Setting the Scene
In this case, the patient underwent knee replacement surgery but was readmitted 12 days later with the wound from the operation not healing sufficiently. The patient was seen by the rehabilitation team and was prescribed antibiotics for a course of several weeks but did not document the reason and it was unclear whether they had viewed the wound or not.
A further 12 days later, the resident rehabilitation physician wrote up a report stating a severe valgus deformity (a condition where the knees are forced outwards which makes walking very difficult). Following a scan, it was shown that the patient had a fracture of the femoral condyle (the ball shaped bone in the knee joint).
The patient underwent surgery for an adjustment of the knee replacement. 3 days later there was considerable discharge from the wound and a swab revealed the infection MRSA (a serious bacterial infection which is resistant to most antibiotics and requires treatment with specialised antibiotics).
The patient was not referred back to the surgical team nor was an infectious diseases specialist consulted. The surgeon was called, and recommended IV antibiotics, but did not offer to take the patient back for acute assessment and treatment, or suggest or organise infectious disease consultation, and the rehabilitation team did not question this plan. The rehabilitation physicians continued to treat this acute and serious infection alone for a further 4 weeks but the wound continued to deteriorate. The antibiotic was later found to be inappropriate for this patient. Finally, unfortunately above knee amputation was advised and actioned.
Main Learning Points
The rehabilitation team were working outside their remit when the wound was found to be healing unsatisfactorily and in particular, when MRSA was encountered. They failed to consult an infectious diseases specialist or transfer the patient back to an acute setting. Even though the surgeon was consulted by phone, the advice was not appropriate, and the doctor under which the patient was admitted remains responsible for the management, regardless of phone advice.
By not transferring the patient back to the surgical team and not including an infectious diseases specialist in the care management when it was clear the wound was abnormal, they put the patient at risk of a very serious outcome; partial amputation of the limb.
The physician’s notes were inadequate. They did not clearly state whether they had personally viewed the wound or were making decisions based on the nursing notes regarding the wound and the dressings required.
Where there is inappropriate advice from an acute team, and a rehabilitation team is asked to practise outside their scope, it remains their responsibility to seek appropriate care, such as by insisting on a transfer, consulting additional disciplines or seeking a second opinion, none of which were done in this case.
- There appeared to be little communication between the different departments and the rehabilitation team continued to manage the care plan remotely, which was outside their area of expertise, particularly when MRSA was detected.
Reducing the Risk of Litigation
By not consulting the relevant specialist (infectious diseases) when it was apparent the wound issues were significant and ongoing, the rehabilitation team put themselves at an enhanced risk of litigation. TMLEP recommends the following:
A rehabilitation department’s remit is for standard or unremarkable rehabilitation following surgery or other treatment, but not for cases when healing is abnormal, or the patient has complications. In this case, wide consultation and often transfer back to acute settings, is required.
Infectious diseases specialists should always be consulted when serious infections such as MRSA have been detected.
Departments need to communicate when a patient appears to be not improving satisfactorily or where there are complications. Surgical input in this case may have enhanced the care management plan.
- Surgical teams should not expect patients with acute issues to remain in the rehabilitation setting, but should be available to re-admit the patient or at a minimum, review in person.
By managing a complex case remotely, the rehabilitation team were practising outside their scope of practice and they should have consulted more widely a relevant specialist, and not accepted phone management by the surgical team. The patient was kept in the rehabilitation setting for too long and should have been referred back to an acute setting after only a couple of days at most. The expertise in the acute setting would have been far more suitable for the complexity of this case. In addition, the frequency and completeness of documentation by the doctors should have been more thorough for such a complex and ongoing case.