline is difficult. This case is a great reminder to be diligent in these settings.
That being said, a good portion of the patients on any single day in the ICU were at an urgent care a few days prior and left with a misdiagnosis.
Yep.... It's always a challenge because a lot of septic patients are altered, and if I have a confirmed UTI or pneumonia or septic foot, etc... the odds of finding meningitis are extremely low (although not impossible). A lot of gray area in some sepsis cases.
A previously healthy 48 old year man that is no longer able to get to into a wheelchair without help is absolutely not fit for discharge regardless of what the diagnosis would be. If the UC really was closing soon, I can see how the PA may be mis-incentivized to downplay the diagnosis rather than stay late waiting for EMS to be dispatched to take the patient to a real ED.
I wish I knew where this UC was. ED transfers are some of the easiest, fastest patients for me in the UC. Unless the UC was more remote, there's not much wait for EMS.
I teach outpatient, primary care pediatrics to medical, NP, and PA students and I tell every one of them that if they learn nothing else from their rotation from me they MUST take away three concepts…
PAY ATTENTION….to the patient, the history, the physical findings, etc.
THINK…before jumping to conclusions regarding the work-up, diagnosis, and disposition of the patient.
LEARN…to recognize when the patient is seriously ill and/or has a condition which is beyond your ability to treat them appropriately and get them to someone who can.
Sadly, none of that happened in this case…
Regardless of the many potential differential diagnoses and of later details or specifics of this patient’s illness, the single overriding error in this case is that his presentation in the UC clearly indicated that he needed to be transferred to a higher level of care rather than, as seems to have happened here, having the mindset that “he came to an urgent care instead of the ER so he must not be that sick and probably has something minor like the flu.” (As Med Mal Reviewer alluded to in his analysis). I, however, choose to believe that any morally and ethically competent medical practitioner who is faced with that determination would not allow the fact that they might have to wait beyond the end of their shift for an ambulance transport to affect their decision.
There are repeated mentions of bacterial endocarditis, yet there is nothing mentioned of any actual confirmation of that diagnosis via echocardiogram or other means. Was it ever actually proven or was it just presumed based on the infarct pattern on the MRI? If it was proven, did the patient have any underlying medical condition which made him at risk for this issue?
As to treating the patient with Tamiflu in the presence of a negative rapid flu test…I can’t argue with or disagree with that under the circumstances. In my city, the public health department recommends the use of anti-virals within the first 48 hours of a flu-like illness during times of influenza surges, even if testing is not performed or the rapid test is negative, the presumption being that the medications are safe and effective and that it is better to treat presumptive cases aggressively. The issue here is not the decision to prescribe Tamiflu, but the failure to recognize the severity of the patient’s illness.
Finally, in the pediatric world, there is a widespread awareness of the correlation between influenza A and catastrophic secondary bacterial pneumonias with both Group A strep and Staph aureus. A reminder such as Med Mal Reviewer presents in his point 5 is always useful and welcomed.
Yeah I'm very curious. I'm half tempted to see if I can track the foreman down on Facebook and interview him. I'm guessing they just wanted to make a statement about how bad they thought the care was.
Even if the clinical dx of Influenza was correct, it doesn’t matter. One reason why we evaluate patients with viral illnesses, particularly Influenza, is to consider secondary bacterial infection. We look out for patients who are sicker than expected. This patient was. BTW, the original inflammatory marker, CRP, was described over 80 years ago in the context of Influenza with secondary Strep pneumoniae. This case is also a good reminder of the “last hour problem”. In any industry, the end of a shift is higher risk for "operator error". At least in the ED, we can sign-out to someone. That process makes us a little smarter, actually, because we have to organize our thoughts to tell our colleague. Also, it reduces the incentive to rush to discharge. UC providers are stuck staying late if they have to arrange for a transfer.
Yep, the last hour issue hadn't dawned on me really... there's certainly pressure to get patients dispo'd to minimize sign out, but I know that I can always sign out. Totally agree in regards to superimposed bacterial infection. After reading the case I linked about GAS pneumonia after influenza, it kind of makes me want to do a strep swab on kids with flu. Not because they actually have a true strep infection (yet). But to figure out if they're a carrier and therefore at higher risk for developing GAS pneumonia. Treating GAS-carrier influenza+ patients is probably a lot of unnecessary antibiotics that have their own associated risks but it's pretty horrific diagnosis that might be preventable.
I know that influenza GAS case quite well. I reviewed it for the plaintiff and ultimately declined to be their expert witness. As for GAS, some of the old teachings are more repetition-based than evidence-based. Dogma dies fast when you see little kids with invasive GAS infections.
So was this patient previously healthy? Any comorbid conditions?
If this was someone who previously has no medical history and has to have assistance to transfer with a gait belt then there is definitely some accountability on the PA. I’m also sure that being so late in the day also contributed to this.
I’ve worked in places like this before and never will again for reasons like this. The difference risk is often too broad and there is NEVER enough time to do an actual work up. I def would’ve punted this guy to the ED
Was this a patient with significant comorbidities? given the profound illness it suggests so, which should have triggered further workup. As a (now retired) EP I hated the whole idea of Urgent Care, Minute Clinics and similar venues that "treat and street" based on limited data, particularly young, old, sick, and complaints like chest pain, dyspnea, belly pain, etc.
And how do you feel about treating the minor stuffy nose and sore throat? As a retired EP, you know that these types of things do present to the ED and are better seen at the urgent care or minute clinic. In this particular case, the PA was out of her element and should have without question referred the patient to the ED. Probably by ambulance.
agreed that the patient should have been referred to the ED! Altered with fever and a negative influenza swab, that's not a hard call. I rarely pushed back on UC providers who wanted to refer patients to the ED. Urgent Care is not an appropriate venue to work up sick people, manage potential life threats like anaphylaxis or chest pain, repair complex lacerations or treat very old or very young people.
A lot of those patients go to UC because the copays are lower. this is not a medical decision. and the vast majority of minor stuffy nose/sore throat do not need any medical treatment whatsoever.
I have worked with a number of highly skilled PAs and have zero negative to say about PA practice.
Remember that this is basically the same scenario that befell the late Jim Henson, diagnosed as "flu" when he actually had septicemia.
Wouldn't it have made sense to at least rule out pneumonia if the influenza came back negative? If the PA had gotten lab results, that would probably have set her on a different track, and we wouldn't be reading this case study.
I'm not a fan of UC either. At least in Fast Track, you can punt more complex and changed patient presentations to the other side. I would say that's been my experience. Or I could consult with my EP colleagues for reassurance.
Nothing more needs to be ruled in or out in urgent care for "AMS & can't walk"; they need to go to an ED by ambulance. Even if they had pneumonia, they can't go home like that. Not a lot of labs to draw in a typical UC... even the most well-appointed ones that I've worked at only have in-house CMP, Hgb, lipids.
20 million is outrageous. When these verdicts are handed down- how do they recoup the money? Seize all the PA’s assets and garnish her entire paycheck for life? If so she’ll literally wind up on the street. If someone was going to garnish my entire paycheck- that leaves me not even able to pay for food. I’d quit my job because it’s pointless to work in that situation
I kind of doubt they seize all her assets or garnish wages for the rest of her life but I'm not really sure exactly. I don't have any expertise about this but from what I'm told, they'll probably appeal and then try to negotiate a lower amount during the appeal. The PA could maybe also go after the insurance company with a "bad faith" claim and make them pay more than policy limits. A lot of complicated legal options from here...
It's a little unclear what the time course is at presentation (i.e. how long after onset did he present but given the Tamiflu prescription, hopefully <48 hours) but even with a flu diagnosis, I would think 5-7 days without *improvement* on Tamiflu is way too long of a window for return/follow up, no? 5 days is long enough to potentially have complete resolution without Tamiflu. *Improvement* in the disease course on Tamiflu should probably start to occur within 48 hours.
With bacterial meningitis, presenting to the ED 12 hours earlier in a case like this might actually have made a difference in the outcome, no?
In my opinion, the 5-7 day thing was probably just the standard template advice given to everyone. That's what most ERs auto-populate onto discharge instructions. When I'm really being a stickler about discharge instructions, I actually break this down into 2 distinct categories: (1) timeframe in which the patient should see an outpatient physician in follow-up - usually their PCP. Although I actually have no control over when their office gets them in. (2) ED return precautions - if things worsen, or if these specific new symptoms arise, or if any other new unexpected symptoms arise, then you should immediately return to the ED.
Earlier treatment with sepsis definitely improves outcome, meningitis is no exception!
And it was only 12 hours difference because the wife essentially went against the PA's instructions. Per the PA, she should have waited a few more days.
Discharging a patient with that set of vital signs and confusion (apparently severe enough that he was refusing medical care and needed to be restrained to have the nasal swab) is definitely negligent. This patient definitely needed to be referred to the ER, preferably via ambulance. A sepsis alert with an initial dose of Ceftriaxone would have helped this man tremendously.
Do urgent cares even have sepsis alerts?
The lack of a sepsis alert is not the problem. (It's not unusual for patients with strep pharyngitis or pneumonia to present to UC with a HR of 90+ and a fever. It would be inappropriate to hit every one of these patients with ceftriaxone and ship them to the ED.) The problems here sound like premature closure and not recognizing the danger signs of altered mental status and inability to ambulate. I don't care what your vital signs are; AMS and can't walk are symptoms meriting an ED transfer from UC.
Excellent analysis. Patients need to be aware of the differences in the level of care they will receive from an Urgent Care clinic and a hospital's Emergency Department.
most often the patients self-select to Urgent Care because of perceived shorter wait times and lower co-pays.
I understand that, but they still need to have a clue about when a longer wait and greater expense might be worth it. Unfortunately, the patient discussed here thought he had the flu. For that, Urgent Care would be more appropriate.
Old adage is that fever and AMS or other neurologic findings demands an LP. We don’t always follow this in practice because determining baseline is difficult. This case is a great reminder to be diligent in these settings.
That being said, a good portion of the patients on any single day in the ICU were at an urgent care a few days prior and left with a misdiagnosis.
Urgent care is tough work.
Yep.... It's always a challenge because a lot of septic patients are altered, and if I have a confirmed UTI or pneumonia or septic foot, etc... the odds of finding meningitis are extremely low (although not impossible). A lot of gray area in some sepsis cases.
Terrible case.
A previously healthy 48 old year man that is no longer able to get to into a wheelchair without help is absolutely not fit for discharge regardless of what the diagnosis would be. If the UC really was closing soon, I can see how the PA may be mis-incentivized to downplay the diagnosis rather than stay late waiting for EMS to be dispatched to take the patient to a real ED.
I wish I knew where this UC was. ED transfers are some of the easiest, fastest patients for me in the UC. Unless the UC was more remote, there's not much wait for EMS.
A tragic case…
Some comments…
I teach outpatient, primary care pediatrics to medical, NP, and PA students and I tell every one of them that if they learn nothing else from their rotation from me they MUST take away three concepts…
PAY ATTENTION….to the patient, the history, the physical findings, etc.
THINK…before jumping to conclusions regarding the work-up, diagnosis, and disposition of the patient.
LEARN…to recognize when the patient is seriously ill and/or has a condition which is beyond your ability to treat them appropriately and get them to someone who can.
Sadly, none of that happened in this case…
Regardless of the many potential differential diagnoses and of later details or specifics of this patient’s illness, the single overriding error in this case is that his presentation in the UC clearly indicated that he needed to be transferred to a higher level of care rather than, as seems to have happened here, having the mindset that “he came to an urgent care instead of the ER so he must not be that sick and probably has something minor like the flu.” (As Med Mal Reviewer alluded to in his analysis). I, however, choose to believe that any morally and ethically competent medical practitioner who is faced with that determination would not allow the fact that they might have to wait beyond the end of their shift for an ambulance transport to affect their decision.
There are repeated mentions of bacterial endocarditis, yet there is nothing mentioned of any actual confirmation of that diagnosis via echocardiogram or other means. Was it ever actually proven or was it just presumed based on the infarct pattern on the MRI? If it was proven, did the patient have any underlying medical condition which made him at risk for this issue?
As to treating the patient with Tamiflu in the presence of a negative rapid flu test…I can’t argue with or disagree with that under the circumstances. In my city, the public health department recommends the use of anti-virals within the first 48 hours of a flu-like illness during times of influenza surges, even if testing is not performed or the rapid test is negative, the presumption being that the medications are safe and effective and that it is better to treat presumptive cases aggressively. The issue here is not the decision to prescribe Tamiflu, but the failure to recognize the severity of the patient’s illness.
Finally, in the pediatric world, there is a widespread awareness of the correlation between influenza A and catastrophic secondary bacterial pneumonias with both Group A strep and Staph aureus. A reminder such as Med Mal Reviewer presents in his point 5 is always useful and welcomed.
What "context" would need to be provided by the jury in association with the verdict? It's a minor detail but I'd love to know what they had in mind.
Yeah I'm very curious. I'm half tempted to see if I can track the foreman down on Facebook and interview him. I'm guessing they just wanted to make a statement about how bad they thought the care was.
Even if the clinical dx of Influenza was correct, it doesn’t matter. One reason why we evaluate patients with viral illnesses, particularly Influenza, is to consider secondary bacterial infection. We look out for patients who are sicker than expected. This patient was. BTW, the original inflammatory marker, CRP, was described over 80 years ago in the context of Influenza with secondary Strep pneumoniae. This case is also a good reminder of the “last hour problem”. In any industry, the end of a shift is higher risk for "operator error". At least in the ED, we can sign-out to someone. That process makes us a little smarter, actually, because we have to organize our thoughts to tell our colleague. Also, it reduces the incentive to rush to discharge. UC providers are stuck staying late if they have to arrange for a transfer.
Yep, the last hour issue hadn't dawned on me really... there's certainly pressure to get patients dispo'd to minimize sign out, but I know that I can always sign out. Totally agree in regards to superimposed bacterial infection. After reading the case I linked about GAS pneumonia after influenza, it kind of makes me want to do a strep swab on kids with flu. Not because they actually have a true strep infection (yet). But to figure out if they're a carrier and therefore at higher risk for developing GAS pneumonia. Treating GAS-carrier influenza+ patients is probably a lot of unnecessary antibiotics that have their own associated risks but it's pretty horrific diagnosis that might be preventable.
I know that influenza GAS case quite well. I reviewed it for the plaintiff and ultimately declined to be their expert witness. As for GAS, some of the old teachings are more repetition-based than evidence-based. Dogma dies fast when you see little kids with invasive GAS infections.
So was this patient previously healthy? Any comorbid conditions?
If this was someone who previously has no medical history and has to have assistance to transfer with a gait belt then there is definitely some accountability on the PA. I’m also sure that being so late in the day also contributed to this.
I’ve worked in places like this before and never will again for reasons like this. The difference risk is often too broad and there is NEVER enough time to do an actual work up. I def would’ve punted this guy to the ED
Unknown if he had any comorbid conditions.
Was this a patient with significant comorbidities? given the profound illness it suggests so, which should have triggered further workup. As a (now retired) EP I hated the whole idea of Urgent Care, Minute Clinics and similar venues that "treat and street" based on limited data, particularly young, old, sick, and complaints like chest pain, dyspnea, belly pain, etc.
It's fine 99.99% of the time. But the cases that define a career or a patient's life are not the standard cases.
And how do you feel about treating the minor stuffy nose and sore throat? As a retired EP, you know that these types of things do present to the ED and are better seen at the urgent care or minute clinic. In this particular case, the PA was out of her element and should have without question referred the patient to the ED. Probably by ambulance.
agreed that the patient should have been referred to the ED! Altered with fever and a negative influenza swab, that's not a hard call. I rarely pushed back on UC providers who wanted to refer patients to the ED. Urgent Care is not an appropriate venue to work up sick people, manage potential life threats like anaphylaxis or chest pain, repair complex lacerations or treat very old or very young people.
A lot of those patients go to UC because the copays are lower. this is not a medical decision. and the vast majority of minor stuffy nose/sore throat do not need any medical treatment whatsoever.
I have worked with a number of highly skilled PAs and have zero negative to say about PA practice.
Remember that this is basically the same scenario that befell the late Jim Henson, diagnosed as "flu" when he actually had septicemia.
Was this a case of Austrian’s triad?
I admit I had to google what that was... I think the odds are pretty high. Thanks for teaching me something!
Wouldn't it have made sense to at least rule out pneumonia if the influenza came back negative? If the PA had gotten lab results, that would probably have set her on a different track, and we wouldn't be reading this case study.
I'm not a fan of UC either. At least in Fast Track, you can punt more complex and changed patient presentations to the other side. I would say that's been my experience. Or I could consult with my EP colleagues for reassurance.
I think a lot of other things would have made sense after the negative flu, ruling out pneumonia with CXR would definitely be high on the list!
Nothing more needs to be ruled in or out in urgent care for "AMS & can't walk"; they need to go to an ED by ambulance. Even if they had pneumonia, they can't go home like that. Not a lot of labs to draw in a typical UC... even the most well-appointed ones that I've worked at only have in-house CMP, Hgb, lipids.
20 million is outrageous. When these verdicts are handed down- how do they recoup the money? Seize all the PA’s assets and garnish her entire paycheck for life? If so she’ll literally wind up on the street. If someone was going to garnish my entire paycheck- that leaves me not even able to pay for food. I’d quit my job because it’s pointless to work in that situation
I kind of doubt they seize all her assets or garnish wages for the rest of her life but I'm not really sure exactly. I don't have any expertise about this but from what I'm told, they'll probably appeal and then try to negotiate a lower amount during the appeal. The PA could maybe also go after the insurance company with a "bad faith" claim and make them pay more than policy limits. A lot of complicated legal options from here...
It's a little unclear what the time course is at presentation (i.e. how long after onset did he present but given the Tamiflu prescription, hopefully <48 hours) but even with a flu diagnosis, I would think 5-7 days without *improvement* on Tamiflu is way too long of a window for return/follow up, no? 5 days is long enough to potentially have complete resolution without Tamiflu. *Improvement* in the disease course on Tamiflu should probably start to occur within 48 hours.
With bacterial meningitis, presenting to the ED 12 hours earlier in a case like this might actually have made a difference in the outcome, no?
In my opinion, the 5-7 day thing was probably just the standard template advice given to everyone. That's what most ERs auto-populate onto discharge instructions. When I'm really being a stickler about discharge instructions, I actually break this down into 2 distinct categories: (1) timeframe in which the patient should see an outpatient physician in follow-up - usually their PCP. Although I actually have no control over when their office gets them in. (2) ED return precautions - if things worsen, or if these specific new symptoms arise, or if any other new unexpected symptoms arise, then you should immediately return to the ED.
Earlier treatment with sepsis definitely improves outcome, meningitis is no exception!
And it was only 12 hours difference because the wife essentially went against the PA's instructions. Per the PA, she should have waited a few more days.