Scientific principles
Diabetic foot infections are associated with substantial morbidity and mortality. Important risk factors for development of diabetic foot infections include neuropathy, peripheral vascular disease, and poor glycemic control. Most diabetic foot infections are polymicrobial, but MRSA is a common pathogen. Although severe diabetic foot infections warrant hospitalization for urgent surgical consultation, antimicrobial administration, and medical stabilization, most mild infections and many moderate infections can be managed in the outpatient setting with close follow-up.
The possibility of osteomyelitis should be considered in diabetic patients with foot wounds associated with signs of infection in the deeper soft tissues and in patients with chronic ulcers. Many patients with confirmed osteomyelitis of the foot benefit from surgical resection.
Complaint rebuttal and discussion
Although Dr. Hospitalist had a negative bone scan result, he should have considered MRSA as a pathogen for KL despite a wound culture growing Klebsiella only. Most experts agreed, however, that it would be pure speculation as to what an MRI would have shown so early in KL’s course and ultimately, Dr. Hospitalist was defensible because KL did have appropriate follow-up just 48 hours after discharge. In fact, more than 21 days from original presentation to his amputation, KL only had 3 days off of intravenous vancomycin.
As a result, defense experts focused on the failure of KL to obtain debridement as the main reason for his injury. Dr. Hospitalist, the PCP and the ED providers at Hospital B, all documented KL’s refusal to allow debridement by a podiatrist other than his own. KL denied this allegation, but the chart was consistent in this regard.
Conclusion
In the era of patient-centered care, patient wishes and preferences are important to integrate into the overall care plan. But when a patient’s wishes and preferences delay or otherwise subvert optimal care, it is vital that the hospitalist document the circumstances in their entirety. Documentation should confirm that the patient has capacity for decision making and that care recommendation benefits, risks for not following said recommendations, and care recommendation alternatives have been fully reviewed.
It is also helpful to have such discussions witnessed by other providers (that is, the nurse) so that the documentation is corroborated. The PCP and Hospital B were dismissed from the case. Hospital A settled with the plaintiff by waiving all hospital charges from his original hospitalization.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.