Arranging for Cover:  Make Sure Your System Works

It seems counter-intuitive that the more physicians involved in a patient’s care, the greater the chance of that patient going without proper attention. When coverage arrangements for a medical group and a surgeon break down, however, the result can be catastrophic.

A 74-year-old patient had been a long-time patient of Drs. C1 and C2, of a cardiology medical group. His history included mitral valve prolapse, some impaired ventricular diastolic function, and kidney stones.

Based on an ER visit resulting in a diagnosis of presumed cholecystitis secondary to gallstones and mild pancreatitis, Dr. C1 referred the patient to Dr. S for surgical management. Because of atrial fibrillation and pancreatitis, Dr. C1 hospitalized the patient for anticoagulation and supportive management.

When the patient’s condition came under control, Dr. S scheduled the patient for laparoscopic cholecystectomy with a cholangiogram. The abdominal exploration was uneventful save for some adhesions around the gallbladder and simple cysts on the liver. Dr. S performed the cholecystectomy without apparent complication, but the cholangiogram indicated no drainage into the duodenum. Dr. S presumed a small distal stone in the common bile duct and consulted with a gastroenterologist, who removed three stones in the patient that afternoon.

On the next post-operative day, a Friday, the gastroenterologist saw the patient in the morning. Meanwhile the patient’s heparin was managed since admission via telephone conversations with two physicians at the cardiac medical group, Drs. C2 and C3.

Dr. S saw that patient that Friday afternoon for complaints of severe pain. He became concerned over possible bile leakage or pancreatitis and ordered lab tests and an ultrasound. The ultrasound was completed early that evening, with the radiologist calling in to Dr. C1 (not Dr. S), presumably because Dr. C1 was the admitting physician. The radiologist’s differential diagnosis for some irregularity in the liver’s left lobe was edema versus laceration, versus contusion. Dr. C1, however, was not working the weekend and did not get the telephone report.

Dr. S did not again see the patient or review the ultrasound report because he also was not scheduled to work that weekend. As it turned out, neither did his cover, because the patient did not make it onto Dr. S’s informal patient list that he leaves at the hospital for his cover to check up on.

Meanwhile, Dr. C1 had arranged for his partner, Dr. C4, to cover for him by asking the office staff person to make such arrangements. Somehow, the patient did not make it onto Dr. C4’s notes and thus did not get a visit that Saturday.

In fact, the only orders made for that Saturday, were for anticoagulation management. Those, however, were generated by the pharmacy, pursuant to Dr. C2’s initial orders and protocol.

And so, over the two days following the ultrasound, no physician made rounds on the patient – even though the radiologist had suspected a laceration. Early Sunday afternoon, the patient began a generalized shaking, which the hospital’s acute-event physician considered not to be a neurovascular event. The nurses called Dr. S’s cover, who advised the nurses he would see the patient after completing surgery, but apparently forgot to do so.

The patient stabilized until around midnight Sunday, then became agitated, tried to get out of bed, coded, and died. A coroner’s report ascribed the cause of death as intra-abdominal hemorrhage, secondary to surface laceration of the liver’s left lobe.

Following the settlement of this case, the cardiology group revamped and simplified its coverage procedures. The surgeon also dropped his practice of having his cover learn of his patients’ names from a list left at the hospital.

Groups with multiple physicians having responsibility for hospitalized patients might do well to test their own systems against such a scenario.
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Gordon Ownby is CAP-MPT’s general counsel. Comments on Case of the Month may be directed to gownby@cap-mpt.com.