Advanced Practice Provider Case Study: Inappropriate Follow Up of Symptoms

A 26-year-old patient presented to his primary care office after two emergency department visits for bloody diarrhea over a two-week period. The patient’s chart showed that he had lost nine pounds in two days between the first and second visit to the ED.

The patient underwent a colonoscopy, revealing severe colitis. His doctor also ordered CBC and IBD 7 serology studies; however, the patient only received the CBC study, which returned normal. The patient was prescribed Prednisone and antibiotics and instructed to return to the office in two weeks. After the colonoscopy, the patient asked his physician if he could possibly be suffering from AIDS.

He called the office four days later to report no appetite and pain with bowel movements. He spoke to a physician assistant (PA) who explained that the pathology report confirmed inflammatory bowel disease and ordered Prilosec. The following week, the patient called the office and again spoke to the PA, reporting dizziness, 22-pound weight loss, infrequent urination, and 4-5 bloody bowel movements per day. During this call, the PA advised the patient to drink fluids with electrolytes and “let the medicine work.” He called again three days later to report his symptoms had not improved, and once again the following day. During that final call, the PA ordered Mesalamine.

Two days following this final conversation with the PA, the patient collapsed at home and suffered cardiac arrest. Though he was resuscitated, he had a second cardiac arrest the following day and expired. The hospital reported a 40-pound weight loss since his first emergency department visit, and experts believed that the patient had undiagnosed AIDS and died from wasting syndrome.

What Went Wrong?

When the patient’s symptoms did not improve with the current treatment plan, the PA should have notified the supervising physician of the patient’s status to decide collaboratively how to proceed with care. This practice did not have the necessary guidelines to coordinate care between the PA and the physician to ensure appropriate input from all parties. In addition, the patient was not instructed to return to the office as his symptoms progressed and only spoke to his care provider over the phone. Had the physician been informed of the situation and the patient seen in person, there may have been an opportunity for the treatment plan to be reconsidered or additional testing completed.

Key Takeaways:

• Physicians must be responsible for managing the health care of patients.
• Physicians are ultimately responsible for coordinating and managing the care of patients and, with the appropriate input of the APP, ensuring the quality of healthcare provided to patients
• The role of the APP in the delivery of care should be defined through mutually agreed-upon guidelines that are developed by the physician and the APP and based. on the physician’s delegatory style.
• Physicians must be available for consultation with the APP at all times, either in person, through telecommunication systems, or via other means.
• The extent of the APP’s involvement in the assessment and implementation of treatment should depend on the complexity and acuity of the patient’s condition, as well as the training, experience, and preparation of the APP, as judged by the physician.
• Develop a policy that outlines when patients need to be evaluated in the office setting or via a telehealth visit.