Delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA): that will be the case over which you are sued.
Over the last 15 years, I’ve served as an expert witness for six or seven malpractice cases. Most were related to spinal cord injuries, and in all but one of those, the etiology was epidural abscess. I’ve been asked to review about 40 or 50 additional cases, and while I’ve turned them down (I just don’t have time to do reviews), I nearly always ask about the clinical picture in every case. A significant number have been SEA-related. This experience has convinced me that SEA poses a particular liability risk for hospitalists.
Of course, it is patients who bear the real risk and unfortunate consequences of SEA. Being a defendant physician in a lawsuit is stressful, but it’s nothing compared to the distress of permanent loss of neurologic function. To prevent permanent sequelae, we need to maintain a very high index of suspicion to try to make a prompt diagnosis, and ensure immediate intervention once the diagnosis is made.
Data from Malpractice Insurers
I had the pleasure of getting to know a number of leaders at The Doctor’s Company, a large malpractice insurer that provides malpractice policies for all specialties, including a lot of hospitalists. From 2007 to 2011, they closed 28 SEA-related claims, for which they spent an average of $212,000 defending each one. Eleven of the 28 resulted in indemnity payments averaging $754,000 each (median was $455,000). These dollar amounts are roughly double what might be seen for all other claims and reflect only the payments made on behalf of the company’s insured doctors. The total award to each patient was likely much higher, because in most cases, several defendants (other doctors and a hospital) probably paid money to the patient.
The Physician Insurers Association of America (PIAA) “is the insurance industry trade association representing domestic and international medical professional liability insurance companies.” Their member malpractice insurance companies have the opportunity to report claims data that PIAA aggregates and makes available. Data from 2002 to 2011 showed 312 closed claims related to any diagnosis (not just SEA) for hospitalists, with an average indemnity payment of $272,553 (the highest hospitalist-related payment was $1.4 million). The most common allegations related to paid claims were 1) “errors in diagnosis,” 2) “failure/delay in referral or consultation,” and 3) “failure to supervise/monitor case.” Although only three of the 312 claims were related to “diseases of the spinal cord,” that was exceeded in frequency only by “diabetes.”
I think these numbers from the malpractice insurance industry support my concern that SEA is a high-risk area, but it doesn’t really support my anecdotal experience that SEA is clearly hospitalists’ highest-risk area. Maybe SEA is only one of several high-risk areas. Nevertheless, I’m going to stick to my sensationalist guns to get your attention.
Why Is Epidural Abscess a High Risk?
There likely are several reasons SEA is a treacherous liability problem. It can lead to devastating permanent disabling neurologic deficits in people who were previously healthy, and if the medical care was substandard, then significant financial compensation seems appropriate.
Delays in diagnosis of SEA are common. It can be a very sneaky illness that in the early stages is very easy to confuse with less-serious causes of back pain or fever. Even though I think about this particular diagnosis all the time, just last year I had a patient who reported an increase in his usual back pain. I felt reassured that he had no neurologic deficit or fever, and took the time to explain why there was no reason to repeat the spine MRI that had been done about two weeks prior to admission. But he was insistent that he have another MRI, and after a day or two I finally agreed to order it, assuring him it would not explain the cause of his pain. But it did. He had a significant SEA and went to emergency surgery. I was stunned, and profoundly relieved that he had no neurologic sequelae.
One of the remarkable things I’ve seen in the cases I’ve reviewed is that even when there is clear cause for concern, there is too often no action taken. In a number of cases, the nurses’ note indicates increasing back pain, loss of ability to stand, urinary retention, and other alarming signs. Yet the doctors either never learn of these issues, or they choose to attribute them to other causes.
Even when the diagnosis of SEA is clearly established, it is all too common for doctors caring for the patient not to act on this information. In several cases I reviewed, a radiologist had documented reporting the diagnosis to the hospitalist (and in one case the neurosurgeon as well), yet nothing was done for 12 hours or more. It is hard to imagine that establishing this diagnosis doesn’t reliably lead to an emergent response, but it doesn’t. (In some cases, nonsurgical management may be an option, but in these malpractices cases, there was just a failure to act on the diagnosis with any sort of plan.)
Practice Management Perspective
I usually discuss hospitalist practice operations in this space—things like work schedules and compensation. But attending to risk management is one component of effective practice operations, so I thought I’d raise the topic here. Obviously, there is a lot more to hospitalist risk management than one diagnosis, but a column on the whole universe of risk management would probably serve no purpose other than as a sleep aid. I hope that by focusing solely on SEA, there is some chance that you’ll remember it, and you’ll make sure that you disprove my first two sentences.
Lowering your risk of a malpractice lawsuit is valuable and worth spending time on. But far more important is that by keeping the diagnosis in mind, and ensuring that you act emergently when there is cause for concern, you might save someone from the devastating consequences of this disease.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at firstname.lastname@example.org.