The Verdict is In
Accreditation Statement Vituity is accredited by the California Medical Association (CMA) to provide continuing medical education for physicians.
Credit Designation Vituity designates the internet enduring activity for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure No one in a position to control the content of this educational activity have any relevant financial relationships with ineligible entities to disclose.

"Return if worse"

The Verdict Image

You know the feeling. That pit in your stomach when you start your shift and see a patient's name on the board whom you saw and discharged 1 or 2 days before. This time they have the admit flag next to their name. The discomfort rises from your gut and you’re afraid to look why they are there. You hope they're okay. You question if you missed something even though rationally you know your care and judgment was right on. Sometimes you can do everything right, but diseases progress, and patients get worse. That is the reality of medicine.

Is "return if worse" really enough? Despite how busy we may be, if the path leads to discharge we must sit down to explain the diagnosis, plan, specifics of return precautions, and ensure they verbalize comprehension.

A real story

A 60-year-old female with no significant PMH presented on a Friday to the ED with severe pelvic pain, nausea, vomiting, chills, and sweats. She denied a fever. Initial vitals and labs were normal. Urinalysis: Trace leukocyte esterase, negative nitrite, 2+ ketones, normal urobilinogen, trace blood, 0-2 wbc, 0-2 rbc's, 2-5 epithelials, and 2+ bacteria. CT: 4mm distal left ureteral stone at the UVJ. Severe proximal hydronephrosis. Soft tissue enhancement involving the adjacent bladder wall, maybe inflammation. Decreased excretion of the left kidney comparable to the right. Fluid on the left kidney.

The patient was given multiple doses of Dilaudid as well as Zofran, Toradol, Compazine, and Flomax. Five hours later, she seemed to be without pain and able to ambulate. The ED MD felt the patient was stable for discharge home to follow-up with the urologist and gave verbal precautions to return if her condition worsened. (The ED MD was likely not aware the discharge blood pressure was documented to be 88/41). The final diagnosis was left distal ureteral stone with hydronephrosis. The discharge printer was down so the ED MD hand wrote on an aftercare template sheet the instructions "Diagnosis: Left distal ureteral stone. Follow-up with Dr. XYZ in 3-4 days. Phone number: (was written in). Additional instructions: Strain the urine to see if the stone passes. Take Zofran if needed for nausea and Percocet if needed for pain. Take the Flomax once daily if you continue to have pain and don’t see the stone pass." The aftercare instructions template also had pre-printed in all capital letters (but small font): "IF YOUR CONDITION BECOMES WORSE, CALL YOUR REFERRAL DOCTOR IMMEDIATELY OR RETURN TO THE EMERGENCY DEPARTMENT." Verbal instructions and this paper were given to the patient and family.

The following day the patient was able to urinate. She had less pain but developed a fever of 101. She talked to family (one member was a nurse) and they decided to watch it. On Sunday the fever was 103, but her pain was again less than when she had been in the ED. They decided to call a friend who was a medical assistant for a urologist and this friend told them to make sure they follow-up on Monday with the urologist. On Monday morning the patient was weak, sustained several falls, and developed confusion. Husband called 911 and they returned to the ED where she was noted to be in septic shock secondary to ureteral obstruction. After an 11-day admission with several days on a ventilator, she was eventually discharged home requiring numerous additional months of PT.

A year later, the physician was served. The bounce-back pit in the stomach sensation now a punch in the gut. The allegation against the physician was negligence due to failure to warn the patient to seek immediate medical care if she developed fever and failure to provide written discharge instructions that warned of the same. The plaintiff claimed the sequalae from her septic event are confusion, memory loss, fatigue, neuropathy, vision changes, bladder issues, depression, and PTSD. The defense was facing a potential loss of $700K due to gaps in communication and documentation.

Learning points are in the questions below.

Survey Questions

1. Overuse of effective antibiotics leaves resistant bacteria, so judgment must be had when determining if your seemingly straight forward kidney stone patient should receive antibiotics. The fact of the matter is secondarily infected stones obstructing the urinary tract can be a life-threatening urologic emergency resulting in pyonephrosis, sepsis, and death. Therefore, you must always look for subtle signs of infection. Which of the following best practice suggestions will you use when seeing and treating kidney stone patients?

  1. Take a cognitive pause before discharging all patients with kidney stones
  2. Order a urine microscopic analysis on all stone patients. Understand pyuria >5 wbc/hpf is significant in the presence of an obstructing stone
  3. Do not discharge patients with persistent tachycardia, borderline hypotension, or fever
  4. Presume the worst if the patient has a leukocytosis and even mild pyuria. Assume this is infection, and not stress demargination and contamination
  5. If you discharge a patient with an obstructing stone, provide ample documentation you considered infection and why you think your patient does not have infection
  6. All the above

2. If you have any of the above reasons supporting or even suggesting infection

  1. Consult your on-call Urologist
  2. Perform a urine culture because a culture cannot be performed reliably later should the infection prove resistant to the prescribed antibiotic
  3. Both A and B

3. Discharge instructions may seem self-explanatory but can be subject to patient perception and interpretation. For example, an instruction to return if worse would depend on the patient’s perception of "if worse" means worse pain or new problems. Be specific. For example, "have your wound rechecked in 36 hours," "return if fever over 100.4," "return if vomiting," "return if increased swelling and new onset numbness or tingling."
True or false? When discharge instructions are clear and unambiguous, and when questions have been answered, it is reasonable for health care providers to assume that patients have understood the discharge instructions as written.

  1. True
  2. False

4. We can’t go back in time, but we can learn from the past in hopes of preventing a similar outcome in the future. If you experience a similar case in your practice, what can you do to minimize your risk?

  1. Address repeat abnormal vitals
  2. Document patient/family verbalized comprehension of the diagnosis, risk, and return precautions
  3. Timely post discharge call-backs
  4. Have the nurse do your discharge in lieu of you
  5. A, B, C