Claims Case Study: The Importance of Documenting Specialty Consult Request Follow-Up

During hospitalization, it is common for care providers to request consultations from specialty physicians. Given the volume of requests that physicians receive, some of these consultations can sometimes be delayed, making it particularly important for the requesting provider to follow up and track the consultation process through its fulfillment.

In this study, we review how a nephrologist’s failure to complete a hospitalist-requested consultation in a timely manner allegedly resulted in a patient’s death. However, in this case, the hospitalists in question followed hospital procedure and documented all follow-up contact with the specialist, ultimately protecting them against undue liability.

The Case

A 63-year-old female patient was admitted to the hospital on a Saturday morning with a diagnosis of vomiting, hyperkalemia, and acute renal failure. Labs were notable for a potassium of 6.2, BUN 78, creatinine 9.43, carbon dioxide 9, and anion gap 34.0, indicative of a serious metabolic acidosis.

Prior to the patient’s admission to her room, the admitting hospitalist wrote orders that included a nephrology consult for “severe acute renal injury with hyperkalemia.” Once the patient arrived in her assigned room, the accepting nurse followed up and attempted to contact the nephrologist and advise him of the new consult and diagnosis. The admitting hospitalist had developed a plan of care to include IV fluids with bicarbonate, anti-emetics, frequent laboratory monitoring, IV antibiotics, and expert consultation with nephrology.

Later that evening, the patient’s care was transferred to a second hospitalist. At around 10:30 p.m., the care nurse called the hospitalist to inform him of a critical lactic acid level of 22.2. She also informed him that the patient was hypotensive and that her level of consciousness had decreased. The decision was made to transfer the patient to the ICU, where additional lab testing was performed, including an arterial blood gas, revealing a pH of 6.63. At the hospitalist’s direction, the ICU nurse called the nephrologist once again and discussed the patient’s condition and laboratory values. Orders were received for changes in her IV fluids, and the nephrologist advised that he would see the patient in the morning. The patient continued to receive treatment from the second hospitalist (including the addition of IV vasopressors) throughout the night and into the early morning.

The nephrologist saw the patient the following morning at 9:00 a.m., and the nephrologist made the decision to place a dialysis catheter for continuous renal replacement therapy. Upon returning from interventional radiology, the patient became unresponsive and went into cardiorespiratory arrest. Resuscitation efforts were performed for one hour, but although her condition stabilized, the patient had suffered an irreversible anoxic brain injury. The family ultimately elected to withdraw support and the patient expired. Had the nephrologist become more intimately involved with patient care at an earlier stage, this adverse outcome may have been avoided through early intervention and treatment.

What Went Wrong?

Fortunately for the hospitalists in this case, all members of the care team kept diligent records of their calls to the nephrologist. This action protected them against undue liability during trial, when the nephrologist gave testimony that he never received any call or consultation about this patient. Since the patient’s care team followed all protocols, the defense team was able to present the nephrologist’s phone records, indicating the multiple times he was contacted, along with orders received during these interactions.

The attorneys representing the hospitalists secured multiple expert opinions that both hospitalists followed the hospital’s established procedures for requesting a consultation, that they provided appropriate care throughout the evening, and that despite multiple calls, the nephrologist did not make an effort to see the patient and did not (through an audit trail review) access her records prior to coming to the hospital the following morning.

Following the trial, a defense verdict was obtained in favor of the hospitalists. The co-defendant nephrologist received an adverse verdict of $10,000,000, which was later reduced to $2,205,000 to align with the cap on verdicts for the state in which this event occurred.

Key Takeaways

Physicians requesting consultations should:

• Know their institution’s policies and procedures for obtaining consultations
• Develop a plan of care that includes, but is not limited to, expert consultation
• Maintain treatment plans while awaiting further consultation or instructions from a specialist
• Continue to closely monitor patients while they await specialty consultations
• Maintain diligent records of requests and conversations with specialists

For further guidance on similar issues, Curi members are encouraged to reach out to our risk management experts at Curi Advisory by calling 800.662.7917.