This case involves a woman who developed pressure sores following a surgical procedure. The patient was admitted to an inpatient rehabilitation facility and was not found to have any pressure wounds at the time of admission. The patient was primarily sedentary during her time in the facility, however, the records indicate that the patient was not routinely assessed for pressure wounds. After 3 weeks, the patient was discovered to have an advanced stage pressure sore on her tailbone. The patient was transported back to the hospital and was diagnosed with sepsis and an infected pressure sore with foul-smelling drainage. The patient developed an infection in her bone secondary to the pressure sore. She required surgical intervention and debridement to treat the wound. An expert in wound care was sought to review the records and opine on the standard of care for prevention of pressure sores.

I am a certified registered nurse and a nurse practitioner specializing in wound, ostomy, and continence care. I am also the director of clinical operations at a large university medical center in the mid-Atlantic. I have worked with wounds and skin issues since 1993, both lecturing and publishing on the topic at the local, regional and national level. Getting people moving is essential to prevent pressure injuries. Assisting in position changes, encouraging position changes, and educating individuals on the importance of position change are all part of the standard of care. We are finding out that pressor use in the ICU setting is having an impact on the formation of pressure injury following cardiac surgery and other serious illnesses. Many pressure injuries initiate before they occur. In addition to prevention strategies, identifying initial issues and prompt intervention can prevent worsening.

1. Please describe your background in wound care. 2. What measures can be taken to prevent decubitus ulcers in rehabilitation patients?

Sedentary Patient Develops Pressure Sores During Rehabilitation

This case involves an elderly female patient who was admitted to the hospital after losing consciousness. She was diagnosed with pneumonia, taken to the ICU, and intubated. For the remainder of her time at the hospital, she was given breathing assistance through a ventilator as well as antibiotics and intravenous fluids. The patient was then transferred to a different facility for a pulmonary procedure where they found she had an advanced bedsore on her lower back larger than the size of an orange. The patient’s condition eventually progressed to cellulitis.

I am a board-certified family physician and a wound care fellowship-trained clinician. I am currently an assistant professor of clinical surgery and family medicine in the section of wound healing and tissue repair. In my role, I treat a wide range of skin-related disorders and train students, residents, and fellows. In addition, my responsibilities, include lecturing and providing educational sessions for the residents and nurses on this particular subject. My professional activities also include participation at the local and national conferences, where I lecture on topics related to skin issues due to pressure, lymphedema, chronic venous insufficiency, diabetes, arterial insufficiency, and many others. Pressure ulcer prevention depends on various factors, including frequent re-positioning, proper offloading, maintenance of urine and stool, prevention of shearing, nutritional support, adequate hydration, etc.

1. What kind of measures should be taken to prevent pressures ulcers?

Patient Develops Bacterial Infection From Untreated Bedsore

This case involves an elderly male patient who was admitted to the nursing home after a hospital stay during which he contracted C-Difficile. Upon admission to the nursing home, the patient suffered from fecal incontinence due to the C-Difficile and was not cleaned appropriately by staff. In particular, the patient suffered extensive sores on his buttocks area. The patient suffered deteriorating health and mental status until for almost 2 months before being removed from the nursing home. Upon removal, he required an additional hospital visit for acute care.

I work as a supervisor in the nursing home setting. I have also worked as a staff development and infection control nurse in the skilled nursing home setting. Due to the potential risk of mortality that coincides with someone having a C-Difficile infection as well as the risk of C-Difficile being transmitted to other patients, there have to be policies and procedures in place for caring for patients with C-Difficile. This would include nursing care protocols. Evidence of training of all nursing home staff (especially nursing staff) regarding how to care for someone with C-Difficile is required. C-Difficile patients must reside in a private room and strict isolation precautions are put in place. Mask, a gown, gloves, and shoe covers must be worn by all staff caring for the patient. Due to the frequency of bowel movements and the potential for skin breakdown, frequent and complete incontinence care must be carried out with barrier creams used to protect the skin from breakdown. These are just a few of the practices that should be in place.

1. Please explain your background in nursing home administration. 2. What protocols or practices should be in place to prevent oversight in nursing care?

Nursing Home Staff Fails To Properly Clean Patient With Persistent Incontinence

The baby was seen by a primary care physician two days after discharge and there were no concerns during that visit. One week later, the baby was rushed to a local emergency room after becoming profoundly lethargic, blue in the skin, and hypothermic. The baby also had a dramatic drop in urinary output and had a reported body temperature of 90 degrees. Aggressive resuscitation efforts were started to get her stabilized for transfer to a PICU at another facility with IVF via IO’s. Antibiotics were not administered nor were labs and cultures drawn prior to transfer. The baby died several days later due to sepsis. A blood culture that had been drawn came back positive for coagulase-negative staphylococci.

I regularly treat newborns with CoNS infections, predominantly in the NICU in the preemie population where it is considered a true pathogen. I have to say, in this patient, CoNS is extremely unlikely to be a pathogen and if it were to be, it is a normal skin colonizer so to say it came from the mother due to any breach in the standard of care would be highly unlikely. Due to the severity of illness of the infant, without knowing the mother's history, I would be highly concerned for disseminated HSV infection and if that was not suspected and tested for then that is a problem. As above, CoNS sepsis evolves primarily in neonates in the NICU who are premature or have indwelling central venous lines that can act as a source. It tends to cause illness but on the whole, is relatively avirulent and does not typically cause fulminant sepsis, like this case. I have never seen an infant die from CoNS even in that population that is most at risk for it. I have reviewed a number of cases of neonatal sepsis and death.

1. How often do you treat newborn patients with coagulase-negative staphylococci infections? 2. What are the most common risk factors for developing CoNS sepsis in a newborn?

This case involves a male newborn delivered via C-section. The mom had been seen in the emergency room for fever with a temperature of 103. After the baby was born, labs and cultures were drawn due to the suspicion of chorioamnionitis. A placental sample tested negative for chorioamnionitis. The baby was in the newborn nursery for several days until discharge. 

Newborn Dies From Sepsis Secondary To Undiagnosed Infection

: Appellate Court of Illinois, First District, Third Division 

An expert witness, by definition, is someone with a specialized skill set who assists the trier of fact make sense of the factual evidence of a case. Usually, an expert witness is an industry professional with years of experience under their belt. In this case, however, a treating ophthalmologist was found to be a reliable expert witness insofar as her testimony fell within the parameters of “a resident and treating physician whose actions were reviewed by an attending physician.”

In 1982, the 17-year-old respondent, Mislich, was sentenced to 36 years in prison after he was found guilty of sexually assaulting two women. In 1998, the State moved a petition to involuntarily commit the respondent to the Illinois Department of Human Services, contending that Mislich was a “sexually violent person”.

In 2006, Mislich filed a petition for conditional release. In the said petition, Mislich asserted that he had “successfully finished 4 phases of treatment” and petitioned the court to observe that he had “made satisfactory progress” to justify a conditional release. After reviewing the petition, the court granted Mislich the conditional release. As per the court’s order, the department drafted a conditional release plan which listed 38 release conditions. Mislich accepted all of the conditions, and the plan was accepted by the circuit court. Mislich was then freed from custody in 2007.

The petitioner afterward attempted to revoke Mislich’s conditional release numerous times over the years based on his supposed breach of several conditions of his release plan.

Mislich was recommitted for 60 days after neglecting to cooperate in sex offender treatment as per the terms of his release plan. After concluding that brief recommitment time, however, Mislich was re-released. He was not constrained to re-confinement until the Petitioner opened revocation proceedings afresh in 2013 by moving a petition to revoke, and afterward the amendment thereto, which leads to this appeal.

The State’s petition was moved after Mislich contracted difficulties with his eyes. Mislich visited the emergency room with an alkali injury to one of his eyes after attempting to unclog a sink using liquid plumber. He eventually went blind after complications related to his injury.

The circuit court presided over a hearing on the state’s conditional release revocation petition. During the hearing, the expert witness, an ophthalmology resident at Chicago Rush University Hospital Eye Center was qualified, over Mislich’s objection, as “a medical expert for determination of illustrating the treatment of Mislich”.

The expert had treated Mislich while he was in the emergency room. Her treatment included irrigating the patient’s eye, conducting an examination of the patient’s eye, placing bandages, monitoring his progress, communicating the patient’s status to attending physicians, and admitting steroid treatment, among other interactions.

The respondent argued that the circuit court mistakenly allowed the resident to provide testimony as an ophthalmology expert. The respondent contended that the ophthalmologist was not eligible to be an expert and that the circuit court had arbitrarily allowed her to testify as an expert.

The court held that the expert’s status as a resident did not prevent her from testifying about her treatment of Mislich. The court indicated that the expert was qualified to testify within the parameters of “a resident and treating physician whose actions were reviewed by an attending physician.” Therefore, it was determined that the circuit court’s opinions that the expert’s qualifications and experience were uncommon to laypersons and that her testimony would help it in reaching its conclusion as to whether to revoke Mislich’s conditional release were not considered an abuse of discretion.

Ophthalmology Resident With Limited Experience Is Admitted As An Expert Witness

Univ. of Miss. Med. Ctr. v. Leontyne Littleton

In this medical malpractice case, the Circuit Court of Hinds County found the University of Mississippi Medical Center (UMMC) liable under the Mississippi Tort Claims Act for the death of a 29-year-old nursing student who died from a hospital-acquired infection. The court awarded the patient’s mother the maximum statutory-damage award of $500,000.

On appeal, UMMC raised issues regarding the adequacy of the causation testimony provided by the plaintiff’s expert hospitalist. UMMC argued that the trial court erred in finding the expert qualified as a hospitalist, that his opinions were speculative, and that his opinions regarding the patient’s cause of death were contradicted by the autopsy reports. The court of appeals found that the trial court erred in relying on the testimony of the expert hospitalist regarding the proximate cause of the patient’s death, and reversed and rendered judgment in favor of UMMC.

The patient presented to the emergency room complaining of headache, nausea, and dizziness. While in the emergency room, the patient was given pain killers and diagnosed with a migraine headache. Several days later, the patient complained of neck stiffness and an extreme headache. She was admitted to the University of Mississippi Medical Center (UMMC) where she was given IV pain medication. The next day, the patient was pronounced dead.

The surgical pathologist who performed the patient’s autopsy indicated in her initial report that the patient had “meningoencephalitis, partially treated, probably bacterial etiology.” The patient’s cause of death was reported as cerebral edema secondary to bacterial meningitis. However, the causative organism for her meningitis was unknown because both her pre- and postmortem cerebrospinal fluid cultures were negative. Additional tests were ordered.

The CDC gave a verbal report to the surgical pathologist that the brain-tissue samples were negative for the bacteria neisseria (the bacteria that most commonly cause meningitis), but further tests were being performed to rule out certain viral pathogens. The final report submitted by the CDC stated that the cause of death was “probably viral etiology.”

The mother of the deceased patient subsequently filed the present medical malpractice lawsuit against UMMC and retained a board-certified emergency room physician to discuss causation. The physician was qualified as an expert in emergency medicine and hospital medicine. In his expert report, the expert testified that the patient’s death was the result of negligence on the part of the nurses and physician at UMMC.

During the trial, UMMC objected to the designation of the expert as a hospitalist, claiming the expert had no regular experience in treating patients on a hospital floor as opposed to the emergency room. The trial court held that the expert was very much qualified to render an opinion as a hospitalist expert and awarded the maximum for statutory-damages to the plaintiff.

UMCC had appealed that the trial court’s decision, alleging that the trial court erred in allowing an emergency room physician to testify about the standard of care for a hospitalist as well as ICU standards of care claiming the expert was not qualified to do so. UMCC further claimed that the expert had only treated an occasional patient with meningitis on the hospital floor, and the majority of his experience was in treating patients with meningitis in the emergency room only before they are sent to the hospital.

The court noted that although the expert testified that UMMC physicians’ failure to provide proper care to the deceased caused her death, he did not explain 

UMMC failed to provide supportive care. Furthermore, he could not explain how or why the patient’s transfer to the ICU caused or contributed to her death. The expert merely reported that the standard of care for meningitis was to place the patient in the ICU with proper monitoring. The expert claimed that admitting the patient to the ICU would have saved her life from an unknown cause of death. Yet he offered no specifics on the treatment that she would have received or how monitoring would have saved her life. To prove causation, the expert would have needed to testify about the procedures that should have been adopted to save the patient’s life.

Moreover, there was no evidence that the unnamed lifesaving procedures which the expert suggested would have been successful, because the patient may well have died anyway from the unknown underlying cause of the cardiac arrest. Treatment in the ICU does not guarantee survival. It was mere speculation on the part of the expert that ICU care would have changed the outcome for the deceased, much less increased her probability of survival beyond 50%.

The court found that the trial court erred in allowing the emergency medicine expert to testify as an expert hospitalist. The court could not find that the expert’s testimony met the lost chance of recovery standard.

Under the lost chance of recovery theory, the expert did not offer sufficient evidence to show that, absent malpractice, there was a greater than a 50% chance that a substantially better result would have occurred had the patient been admitted to the ICU. The judgment was rendered in favor of UMCC.

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MRSA Infection Expert Witness Case Studies

Sedentary Patient Develops Pressure Sores During Rehabilitation

Patient Develops Bacterial Infection From Untreated Bedsore

Nursing Home Staff Fails To Properly Clean Patient With Persistent Incontinence

Newborn Dies From Sepsis Secondary To Undiagnosed Infection

Ophthalmology Resident With Limited Experience Is Admitted As An Expert Witness

Court Reverses $500K Award After Expert Hospitalist Fails to Meet Lost Chance of Recovery Standard

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