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Illinois Risk Management Services

In Focus Cascading Impact of a Failed Referral

Illinois Risk Management Services 2

2020 Case Study – Facts of Case

• 20-year-old female presented to a local optometrist on June 24th with complaints of

peripheral vision issues in her left eye and 4

week history of temporary blackouts in the eye.

• The OD identified papilledema and he referred

the patient to a retina specialist due to

suspicion of a partially detached retina.

• The retina specialist saw the patient on the

following day and his exam findings were consistent with pseudotumor cerebri (PTC).

Pseudotumor cerebri (also known as idiopathic intracranial hypertension) means “false brain tumor”

because its symptoms are similar to those caused by brain tumors. It is a condition in which the

intracranial pressure increases, causing headaches and vision problems. If left untreated, it can

result in permanent deficits.


Facts of the Case (cont.)

• The retina specialist contacted a neuro-ophthalmologist, who agreed to see the patient.

The retina specialist walked the patient to that

office, which was next door to his own.

• A vision field test was performed in the office of

the neuro-ophthalmologist by an unknown staff

member but it was not reviewed by the neuro-ophthalmologist, who was in another office on

that date.

• The office manager informed the patient that her

insurance was not accepted by the office and

the mother declined further service.

IHA 9/23/2020

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• In later testimony, the office manager indicated she gave the mother the address and number of

a neuro-ophthalmology department at a nearby

tertiary care center and she assumed they planned on proceeding to that facility since they

took the written information given to them.

• The office manager also testified she notified the retina specialist that the patient was not

seen. The mother denied being given this option and the retina specialist denied any

further contact from the neuro-

ophthalmologist’s office.


What do you think?

Was this patient successfully referred from the retina specialist to a neuro-ophthalmologist?

YesNo

Unsure


Measures of a Successful Referral

• The patient’s needs are met within the necessary time frame

• The patient’s needs and preferences are

conveyed at the right time to the right people

• Patient is engaged in, but not solely responsible

for, the referral process

• Referring provider receives a report or other communication from the specialist

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Where did this referral go wrong?

A. The retina specialist B. The neuro-

ophthalmologist/office staff

C. The patientD. A, B, and C all contributed to

the referral not being completed as originally planned by the

retina specialist

What do you think?



• The mother contacted the PCP’s office the following morning, a Friday, and the patient was

worked in late that afternoon after the office

closed.

• The mother told the PCP her daughter had been

seen in the office of a retina specialist and

neuro-ophthalmologist on the previous day and they were instructed to obtain a referral for a

local specialist from the PCP. She also informed the physician of the diagnosis of pseudotumor

cerebri.



• The patient denied any change in vision since the previous day. Since it was after hours, the

PCP instructed staff to contact specialists in the

area first thing Monday morning.

• The patient was also instructed to go to the

nearest ED if her vision changed or worsened

before she saw a specialist.

IHA 9/23/2020

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• The office received a letter from the retina specialist on Monday, the 29th.

• This letter and the PCP’s office record were

faxed to a local neurologist, who agreed to see the patient based on her diagnosis. The

neurologist’s office attempted to contact the

patient and left a message on July 2nd.

• The mother called the PCP’s office on July 3rd

and reported swelling in her daughter’s eye. She was told to go to the nearest ED.



• The patient presented to Hospital A and informed the ED MD of the recent visit to the

retina specialist and the diagnosis of PTC.

• During the exam, the patient denied any injury to the eye or any change or loss of vision. A CT

of the brain did not show any acute abnormality.

• The patient was discharged with a diagnosis of left eye pain and instructed to follow up with her

PCP.

• An ED nurse attempted a courtesy call back to the patient on the next day without success.



• The family went on vacation on July 4th and their testimony was that the patient’s vision

changed during their time away.

• The mother contacted the neurologist’s office on July 6th and an appointment was made for

the 22nd.

• The mother called the PCP’s office on July 10th, the day after they arrived back home, and

reported the vision changes. According to the mother, she was told to take her daughter to the

ED in “a few hours.”

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• The patient presented to the ED at Hospital B several hours later and her condition was

assessed as emergent.

• She was transferred to a tertiary care center and diagnosed with fulminant PTC. A spinal tap was

attempted without success.

• Optic nerve fenestration was done on July 12th.

• Vision initially returned in both eyes but it

subsequently worsened and patient was

declared legally blind.


Summary of Course of Events

June 24 – Seen by local optometrist

June 25 – Seen by retina specialist and escorted to

office of neuro-ophthalmologist

June 26 – Seen by PCP for referral

June 29 – PCP received a letter from retina specialist

and office made attempts to find local

specialist

????? – Local neurologist agrees to see patient

Attempt was made to contact patient on

July 2nd

July 3 – PCP’s office contacted about eye swelling –

patient directed to go to the ED

Seen in ED at Hospital A that day


Summary of Course of Events (cont.)

July 4-July 9 – Patient went on family vacation

July 6 – Mother contacted neurologist’s office, appointment made for July 22

July 10 – PCP’s office notified of changes in vision – patient directed to go to ED

immediately

Presented to ED at Hospital B several hours later

Transferred to tertiary care center

July 12 – Optic nerve fenestration done but unsuccessful in restoring vision

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Lawsuits Filed

• For purposes of venue, the plaintiff’s attorney filed three Complaints:

• One against the retina specialist, the neuro-

ophthalmologist and their groups

• A second against the optometrist, the PCP, the

neurologist who accepted the referral, the ED

MD/group who saw the patient on July 3rd, and Hospital B

• A third against Hospital A where the patient was

seen in the ED on July 3rd


Allegations

• The initial allegation against all parties centered on the failure to treat PTC in a timely manner.

• After several amendments, the final allegations

against the physicians were:

• Failed to recognize that plaintiff’s condition

presented a medical emergency;

• Failed to appropriately obtain a timely consultation;

• Failed to order or render timely treatment for

plaintiff’s condition; and

• Failed to obtain an adequate history


Allegations

• The Complaint against Hospital A was amended to add allegations related to proper

implementation of the call-back program and

those of apparent agency for the ED physician and actual agency for the PCP.

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Emergency Department Call-Backs

• P&P listed patients who were to receive two call-back

attempts – “eye injury” was

on the list

• RNs were to attempt, as time

allowed, a single “courtesy”

call-back for patient’s not on the P&P’s list


Would you define “eye injury” to include diseases involving the eye?

YesNo

What do you think?


Call-back P&P

• Indications for call-backs should be approved by hospital’s medical staff/ED committee

• ED providers should be aware of the call-back

policy, and indications for a call-back

• IPT/IRMS/MAIC should not be listed as

references on P&Ps

IHA 9/23/2020

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Damages

• Loss of Vision

• Medical Bills of ~$144,000

• Lifetime of Lost Wages


Strengths of the Case

• Experts were secured who strongly supported the care of the PCP.

• The plaintiff’s FP expert was weak and he made

concessions during his deposition that were helpful to the PCP.

• The ED MD secured experts in Emergency

Medicine and Ophthalmology that addressed standard of care and causation.


Strengths of the Case

Some of the testimony from the subsequent treating physicians at the tertiary care center was

helpful.

1. They would not expect a FP MD or ED MD to diagnose papilledema.

2. PTC is not necessarily an emergent condition.

3. Earlier intervention may not have changed the outcome.

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Weaknesses of the Case

• Perceived lack of continuity of care between retina specialist and neuro-ophthalmologist

• Contradiction in testimony by office manager

regarding vision field test

• Conflicting testimony about referral from neuro-

ophthalmologist’s office

• Emergent nature of patient’s condition not communicated to PCP


Weaknesses of the Case

• The documentation by the ED MD at Hospital A was very sparse given the gravity of the known

diagnosis.

• Neuro-ophthalmology reviewer retained on behalf of PCP was critical of the ED physician’s

failure to understand the emergent nature of the

condition.

• ED MD was alleged to be the apparent agent of

the hospital.

• Expertise of plaintiff’s attorney


Demand

• The plaintiff’s attorney made a policy demand to all named defendants.

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What do you think the overall value of this case is?

$0

$10,000 - $99,999

$100,000 - $500,000

$501,000 - $999,999

$1,000,000 - $4,999,999

$5,000,000 - $10,000,000

Over $10,000,000

What do you think?


From the perspective of the hospital, would you recommend:

A. Defend

B. Attempt to settle

From the perspective of the PCP, would you recommend:

A. Defend

B. Attempt to settle

What do you think?


What do you think is the more likely verdict for the:

What do you think?

Verdict

Retina Specialist Guilty Not Guilty

Neuro-Ophthalmologist Guilty Not Guilty

PCP Guilty Not Guilty

Local Neurologist Guilty Not Guilty

ED/MD Group Guilty Not Guilty

Hospital A Guilty Not Guilty

IHA 9/23/2020

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Apparent Agency

• Best: Separate Form

• Good: Separate Paragraph

• Larger font &/or bolding

• Paragraph titled “Notice of Independent Practitioners”

• Line to initial or sign immediately after paragraph

• Rename General Consent Form: “ … and Independent

Contractor Disclosure”


Is your hospital’s independent contractor language on a separate form for the patient to acknowledge

and sign?

Yes

No

In the process

Not sure/Don’t know

What do you think?


Apparent Agency

E-Sigs:

• Patient is consistently provided the form to read

• I acknowledge that any questions about the Independent

Contractor disclosure form and the important information

contained in it have been answered to my satisfaction.

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Apparent Agency

• Signage

• Professional buildings

• Exterior and interior signage issues

• Web sites

• Advertising

• Lab coats, name badges, etc.

Williams v. Tissier

https://cases.justia.com/illinois/court-of-appeals-fifth-appellate-district/2019-5-18-0046.pdf?ts=1576782541


Questions

https://cases.justia.com/illinois/court-of-appeals-fifth-appellate-district/2019-5-18-0046.pdf?ts=1576782541

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