Risk Management

Pressure for Early Discharge? Case History Points to Physician Liability

By Kimberly A. Neely, MD, PhD

[Argus, March, 1995]

Physicians treating patients who require IV medications may be pressured by hospital administrators to discharge patients at the earliest possible time and to continue IV therapy at home. Early discharge and home management expose the patient and the physician to new risks and responsibilities, as illustrated in the following case history.

Endophthalmitis Resulting From Foreign Body

A 20-year-old woman was mowing her lawn and suddenly felt a foreign body in her left eye. She saw an ophthalmologist the next morning because her left eyelid was swollen shut and the eye had become painful. Examination revealed visual acuity in the left eye of hand motions, a corneal ring infiltrate, no hypopyon, and dense vitritis preventing examination of the posterior segment. B-scan ultrasonography revealed the retina was flat. Computed tomographic studies of the orbits revealed a linear metallic foreign body approximately 11mm long in the left globe. The diagnosis was endophthalmitis secondary to intraocular foreign body.

The patient was referred to a university hospital the same day where a vitreous biopsy followed by intravitreal injection of antibiotics was performed immediately. Computed tomography was repeated to better localize the foreign body. Pars plana vitrectomy was performed utilizing a temporary keratoprosthesis with autograft. At vitrectomy, the retina was found to be white, necrotic, and indistinguishable from the purulent vitreous. The eye was retained, but no vision was salvaged. Vitreous cultures grew Bacillus cereus.

The patient remained in the hospital postoperatively for IV antibiotic therapy. The utilization review team raised the issue of outpatient therapy 24 hours later. The physician believed the patient did not have the intellectual capacity to administer the IV antibiotics at home and wrote this on the hospital chart.

The home IV therapy company that contracted with the hospital and the patient’s insurance company was asked to evaluate the patient. The nurse who did the evaluation concurred with the physician’s assessment but believed the patient’s mother and another family member could learn to safely administer the medications. The physician did not object and specified the dosages of medications and duration of therapy to be given at home. The patient was discharged approximately 36 hours after her vitrectomy. The family members were to administer the midnight doses, and a home IV therapy nurse was to see the patient the next morning.

Early the next morning, the company’s nurse called the physician, reporting that at midnight the family had given the patient four doses of each of three different antibiotics, one of which was gentamicin. The physician instructed the nurse to confiscate the remaining medications and to send the patient back to the hospital immediately. She was readmitted and continued to receive IV antibiotics except for gentamicin. Fortunately, the patient had sustained no renal toxicity or ototoxicity and was discharged several days later on oral antibiotics.

Risk Management Issues That May Arise

If pressured by hospital administrators to discharge the patient early, the physician should thoroughly document the conditions requiring continued hospitalization to help reassure the utilization review team that the patient should remain in the hospital for valid (and reimbursable) reasons. When faced with administrative pressures, the physician must exert his or her best medical judgment.

Inability to safely continue the patient’s treatments at home is a valid reason for continued hospitalization, at least until skilled home nursing assistance can be arranged. The physician may disagree with hospital administrators or the home IV therapy company regarding the ability of the patient or the family to administer home therapy. He or she should document the reasons in the chart and refuse to discharge the patient until alternative solutions such as skilled home nursing assistance can be arranged. The physician must consider what is best for the patient and not compromise the patient’s safety.

The physician should become familiar with the services offered by the home IV therapy company, its system of evaluating the patients’ and families’ abilities to safely administer IV medications, and the extent of patient support and surveillance offered.

In this case, the decision that family members could give the midnight doses of antibiotics on their own proved to be a mistake. The patient was exposed to possible hazards of renal toxicity or ototoxicity, and the physician, who bears ultimate legal responsibility for the treatment, was exposed to a significant malpractice risk.

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