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SOUTHCOAST HOSPITALS GROUP 363 HIGHLAND AVENUE FALL RIVER, MA 02720 July 19, 2011
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on interviews, documentation review and a review of the interview information and the documentation by a Massachusetts Department of Pubic Health (MDPH) Physician Consultant it was determined signs and/or symptoms of postoperative infection were not recognized and addressed in 1 of 1 applicable surgical cases (Patient #1) in a sample of 10 surgical cases.

Findings included:

Medical record documentation indicated Patient #1 underwent a laparoscopic appendectomy for a ruptured appendix with peritonitis (inflammation/infection in the membrane that lines the abdominal cavity and covers the abdominal organs) without complications on the evening of 5/2/11. Patient #1 tolerated the procedure well and was transferred to the Post-Anesthesia Care Unit (PACU) in stable condition with a fever of 101.6 degrees. Postoperative Physician Orders included an order for intravenous (IV) Zosyn (an antibiotic) every 6 hours.

Surgeon #1 was interviewed in person at 11:00 AM on 7/18/11. She said Patient #1's appendix looked worse than expected and more like an appendix with appendicitis that had started 48 hours prior to presentation; not 24 hours prior to presentation.

Medical record documentation indicated Patient #1's postoperative course was complicated by intestinal muscle paralysis (postoperative ileus) and fever. The ileus and fever eventually resolved and Patient #1 was discharged home with Discharge Instructions on 5/7/11. The Discharge Instructions included instructions to call Surgeon #1 for fever over 101 degrees and to schedule an appointment with Surgeon #1 to occur in 7 days. Patient #1 was not discharged home on antibiotic therapy.

Surgeon #1 said Patient #1 did not need post-hospitalization antibiotic therapy because Patient #1 was afebrile (without a fever) and had a normal white blood cell (WBC) count of 10,700 (normal = 4,800-11,200; an elevated WBC count is indicative of inflammation/infection) on 5/3/11.

Surgeon #1 said Patient #1 called her about a week following discharge and reported not feeling well and having chills, but no fever. Surgeon #1 said Patient #1's symptoms seemed like typical postoperative symptoms and she relayed this to Patient #1.

Patient #1 was contacted by telephone at 1:55 PM on 7/14/11. Patient #1 indicated he/she was evaluated by Surgeon #1 in Surgeon #1's office on 5/16/11 and at that time; told Surgeon #1 he/she was having night sweats, intermittent fevers, and sharp pain in the right chest upon deep inspiration. Patient #1 indicated Surgeon #1 seemed unconcerned about the symptoms and said it would take time for all the junk in his/her belly to work itself out (of the body). Patient #1 also indicated that Surgeon #1 asked if she had prescribed post-hospitalization antibiotics and that he/she informed Surgeon #1 she had not.

Patient #1 indicated that 2 days following his/her office visit with Surgeon #1, the fevers increased and he/she was feeling worse, so he/she called Surgeon #1's Office. Patient #1 reported waiting all day for Surgeon #1 to call back and not receiving a call. Patient #1 said the next morning, he/she called Surgeon #1's Office again, and was told Surgeon #1 would be in the Office that afternoon, and would return the call. Patient #1 indicated that when afternoon came and he/she had not received a call from Surgeon #1; he/she called his/her Primary Care Physician (PCP) and told him of the situation. Patient #1 reported that the PCP advised him/her to wait for a return call and to call him if he/she did not get one.

Patient #1 reported receiving a call from Surgeon #1 less than half-an-hour after talking with his/her PCP. Patient #1 indicated that Surgeon #1 directed him/her to the Hospital's Emergency Department (ED) for a series of tests.

Surgeon #1 said Patient #1 and Patient #1's PCP called her Office on 5/19/11 and the PCP asked her to call Patient #1. Surgeon #1 reported calling Patient #1, hearing about Patient #1's symptoms, referring Patient #1 to the Hospital's ED and calling the ED to tell the staff about Patient #1's impending arrival, history and need for blood testing and CT scans.

A PreCall Referral Form within Patient #1's 5/19/11 ED medical record indicated Surgeon #1 contacted the ED at 1:40 PM and indicated Patient #1 had a perforated appendix/appendectomy on 5/3/11, currently had a fever of 102 degrees and needed to have blood and urine testing and abdominal and pelvic CT scans performed.

Documentation indicated Patient #1 presented to the ED at 2:18 PM on 5/19/11 with a fever of 99.5 and clean and dry incision lines. Patient #1 denied pain and/or urinary tract infection (UTI) symptoms. Blood was obtained for testing and Patient #1 was evaluated by ED Physician #2 at 4:00 PM. ED Physician #2 noted Patient #1's history, symptoms and WBC count of 10,000 and ordered a urinalysis and abdominal and pelvic CT scans with oral contrast. Patient #1 provided a urine sample and was administered the CT contrast prior to going to the CT scanner at 5:17 PM. The urinalysis revealed findings indicative of UTI and a urine culture (a laboratory test in which a urine sample is placed in a culture medium to detect microorganisms causing infection) was ordered. The CT scans revealed a small tubular collection of fluid measuring approximately 5 centimeters (cms)X1 cm in the area where the appendix had been and a very small (1X1.5 cms) fluid collection along the posterior aspect of the right lobe of the liver. ED Physician #2 diagnosed Patient #1 with UTI and ordered Macrobid (an antibiotic utilized to treat UTI). Patient #1 was administered a dose of Macrobid and discharged home with Discharge Instructions and a prescription for Macrobid at 6:28 PM. The Discharge Instructions included instructions to call the PCP and Surgeon #1 to schedule appointments to occur in 3-5 days and to return to the ED for pain or persistent fever.

Patient #1 said that ED staff called Surgeon #1 to verify what they were prescribing for him/her and that he/she waited in the ED for Surgeon #1's return call, but Surgeon #1 didn't call back, and the ED staff finally let him/her leave.

Surgeon #1 said she was expecting a call regarding Patient #1 from the ED and when she did not receive one; she called the ED. Surgeon #1 said she spoke with an ED physician (she could not recall which ED physician) and the physician indicated Patient #1 had already left the ED, his/her WBC count was normal, the CT scans showed fluid fairly consistent with normal postoperative findings, a urinalysis revealed findings indicative of UTI, and Patient #1 was started on an antibiotic.

Surgeon #1 reported calling Patient #1 after speaking with the ED physician and said she told Patient #1 to take the antibiotic; as prescribed, and to call her if he/she was not feeling better.

A Laboratory Report related to Patient #1's 5/19/11 urine culture indicated the culture revealed low colony counts of mixed microorganisms (usually not considered significant).

Patient #1 reported taking the antibiotic prescribed by ED Physician #2 for 5 days, feeling no better and calling his/her PCP. Patient #1 said the PCP called Surgeon #1's Office to get an update and was told Surgeon #1 was unavailable. Patient #1 said the PCP then suggested another surgeon (Surgeon #2) so that his/her condition could be addressed right away.

Surgeon #1 said Surgeon #2 was covering for her when Patient #1's PCP telephoned (on 5/26/11).

Medical record documentation indicated Patient #1 underwent abdominal and pelvic CT scans with contrast and had blood and urine testing performed on the afternoon of 5/26/11. The CT scans revealed collections of fluid posterior to the right lobe of the liver and along the right pericolic gutter (around/near the colon) without significant interval change in size since CT scanning performed on 5/19/11 consistent with abscess (a localized collection of pus) formation. The blood testing revealed a WBC count of 11,200 and the urinalysis revealed findings indicative of UTI.

Patient #1 said Surgeon #2 met him/her at the Hospital and discussed the CT scan findings and treatment options. Patient #1 indicated he/she opted for surgery and the operation was performed on 5/27/11.

Medical record documentation indicated Patient #1 was admitted to the Hospital and started on IV Zosyn on 5/26/11 and underwent a laparoscopic exploration with drainage of pelvic fluid collections and extraction of pelvic debris without complications on 5/27/11.

The Hospital's Risk Manager was interviewed throughout this On-Site Investigation. The Risk Manager said Patient #1's surgical care was scheduled to be reviewed by the Department of Surgery in September 2011.

Medical record and interview information were reviewed by a MDPH Physician Consultant. The Physician Consultant indicated:
1.) It may have been prudent to check Patient #1's WBC count sometime between 5/3 and 5/7/11 (but such a check was not absolutely indicated).
2.) The night sweats, intermittent fever and sharp right-sided chest pain upon deep inspiration reported by Patient #1 on 5/16/11 should have been a "red flag" for infection and should have triggered a diagnostic work-up for possible abdominal infection given Patient #1's history of ruptured appendix two weeks earlier.
3.) Patient #1's 5/19/11 CT findings should have raised the possibility of abdominal infection/abscess given his/her history of ruptured appendix and 5/16/11 report of night sweats, intermittent fever and sharp right-sided chest pain upon deep inspiration.
4.) The 5/19/11 CT Report was only descriptive and did not offer differential diagnoses to guide ED Physician #2 and/or Surgeon #1.