Who should be held responsible?

[frosted_flake]

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Who do you think is responsible for this? Parents? Discharging physician?

Could be an interesting chat...

http://www.msn.com/en-us/news/us/th...-obamas-heart-just-died/ar-BBr2VHe?li=BBnb7Kz

 

[AvacadosAtLaw]

It doesn't seem like there is much to discuss. It's clearly the discharging physicians fault. The parents had told her doctors that she was recovering from an addiction so it should have been somewhere in her chart and the discharging physician missed it.

 

[mimelim]

Hard to say based on this news article. Feel free OP (or others to correct me if I'm wrong), but in summary:

Patient with a long history of substance abuse went in for surgery.
Family discussed with treatment team history of substance abuse before surgery.
Discharged home with PICC line in place and a script for 50 tabs of oxycodone.
Physician that discharged her home with script had no idea that she was a former substance abuser.

---------------------------------------------------------------

It is a bit odd that they put in a PICC line and discharged her post-op. What exactly were they planning to put through it? IV antibiotics? IV pain meds? It is strange. It isn't wrong to send a post-surgical patient home on narcotics, even if they are a former addict. It is certainly higher risk and certainly something that should be considered and acknowledged, but post-surgery you need pain control and while there are a lot of things you can do with non-opioids, many will still use them.

 

[MDProspect]

I don't see how it could be the parents' fault, she was a 30 year old, autonomous adult. They convinced her to go to rehab and she did. But I am curious though, is drug addiction listed in the patient's chart?

 

[frosted_flake]

Hard to say based on this news article. Feel free OP (or others to correct me if I'm wrong), but in summary:

Patient with a long history of substance abuse went in for surgery.
Family discussed with treatment team history of substance abuse before surgery.
Discharged home with PICC line in place and a script for 50 tabs of oxycodone.
Physician that discharged her home with script had no idea that she was a former substance abuser.

---------------------------------------------------------------

It is a bit odd that they put in a PICC line and discharged her post-op. What exactly were they planning to put through it? IV antibiotics? IV pain meds? It is strange. It isn't wrong to send a post-surgical patient home on narcotics, even if they are a former addict. It is certainly higher risk and certainly something that should be considered and acknowledged, but post-surgery you need pain control and while there are a lot of things you can do with non-opioids, many will still use them.

@mimelim that is what I gathered from the article. I also thought that the PICC line was strange.

I do think that perhaps the former addiction status (really former? it has been 6 months off of IV drug abuse) should have been somewhere in the discharge summary, but then would they have sent her home without a script for pain killers? People would be screaming and kicking then too.
I think the parents should have spoken up before leaving the hospital, and then been present to see her post-surgery care to completion (and then subsequently disposing of any remaining pain killers).

 

[frosted_flake]

I don't see how it could be the parents' fault, she was a 30 year old, autonomous adult. They convinced her to go to rehab and she did. But I am curious though, is drug addiction listed in the patient's chart?

At the hospital where I work (ED) there is no 'addiction designation' per se, it is more along the lines of 'this person comes in 5x/week asking for pain meds, keep an eye on them.
We have security watch the known IV drug abusers to make sure they don't run out with the IV.

 

[prettyNURSEtoMD]

Yeah, I would need to know the surgery, to determine the actual need of the PICC. Was she needing continued abx? In these situations you would hope your patient was at the level where she could have told them she was a recovering addict, if indeed he didn't know, but of course it's a lot harder for patients to reveal such hx. It's unfortunate all around.


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[frosted_flake]

Yeah, I would need to know the surgery, to determine the actual need of the PICC. Was she needing continued abx? In these situations you would hope your patient was at the level where she could have told them she was a recovering addict, if indeed he didn't know, but of course it's a lot harder for patients to reveal such hx. It's unfortunate all around.


Sent from my iPhone using SDN mobile

I thought that as well @prettyNURSEtoMD ... and with you being a nurse... I am sure you know the lengthy paperwork that is provided for patients at discharge!

 

[MDProspect]

At the hospital where I work (ED) there is no 'addiction designation' per se, it is more along the lines of 'this person comes in 5x/week asking for pain meds, keep an eye on them.
We have security watch the known IV drug abusers to make sure they don't run out with the IV.

So if someone, like Jessica, came into your ED for the first time then you wouldn't know whether she is an addict, correct?

 

[frosted_flake]

So if someone, like Jessica, came into your ED for the first time then you wouldn't know whether she is an addict, correct?

The triage nurse (then the patients nurse) each ask about social history which includes previous or present use of medications (Rx, OTC and street) alcohol, etc.
The patient has two opportunities to let the staff know that they use drugs/drink alcohol. Other than that, unless there is a previous history of the patient at our facility, we would not know if it were a Jane Doe off of the street (unless there are obvious signs of IV drug abuse).

 

[Mad Jack]

Hard to say based on this news article. Feel free OP (or others to correct me if I'm wrong), but in summary:

Patient with a long history of substance abuse went in for surgery.
Family discussed with treatment team history of substance abuse before surgery.
Discharged home with PICC line in place and a script for 50 tabs of oxycodone.
Physician that discharged her home with script had no idea that she was a former substance abuser.

---------------------------------------------------------------

It is a bit odd that they put in a PICC line and discharged her post-op. What exactly were they planning to put through it? IV antibiotics? IV pain meds? It is strange. It isn't wrong to send a post-surgical patient home on narcotics, even if they are a former addict. It is certainly higher risk and certainly something that should be considered and acknowledged, but post-surgery you need pain control and while there are a lot of things you can do with non-opioids, many will still use them.

I'm betting IV antibiotics. While the most likely offender is Staph, given her history, she could have had something more unusual that necessitated PICC access.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884905/

Surprisingly, antibiotics are the second most common reason for using outpatient infusion services. I mean, I guess it isn't that surprising given that the only other big indication I can think of is chemo, but still, it's more common than I thought.

 

[mimelim]

After discussing this with my wife (ADA), with regard to the discharging physician...

The first question is, would this patient being an addict change what they would have done? If the answer is no, which, depending on the clinical circumstances very may well have been, then there is no negligence and it is hard to really put any blame on him. We always look back at things and say, "you should know everything in a patient's chart." But that just isn't realistic. If the answer is yes, an argument can be made for negligence. In many states, negligence alone isn't always enough for medical malpractice. And it is easy to argue that the patient herself is obviously a large part of the allocation of fault.

Again, hard to really know whats what without the clinical scenario. Sad regardless.

 

[operaman]

the article says at some point the picc was for long term abx for osteo, so totally legit indication for it. Not sure what could have been done differently. 50 oxycodone are not really that many pills - if you write someone for a week's worth you're basically there. They never say outright, but I guess we're to assume she found a way to inject them via the picc, is that right?

Not sure what the answer is for situations like this. Maybe something along the lines of what we do for people on chronic opioid therapy through a pain Mgmt physician where we coordinate with them to provide outpatient post op pain control for that patient. Even that isn't really a good fix. The reality is that at a certain point, if people are determined to do something like this to themselves, there's little we can do to stop it. Sounds like she had overdosed multiple times in the past without any help from a picc line. Just a sad situation all around.

 

[frosted_flake]

the article says at some point the picc was for long term abx for osteo, so totally legit indication for it. Not sure what could have been done differently. 50 oxycodone are not really that many pills - if you write someone for a week's worth you're basically there. They never say outright, but I guess we're to assume she found a way to inject them via the picc, is that right?

Not sure what the answer is for situations like this. Maybe something along the lines of what we do for people on chronic opioid therapy through a pain Mgmt physician where we coordinate with them to provide outpatient post op pain control for that patient. Even that isn't really a good fix. The reality is that at a certain point, if people are determined to do something like this to themselves, there's little we can do to stop it. Sounds like she had overdosed multiple times in the past without any help from a picc line. Just a sad situation all around.

I wonder if she got ahold of heroin to use in that PICC line?

 

[MDProspect]

deleted

 

[DrBowtie]

We've had to keep a few addicts in the hospital or send them to a monitored nursing facility for up to 6 weeks while getting ABx via PICC lines.

 

[DrBowtie]

That's what I was thinking. The article mentions that the script was in her home, meaning that it wasn't filled. The author of the article also seems to be alluding to her death being a result of the PICC line.

It says she filled it at the hospital

 

[MDProspect]

It says she filled it at the hospital

"After Grubb's death, her parents drove to Ann Arbor to pick up her things and to talk to the police. In her apartment, they discovered the prescription for the 50 pills." I misread the article.

 

[DrBowtie]

"After Grubb's death, her parents drove to Ann Arbor to pick up her things and to talk to the police. In her apartment, they discovered the prescription for the 50 pills." I misread the article.

No worries. Prescription is used to refer both to the paper and the medication so ambiguity exists.

 

[mimelim]

We've had to keep a few addicts in the hospital or send them to a monitored nursing facility for up to 6 weeks while getting ABx via PICC lines.

Who pays for the additional length of stay? While I think that it is clearly medically justifiable, I think I would have a hard time arguing that with an insurance company.

 

[frosted_flake]

Who pays for the additional length of stay? While I think that it is clearly medically justifiable, I think I would have a hard time arguing that with an insurance company.

I have seen docs have trouble trying to justify a rehab stay for a patient who just had a hip or knee replacement.
Seems like it would definitely be an uphill battle.

 

[DrBowtie]

Who pays for the additional length of stay? While I think that it is clearly medically justifiable, I think I would have a hard time arguing that with an insurance company.

That is beyond my scope of knowledge. I agree the cost benefit ratio is difficult to calculate.