Legal Review & Commentary
Improper credentialing of ED physician delays heart attack diagnosis: $3.1 million verdict
By Radha V. Bachman, Esq.
Trish Calhoun, JD, RN
Buchanan Ingersoll & Rooney PC
Tampa, FL
News: A man presented at an emergency department (ED) complaining of shortness of breath and chest pain. He was seen by an ED physician who ordered blood studies and an EKG. The tests were negative for heart attack or cardiac issues. Three hours after being admitted, the man again complained of tightness in his chest, but the hospital failed to perform any additional tests. The man was transferred to another hospital, where the physician diagnosed him with a myocardial infarction and he received treatment. Thirty months later, the man suffered an embolic stroke that resulted in speech complications, rendering him unable to work. The plaintiff sued the hospital, claiming that it did not properly verify the ED physician's qualifications and negligently allowed him to practice at the hospital.
Background: An otherwise healthy 37-year-old attorney presented at the ED of the defendant hospital with shortness of breath and intermittent chest pain. At the time the man arrived at the hospital, he admitted that the chest pain had temporarily subsided. The on-call ED physician examined the man and ordered blood studies and an EKG to check cardiac function. The testing came out negative, indicating no heart attack or cardiac problems at the time. Three hours later, the man began complaining of chest pain and tightness. However, no additional tests were performed. The patient was ultimately transferred to another hospital and examined by his personal physician, who ordered another EKG, which revealed an acute myocardial infarction. Upon receiving the results, however, the man remained in the ED for approximately 23 hours before being transferred to the intensive care unit. He did not receive a thrombolytic infusion for approximately 1½ hours after arriving at the hospital and did not see a cardiology consultant until 24 hours after his admission. The man also underwent an angioplasty and was soon well and able to return to work.
Approximately 2½ years later, the man suffered an embolic stroke, which caused significant speech deficits and forced him to stop working. The plaintiff sued the hospital and alleged that the delay in diagnosing and treating the myocardial infarction caused heart muscle scarring, resulting in the formation of clots in his heart that broke off, traveled from his carotid arteries to his brain, and caused the stroke. The man further alleged that the hospital had failed to adequately investigate the ED physician prior to credentialing him by performing primary source verification and that this failure contributed to the man's injuries. Specifically, the ED physician had noted on his application that he was board-certified when, in fact, he had failed the board certification examination on multiple occasions.
The hospital argued that the ED physician had not acted negligently in the care of the man, nor did it violate any standard of care in its credentialing process. The hospital further defended that the stroke over two years later was wholly unrelated to the heart attack and that the man had several risk factors for stroke, including hypercoagulability of his blood and significant atherosclerotic disease. A jury verdict in the amount of $800,000 was originally awarded to the plaintiff, but a new trial was later conducted on the issue of causation and damages. At the second trial, the jury returned a verdict of $3,186,047.
Interestingly, the man also sued the second hospital, but the plaintiff's attorney settled that case without the man's authorization. The plaintiff then pursued an action in court to reinstate the case against the second hospital.
What this means to you: The first thing that comes to mind when reading this set of facts is whether the hospital ED had protocols for treatment of chest pain. Many hospitals do - and if the hospital did have a protocol, and followed it - it is a very helpful and persuasive way to demonstrate to a jury that the treatment was appropriate. In this case, the jury essentially determined that the physician would have done something differently if the physician had been board-certified. If the issue of board certification could have been minimized (which is more likely had a protocol been in place), it would have decreased the likelihood that the hospital would have been held liable.
However, on the flip side, if the hospital failed to follow its own protocol, the physician must provide a competent and believable explanation as to why he or she deviated from standard procedure. Most physicians have very little problem providing such an explanation and can provide clinical evidence to support their actions. Nevertheless, it is important for hospital staff to note whenever a physician does not follow an accepted protocol. The most effective way to do this is to put the protocol orders on the chart, and then request that the physician delete or cross out those orders that he or she does not want implemented. This method illustrates to a third-party reviewer that the hospital staff were aware of the protocol and that the physician made a conscious decision to treat that particular patient differently. This approach is a perfectly acceptable option - since every patient is different - and the position is more defensible at trial.
Hospital staff should avoid making notes in the patient's chart that disparage the physician's decision regarding the protocol. For example, staff should refrain from making notations such as, "Doctor X refuses to follow AMI protocol." Unfortunately, nurses' notes frequently include similar comments.
Another lesson that can be learned from this scenario is that hospitals should consistently examine policies and actual practice patterns to make sure that patients receive care in a timely manner. The 1½-hour delay in receiving the thrombolytic infusion is troubling, as is the delay in being seen by a cardiologist. The 23-hour ED stay is unfortunately all too common and should not be a viable basis for a malpractice claim or plaintiff verdict - so long as the appropriate treatment was provided while the patient was being held in the ED. That does not mean that a potential plaintiff will not claim that it is a breach in the standard of care to have such an extended stay, but where the patient is held is much easier to defend than what treatment was not provided.
With regard to the hospital credentialing issue, hospitals should review their medical staff bylaws and identify those credentialing requirements that are necessary for extending privileges, support the mechanisms required to perform credentials review and enforce the requirements. Primary source verification mandates that the medical staff office make direct contact with the source of the specific credential provided in an application for privileges. Primary source verification is vital in credentialing matters, and the medical staff office should prepare and maintain documentation to confirm compliance with primary source verification requirements in the event credentialing issues arise. In this case, it appears that the initial investigation into the physician's credentials was not performed, and yet the application was approved, despite the fact that there was missing information related to his board certification. The facts in this case only allege a failure with regard to the board certification piece. If the hospital had failed to confirm compliance with more than one requirement or had failed to obtain proper primary source verification regarding training and past work experience, it is likely that the jury would have awarded the plaintiff a figure in excess of that which was awarded.
Reference
Cook County (IL) Circuit Court, Case No. 01L-14480.
A man presented at an emergency department (ED) complaining of shortness of breath and chest pain. He was seen by an ED physician who ordered blood studies and an EKG.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content