The Case

A 52-year-old woman presented to the emergency department (ED) of a tertiary care university hospital after recently undergoing cosmetic abdominoplasty at a private community hospital. Upon evaluation in the ED, the patient was found to have a profound lactic acidosis and leukocytosis, and vasopressor medication was initiated through a peripheral intravenous catheter.

The Plastic Surgery service was notified and evaluated the patient; the team recommended debridement of a presumed necrotizing soft tissue infection (a.k.a., necrotizing fasciitis) by the Emergency General Surgery (EGS) service. An intern from the EGS service evaluated the patient and discussed the patient with the EGS attending on call. However, the EGS attending refused to see the patient because the patient had undergone a “plastic surgery procedure.” The Emergency Medicine attending did not communicate the EGS attending’s refusal to see the patient to the Plastic Surgery team who initially evaluated the patient. Four hours later, the Plastic Surgery attending realized the patient was still in the ED and had not been treated and decided to intervene. The delay in treatment allowed the infection more time to progress, and the patient ultimately required excision of a large area of skin and soft tissue. The patient was subsequently admitted to an Intensive Care Unit for several days.

The Commentary

By Tanya Rinderknecht, MD and Garth Utter MD, MSc

Background: Necrotizing Soft Tissue Infections 

Necrotizing soft tissue infections (NSTIs) are destructive, fast-expanding soft tissue infections that can lead to marked morbidity and mortality if not (and sometimes even when) treated in a timely and aggressive manner.¹ Rarely, NSTIs can occur as a severe postoperative wound complication. The diagnostic challenge lies in differentiating severe but uncomplicated cellulitis from a true NSTI, as the former will likely improve with intravenous antibiotics and supportive care, while the latter requires emergent and then repeated surgical debridement, as well as meticulous supportive critical care. 

History and exam are essential in making the diagnosis of a NSTI, but a number of diagnostic adjuncts, including laboratory tests and imaging, can be useful as well. The ‘Laboratory Risk Indicator for Necrotizing Fasciitis’ (LRINEC) score is a risk stratification score to help providers identify potential NSTIs; it includes six laboratory criteria (CRP ≥15 mg/dL, WBC ≥15K or 25K/mm³, hemoglobin <13.5 or 11 g/dL, sodium <135 mEq/L, creatinine >1.6 mg/dL, glucose >180 mg/dL), each of which is assigned a point value from 0-4. The developers reported that a LRINEC score ≥6 had a sensitivity of 90-93% and a specificity of 92-97%.² However, subsequent studies yielded poorer sensitivities of around 60% and specificities of around 80%.³ As a result, a score < 6 should not be used to rule out the diagnosis, and thus clinical suspicion remains paramount.

The only definitive way to rule out an NSTI is with incisions to the depth of the fascia, typically performed in an operating room. In necrotizing infections, these surgical cut-downs will reveal tissue ischemia and death, with a pathognomonic ‘dishwater’ fluid. These concerning findings often extend beyond the borders of the overlying skin changes, requiring much more extensive debridement than initially anticipated. Serial trips to the operating room for exploration and debridement are standard; only rarely is a true NSTI completely excised during the initial operation.

NSTIs can be rapidly fatal and increasingly morbid if not debrided in a timely fashion,⁴ and a recent expert panel concluded that operation for NSTIs should optimally occur within one hour after diagnosis.⁵ If there is a genuine concern that a patient has an NSTI, the situation is generally treated as a surgical emergency until proven otherwise.

Identifying Risks to Patient Safety

In the presented case, there were undoubtedly multiple failures that led to the delay in the patient’s care, but the overarching concern is that two surgical teams were called and neither one ensured prompt care for the patient. How could this happen, especially in regard to a life-threatening diagnosis? Assumptions about who treats NSTIs and who was responsible for this patient caused unprofessional initial delay, and communication failure worsened that delay. Additionally, an underlying layer of physician burnout is likely both to have exacerbated the effect of those assumptions and to have contributed to the communication issues.

Whose problem are NSTIs?

In this era of sub-specialization of medicine and surgery, diagnoses tend to be assigned to the care of a single subspecialty. This practice generally leads to more efficient consultation from the emergency department and less confusion and conflict about who should take care of the patient. In most hospitals, general surgeons are the first to be called about NSTIs. However, surgeons of all specialties are trained to recognize NSTIs, and the tenets of early diagnosis and prompt and aggressive management are taught repeatedly throughout surgical training.  

Any plastic or general surgeon is certainly technically capable of debriding an NSTI, but the key skills for successful management of NSTIs involve surgical judgment, not technique. Accordingly, general surgeons are usually the best surgeons to spearhead the care of patients with NSTIs. First, they see the disease process the most frequently, and therefore are the most familiar with the diagnosis and management. Second, they have at least some training in critical care, and many of these patients require lengthy ICU stays with coordinated critical care and surgical care. Third, in our current practice models, EGS groups are the most likely to have a surgeon immediately available to see the patient and manage the multiple, often daily, trips to the operating room that may be required. And fourth, data have shown that NSTI outcomes are improved when patients are managed by an experienced, multi-disciplinary team familiar with the disease process,⁶ so the consistency of a specific surgical service, like an EGS group, for managing this problem is desirable. 

Whose patient is it?

In surgical culture, a surgeon is generally responsible for the post-operative care that follows an operation that he or she performs. This means that the surgeon will manage any complications related to the initial diagnosis or procedure, or, if that management is outside the scope of his or her practice, the surgeon will at least help coordinate the appropriate care. This responsibility – sometimes referred to as patient ‘ownership’ – is made clear in the American College of Surgeons’ code of professional conduct,⁷ and has been a great source of pride for surgeons. This tradition is presumably the reason the Plastic Surgery service was called first in regard to the patient in this case.

As surgery has become more and more subspecialized, and models of care have transitioned to more group coverage with shared call responsibilities and cross coverage, this ‘ownership’ concept has been diluted. The limits of ‘ownership’ are called into question in this case. Wound infections are routinely managed by operating surgeons of all types, but whether an NSTI fits under that umbrella of post-operative care or constitutes a new, urgent diagnosis that supersedes the previous ownership is an open question. To add to the complexity in this case, a community plastic surgeon performed the operation, so the plastic surgery team at the university hospital might have felt even less responsibility for this patient. Although the general surgeon should have seen this patient with an NSTI immediately, the plastic surgery team also temporarily lapsed in its professionalism and commitment to the patient in this case by failing to ensure and expedite appropriate management initially.

Communication failure

In general, when a system fails to prevent an adverse outcome, poor communication is almost always a contributing factor. In this case, there are few details available, but these questions should be raised:

• Did the plastic surgeon think to call the general surgeon directly, given the surgical emergency in a colleague’s patient? It would have streamlined communication and provided greater courtesy to the EGS surgeon and the patient’s original community plastic surgeon to have done so.
• Did the surgical intern who spoke with the EGS attending surgeon adequately understand and describe the problem at hand? If he or she described a ‘wound infection in a plastic surgery patient,’ for example, this would have been inadequate and misleading, although not false. Inadequate communication in this interaction may have reflected lack of understanding by the surgical intern, but it also may have reflected inappropriate deference and poor team function if the intern or other members of the clinical team (e.g., nurses) did not feel empowered to insist on the urgency appropriate for possible NSTI.
• Why did the emergency medicine physician neither talk to the attending EGS surgeon directly nor alert the plastic surgery service that EGS was not accepting the patient? A patient in septic shock with a surgical diagnosis should prompt a more persistent effort to address the patient’s needs in a timely, if not urgent, manner.

Burnout

Physician burnout (also referred to as “moral injury”) is an ongoing topic of discussion in medicine, and it may have contributed in this case. Our understanding of how burnout influences clinical care is still growing, but it has been associated with increased patient safety events and medical errors, and decreased quality ratings.⁸ Surgeons overall have particularly high rates of burnout, and the EGS population is likely at even greater risk due to job structure and working odd hours and more nights than other surgeons.^9,10 EGS surgeons also face the risk of feeling under-appreciated and under-respected: they do much of their work outside of business hours, perform many of the necessary but less surgically rewarding operations (like NSTI debridement), and often work alone rather than with colleagues, all of which may contribute to decreased career satisfaction and increased rates of burnout. Symons et al. summarized these concerns nicely in their survey of subspecialty surgeons: “while EGS surgeons appear to meet [a clinical] need and relieve some pressure from...consultants, this may be at the expense of the EGS surgeons themselves.¹¹ In this particular case, burnout may have contributed to the substandard care provided in that the general surgeon responded with apparent resentment to an appropriate consultation request. In a world without burnout, we would expect the surgeon not only to see the patient without objection, but also to speak directly with the patient’s other treating physicians if there was any concern about the consultation.

Proposed Systems Change Needed/Quality Improvement Approach

In this case, the patient had two surgical teams called - the team that ‘owned’ the diagnosis, and the team that ‘owned’ her prior surgical care. However, rather than working together to provide a double layer of security, this dual ‘ownership’ resulted in lack of ownership and delayed care. There are many ways that a well-functioning system can help prevent this scenario, including a more structured consultation process and increased attention to physician work culture.

To begin, a health system can create guidelines for emergency department consultations, built around diagnoses, communication, and staffing. For example, mutually agreed-upon, diagnosis-based guidelines would help generate consistency and agreement concerning whom the emergency department should call. Involving specialty services in creating these guidelines builds buy-in and provides an appropriate space and time to discuss patient disposition amongst services. Mandating that a certain level of physician (i.e., a senior resident or attending) see all or certain consults may help ensure that critical diagnoses are not missed or ignored. In addition, establishing ‘time to treatment’ quality metrics for critical diagnoses like NSTIs (similar to door-to-balloon times for myocardial infarction) may help generate the appropriate urgency both in consultation and response. A policy for managing any physician’s refusal to see a consult would provide another safeguard. For example, a requirement for an attending-to-attending conversation would help avoid communication failure, and a requirement to elevate unresolved issues to an on-call physician leader would both discourage refusal and provide a clear next step in the process. 

Physician work culture is the other area of focus for systems improvement in relation to this case. Burnout affects not only the physician experience, but also patient safety and outcomes. Many contributors to burnout are hard to modify; overnight call periods, for example, are unavoidable but are taxing, often lonely, and disruptive to sleep cycles. However, at an organizational level, health systems can effectively support positive physician work cultures and thereby mitigate burnout.¹² Encouraging direct, respectful communication between physicians (in this case, a call from the plastic surgeon to the EGS surgeon asking for assistance) would increase the mutual amity and participation of all parties while simultaneously improving patient care. Including physicians in the discussion and design of new patient-focused initiatives engenders feelings of engagement and ownership. Broadly and clearly publicizing expectations and new guidelines helps to create a work culture that feels fair and allows for accountability. Establishing systematic ways to publicly acknowledge the work of all physicians improves motivation and makes people feel like genuine members of a team. Using the system structure to create a more positive working environment can help address the burnout that plagues physicians and thus also affects patients.

The importance of autonomy deserves special mention. The obvious downside to creating guidelines and policies is that physicians are already struggling with a significant loss of autonomy in their professional realm, which in turn contributes to burnout. Systems must strive to enforce truly useful and essential policies to ensure quality care (e.g., via care pathways), while also supporting physician autonomy and thus preserving physician wellness and motivation. If a hospital can succeed at building multidisciplinary consensus around the rules that are useful and important, that will ultimately lead to a culture of safety, where doing the safe thing feels natural, rather than enforced, thus augmenting rather than diminishing physician autonomy.¹³  

Take-Home Points

• Necrotizing soft tissue infections (NSTIs) require prompt surgical evaluation and debridement, and no surgeon should consider it appropriate to abandon a patient who potentially has such an urgent condition without ensuring an alternate plan for the management of that condition.
• Systems should clearly designate which physicians should be contacted for particular clinical problems and how disputes regarding responsibility should be adjudicated in real time.
• Physician burnout demands attention both as an underlying cause of decreased patient safety as well as an unintended consequence of well-intentioned systems changes.

Tanya Rinderknecht, MD
Assistant Professor of Surgery
Department of Surgery, Division of Trauma
UC Davis Health

Garth Utter, MD, MSc
Professor of Surgery
Department of Surgery, Division of Trauma
UC Davis Health

References

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