Risk Management

Delayed Consultation Referral of Managed Care Patient with Endogenous Endophthalmitis

Digest, Spring, 1996

ALLEGATION  Failure to respond in a timely manner to a referral request, resulting in delayed diagnosis and treatment of endogenous endophthalmitis.

DISPOSITION  Case settled on behalf of all codefendants.

Case Summary

The patient, a 75-year-old male with a medical history of recurrent urinary tract infections, had been receiving ophthalmic care from the insured for several years. On May 4, the patient called the insured’s office complaining of discomfort, blurred vision, and floaters OS. An appointment was scheduled for May 6; in the meantime, however, the patient was admitted to the hospital by his primary care physician for inpatient treatment of bacteremia and urosepsis after a blood culture revealed the presence of E. Coli. Family members called to cancel the appointment with the ophthalmologist.

During the hospital admission, the patient continued to complain of pain, redness, and blurred vision in the left eye, prompting the primary care physician (a non-ophthalmologist) to leave orders with the hospital nursing staff to request an ophthalmology consult from the insured. Unfortunately, when the hospital nurse called the insured’s office on May 7, she was told that the ophthalmologist would be out of town until May 10 and that the ophthalmologist on call during his absence was not a participating physician of the patient’s managed care plan. This fact was documented in the hospital chart. The primary care physician gave no additional orders for another ophthalmologist to be contacted until May 10 when family members complained to the nursing staff that the patient still had not been evaluated by an ophthalmologist. After examining the patient, the primary care physician documented his impression as “conjunctivitis, rule out other causes.” He ordered Tobradex eye drops every three hours and an eye patch. He also left orders for the nursing staff to again contact the insured’s office for a consultation, which they did.

The following afternoon, the primary care physician saw the patient again and, concerned about the persistent nature of the swelling and redness of the left eye, ordered a culture and sensitivity of drainage from the patient’s eye. Although he was aware the patient still had not been seen by the ophthalmologist, he took no other action regarding the consultation request until May 12 when he left orders for the nursing staff to again contact the insured and request that he see the patient that day. A nurse called the insured’s office for the third time on May 12 and communicated that the patient was to be seen for conjunctivitis. Based on this diagnosis, the insured believed an emergency examination was unnecessary. He told the nurse he would be in to see the patient the next day.

Due to a lack of ophthalmic equipment at the hospital, the insured had the patient brought to his office for an examination on May 13. He noted a red painful eye with an IOP of 53 and visual acuity of light perception. An ultrasound revealed endophthalmitis. The insured then personally called a retinal specialist to make an emergency referral. The retinal specialist diagnosed endogenous endophthalmitis secondary to E. Coli sepsis. The patient underwent a vitrectomy and IV antibiotics regime. Unfortunately, he went on to develop a retinal detachment and never recovered vision in his left eye.

Analysis

Failure to communicate to the ophthalmologist the urgency of the referral delayed the diagnosis and treatment of this patient. The prognosis for this condition is poor even when an early diagnosis is made; however, in the minds of jurors, causation arguments often pale in comparison to a plaintiff’s allegations of careless communication and neglect. In this era of managed care, the public frequently perceives medical care as an impersonal, numbers-oriented proposition, and that perception can engender great sympathy for a plaintiff who appears to have “fallen through the cracks.”

That family members went to hospital staff on several occasions to voice their concern about the patient’s vision problems and their dissatifaction that the patient had not been seen by an ophthalmologist led medical experts, defense attorneys, and claims professionals who evaluated this case to agree that the plaintiff could successfully portray himself and his family as pleading for treatment that came too late. It also became clear during depositions that despite their best efforts to avoid finger pointing, the codefendants each blamed the other for the miscommunication and delays. Both situations can be disastrous during a trial.

After assessing the defensibility problems involved in this case, the parties pursued mediation, a form of alternative dispute resolution that resolved the case earlier and at lower cost that would have been likely had this been tried

Risk Management Principles and Commentary

In a managed care environment, referral issues can become a major area of risk exposure. If the on call physician covering for the insured had been a provider under the patient’s plan, the consultation process probably would have proceeded without delay. One of the reasons the primary care physician said he decided to wait for the insured to return was because he was familiar with the insured and not with the other ophthalmologists in the plan. Establishing reciprocal on call relationships with other ophthalmologists who participate in the same managed care plans may help avoid scenarios like this one.

Some of the miscommunication in this case also could have been avoided had the insured ophthalmologist insisted on more information concerning the patient’s condition and the urgency of the referral. At no point in this case did the referring physician and the consultant ophthalmologist communicate directly; instead they relied on a hospital nurse to relay messages. More direct communication between the physicians in this case would have clarified how concerned the primary care physician actually was about the patient’s eye and probably would have resulted in the patient being seen earlier by the ophthalmologist.