Case Presentation: We present a 25-year-old female with past medical history of right fibular hemimelia who presented with acute on chronic leg pain. She had a history of multiple prior limb lengthening surgeries complicated by Staphylococcus aureus infection with hardware removal. Patient endorsed weeks of worsening leg pain and cramping. Had been seen by orthopedic surgery as outpatient who recommended nonemergent MRI of the leg, however patient presented to emergency department soon after due to uncontrolled pain. She was initially admitted under observation status. Inflammatory markers were elevated without leukocytosis; vital signs stable. X-ray femur, hip, tibia/fibula demonstrated chronic postsurgical changes. MRI femur was unable to be fully completed due to pain however within limits taken, no evidence of osteomyelitis. Patient remained with severe, ongoing pain requiring intravenous pain control, and she was upgraded to inpatient status. Discussed with orthopedic surgery who recommended outpatient follow-up and pain service consult for uncontrolled pain. Patient advocated for reattempt of MRI femur with hospitalist team given degree of pain of unclear etiology. MRI femur was re-done, showing likely acute on chronic osteomyelitis. Orthopedics was reengaged and infectious disease consulted. Patient was started on empiric IV vancomycin. Bone biopsy and culture obtained for further management with cultures growing methicillin-susceptible susceptible Staphylococcus aureus. Transitioned to oral Cefadroxil with significant improvement reported on outpatient follow-up with plans to continue conservative management.
Discussion: In 2013, the Centers for Medicare and Medicaid Services introduced the two-midnight rule to distinguish between observation and inpatient admissions. Initially, as an effort to distinguish between Part A versus Part B coverage of services, this differentiation has caused many more effects within healthcare, particularly with hospitalists. A 2017 survey by the Society of Hospital Medicine revealed that two-thirds of respondents noted the rule has not improved their ability to focus on providing care and added burden to daily routines. This can be seen among hospitalists when deciding inpatient versus outpatient management of complex issues with an observation status patient given the pressured timeframe that can be felt as a deadline. Our case demonstrates the balance in providing quality care with complex patients admitted under observation status. While admitted for pain control, our patient advocated for further imaging that would extend beyond the 2-day observation period. Our hospitalist team upgraded the patient to inpatient status with further imaging showing osteomyelitis leading to a prolonged hospital course including invasive procedures and complex care coordination, which was in the patient’s best interest. This case also highlights the difficulties in balancing consultant recommendations and patient expectations while admitted.
Conclusions: While observation status can help distinguish coverage for hospital admissions, there can be added pressure on hospitalists to discharge patients quickly. These constraints can be difficult to relay to patients, particularly those with multiple complex comorbidities. As hospitalists, these choices should be considered although the highest priority should be placed upon the individual patient at hand and advocating for their needs, level of care, and appropriate clinical status while admitted.
