A 40-year-old female was referred by her new PCP to the local Emergency Department with complaints of fever, severe headache for six days, myalgias, and joint pain. In the ED, she also reported that she had had recent episodes of fainting in the shower and nausea. Her initial evaluation revealed a temperature of 103, blood pressure of 135/77, heart rate of 128, and respiratory rate of 20. A CT scan of her head was normal; a lumbar puncture was negative; and she was not pregnant. The patient had two blood cultures drawn, and was treated with a single dose of IV antibiotics.

Because her providers believed her that her symptoms were improving, she was discharged with instructions to follow-up with her PCP within a week.

Two days later, a Thursday, her blood cultures came back positive for Group B streptococcus. The results were received by the ED physician on duty, who had not been her treating physician during her visit. Per hospital policy, a dedicated LPN in the ED followed up on abnormal test results. The LPN tried to reach the patient that afternoon, and left a message to call the hospital.

The following morning (Friday), the ED tried again, and was also unsuccessful at reaching the patient. (The phone number the patient gave during triage was for her husband’s workplace). The staff nurse told the ED physician that she was still unable to reach the patient. No other attempts were made over the weekend, as the doctor felt the patient should be fine with the one dose of IV antibiotics she received during her first ED visit. Additionally, the patient’s chart included no documentation of the identity of the PCP, who had initially called the ED to let them know that she was coming in.

On Monday, the patient returned to the ED with chills and a fever of 103. Her white blood cell count was 12.1, and a chest x-ray was negative, as was an initial echocardiogram at the bedside. Her positive blood culture results were obtained, and the patient was admitted for IV antibiotics. The patient was diagnosed with bacterial endocarditis, which was confirmed by a transesophageal echocardiogram with vegetation noted on the aortic valve. The patient experienced some complications of supraventricular tachycardia during her stay. She was discharged 15 days later, and remained on IV antibiotics for five weeks.

A month and a half later, the patient was admitted with a left thalamic stroke, which resolved with no residual side effects. The patient is currently healthy, but will most likely require an aortic valve replacement in the future.

Clinical Perspective

1. The patient’s abnormal blood cultures came back after the patient was discharged, and were not communicated to the patient in time, despite repeated attempts.
   Every ED needs a mechanism to ensure that the loop has been closed for all abnormal results that return after the patient has been discharged. Abnormal results with serious implications require more determined follow-up to ensure that the patient receives the appropriate care in a timely manner. ED policies should address an appropriate number of attempts to contact a patient and what to do if those attempts are unsuccessful. If the case poses an immediate threat to the patient, the police might be utilized. Not closing the loop on significant results puts the patient, the ED, and the clinicians who treated the patient at risk.

Patient Perspective

1. The patient gave the hospital her husband’s workplace phone number for emergency contact.
   With so much paperwork and so many forms for patients to fill out, some of the information can become perfunctory; however, personnel need to view an emergency contact number as a vital piece of information upon intake. A moment to explain to every patient why the ED may need a contact number (including to convey test results post-discharge), not only saves time later, but can mean the difference between effective care and disaster.

Risk Management Perspective

1. The patient was seeing a new PCP for the first time, and consequently there was no PCP listed in the patient’s record; however, the PCP called the ED ahead of her visit, to alert the department of her arrival.
   PCPs can be helpful locating the patient when abnormal lab values need to be communicated. The ED needs to ensure a reliable system for vital communications between the ED and the PCP. Proper training of personnel who are responsible for locating patients and their physicians might include looking beyond the most likely source of this information if the health threat warrants an intensified search.
2. The LPN was responsible for deciding which values were abnormal and which required additional follow-up.
   Use of physician extenders is becoming more standard practice. It is important to make sure every individual has the appropriate credentials and supervision to make the decisions necessary to perform the job effectively. Routine evaluation of individual skill sets can be helpful to this end.

Legal Defense Perspective

1. Even though the physician who received the abnormal lab results had not seen the patient, she was held accountable for not transmitting the test results in a timely manner to the patient.
   Even if a subordinate is in the role of contacting a patient with abnormal test results, courts will consider whether the physician provided the appropriate supervision, including a more active role when the situation calls for increased vigilance.