Originally published December 2014
Hospital-acquired infections can make patients sicker, lengthen hospital stays, and even result in significant disability or death. Prevention is an important quality of care measure. Although healthcare facilities are responsible for enforcing infection control practices, it is the responsibility of all healthcare providers, including physicians, to follow the practices.
In a review of recent CMPA medico-legal cases (closed between 2008 and 2013) with a suspected or proven healthcare-associated infection in patients, the physicians most often involved were orthopaedic surgeons, general surgeons, and family physicians. The most common types of micro-organisms were Staphylococcus aureus — including methicillin-resistant (MRSA), Escherichia coli and Clostridium difficile (C. diff). The sources of infection included care that involved implanted devices, indwelling urinary and vascular catheters, and surgical wounds.
In two-thirds of the cases, the physician was felt to have met the requisite standard of care, but in some of the cases, peer experts noted that infection prevention and control is a responsibility of both the hospital and individual care providers.
The issues related to physicians' involvement included the assessment, management, and follow-up phases of the diagnostic process.
The most common problem in the cases was a deficient assessment, particularly when the patient showed symptoms and signs of infection. The physician often failed to order the necessary diagnostic tests (e.g. cultures) or imaging (e.g. ultrasound, CT scan). In a few cases, the physician did not consider the patient's increased risk of developing an infection because of co-morbid conditions (e.g. advanced age, diabetes, and immunosuppression), extended hospital stay, previous antibiotic therapy, or the presence of a C. diff hospital outbreak.
Case example: Ruling out infection
A 39-year old man undergoes an uneventful arthroscopic meniscectomy and debridement of the right knee. One week later, he presents to the emergency department (ED) complaining of increasing pain, swelling of the knee, and decreased mobility. The patient is afebrile with localized erythema and tenderness around one of the portal sites with some purulent drainage. The ED physician diagnoses infection and refers the patient back to his orthopaedic surgeon who does not feel there is an obvious infection and decides to observe the patient and re-assess him at the next scheduled appointment. The documentation of this visit is scant.
A few days later, the patient attends another ED and is referred to a general surgeon who drains and debrides an abscess near the portal site but does not think it communicates with the knee joint. At follow-up a week later the general surgeon suspects a deep infection and refers the patient back to his orthopaedic surgeon. Suspicious of septic arthritis, the orthopaedic surgeon debrides and irrigates the patient's knee. Cultures are positive for Staphylococcus aureus requiring six weeks of parenteral antibiotics. The patient subsequently undergoes a total knee replacement.
The patient initiates a legal action alleging the orthopaedic surgeon delayed investigating and treating the infection, which led to an earlier-than-planned joint replacement surgery. Experts are of the opinion that when the patient presented one week after surgery, the orthopaedic surgeon should have ordered bloodwork, aspirated the knee, and assessed the need for antibiotics. Experts also comment that the lack of documentation failed to demonstrate that appropriate steps were taken to rule out infection.
Without expert support, a settlement is paid to the patient by the CMPA on behalf of the orthopaedic surgeon.
Management and follow-up
In many cases of suspected infection, necessary cultures were not obtained, antibiotic administration was not initiated or delayed, or the choice of antibiotic was not appropriate. In a few cases, experts felt the patient should have been referred to an infectious disease specialist.
Case example: Prescribing the inappropriate antibiotic
Two days after undergoing a cystoscopy, a patient arrives in an ED with fever, chills, abdominal discomfort, dysuria, and urinary frequency. The patient is seen by the on-call urologist and diagnosed with post-cystoscopy urosepsis. IV antibiotics are prescribed and the patient is referred back to his treating urologist.
The next day, the treating urologist does a limited assessment of the patient noting that the patient had no fever and no pain, diagnoses a lower urinary tract infection, and discharges him with a prescription for nitrofurantoin. The patient calls the urologist's office the next day because he is still feeling unwell, and an appointment is given for three days later. The patient attends another hospital and is admitted with urosepsis. His urine cultures grow Pseudomonas aeruginosa, and he is treated with an aminoglycoside and a carbapenem.
The patient complains to the College and alleges the urologist prematurely discharged him. The College expresses concern about the physician's choice of antibiotic, incomplete assessment prior to discharge, and lack of definite follow-up.
System problems were related to hospitals' inadequate processes in managing C. diff outbreaks and hospitals not adequately informing its personnel, as illustrated in the following case.
Case example: Communicating a hospital outbreak
A 46-year-old woman, who is obese, diabetic, and a smoker, is referred to a general surgeon for recurrent diverticulitis. The patient refuses surgery and is treated with multiple courses of antibiotics. A year later, the patient consents to surgery, and the surgeon extensively documents a consent discussion. The patient undergoes a laparoscopic sigmoidectomy. Four days later, she develops an acute C. difficile infection and requires ICU admission. It is thought that the patient is colonized with C. diff because of repeated use of antibiotics prior to surgery. The patient's condition deteriorates, and she is diagnosed with pseudomembranous colitis requiring a subtotal colectomy with ileostomy.
A legal action ensues and the patient alleges the consent discussion did not include information regarding C. diff infection, and the surgeon failed to adequately prevent and manage the infection. During the course of the action, the hospital acknowledges that there was a C. diff outbreak at the time of the patient's first surgery. An expert surgeon is supportive of the surgeon's care and consent discussion, but notes some communication challenges and lapses in documentation. He adds that the hospital had given no instructions to avoid surgeries due to a C. diff outbreak.
The legal action is dismissed against the surgeon, and a settlement is paid to the patient by the hospital.
Risk management considerations
Based on the expert opinions in the cases reviewed, you should consider the following risk reduction strategies in your practice:
Consider if patients' comorbidities increase their risk of acquiring an in-hospital infection, and if so, be alert to any symptoms and signs of infection.
Adhere to recommended hand hygiene practices.
If appropriate, obtain relevant cultures when an infection is present or suspected before initiating antibiotic therapy. When available, review sensitivity and resistance results.
Consider assessing patients when notified of a change in their condition by the patient, the nursing staff, office employees, or when seen by other healthcare providers following discharge.
Consult an infectious disease specialist when treatment is ineffective or in a complicated infectious process.
Ensure effective communication with patients and families, advising on signs and symptoms that may indicate a complication is setting in, and how and when to seek further medical care.
Have a clear understanding of how your institution defines and contains an outbreak of a communicable disease and how that information is communicated to patients, staff, and the community.