News: In 2013, a middle-aged man underwent a spinal fusion surgery that was expectedly difficult. After the surgery, the patient remained at the hospital for postoperative care and management of his severe pain. During that time, the patient’s oxygenation level drastically and suddenly dropped. He was administered medication, which ultimately stabilized him. The patient alleged that he was resuscitated, but evidence contradicted that allegation.

The patient filed suit, alleging that negligence by the hospital’s rapid response team, including an aggressive head tilt, dislodged the hardware recently implanted in his spine. The case proceeded to trial, where a “battle of the experts” ensued and the hospital presented arguments that its own medical staff contributed to the failure of the hardware in the patient’s spine. The jury rendered a special verdict in favor of the defendants.

Background: On Aug. 20, 2013, a 53-year-old man underwent a posterolateral spinal fusion surgery. This was a co-surgeon operation performed by two spinal surgeons. The surgery was noted to be particularly challenging, as it required twice the usual operating room time and significant operative devices, including a microscope, stereotactic navigation, and operative neurologic monitoring.

The patient remained at the hospital for postoperative care and pain management. He received pain medication and he reported that the pain levels vacillated between an eight and nine out of 10. The pain management team consisted of physicians and a physician assistant. Approximately five days after the surgery, the patient’s oxygen saturation levels were notably low and on Aug. 26, 2013, his oxygenation level dropped into the 70s.

A rapid response team was called in and three doses of Narcan were administered over a five-hour period. Shortly thereafter, the patient’s oxygen saturation levels normalized, and he remained more alert and arousable until his discharge on Aug. 28, 2013.

The patient filed a medical malpractice action against the hospital and the physician assistant, alleging inappropriate management of his postoperative pain. Specifically, the patient alleged he was over-sedated on narcotics, which purportedly necessitated manual chest compressions to resuscitate him. He also claimed that, because of the rapid response team’s use of an Ambu bag for oxygen administration, which included an alleged “violent” chin and head tilt, the surgically implanted spinal hardware loosened, thus requiring a subsequent repair surgery. The patient further alleged that the Narcan caused violent shakes and seizures, further causing or contributing to the loosening of the spinal hardware and loss of fixation.

The plaintiff requested $250,000 in non-economic damages and between $564,000 and $798,043 in special damages for the cost of repair surgery and future medical care.

The hospital contended that its nursing and ancillary personnel complied with the standard of care for this patient throughout his hospitalization. The hospital claimed that the administration of the prescribed doses of medication to the patient and the continued monitoring of his reactions to the medications were in accordance with the applicable standard of care.

The hospital further alleged that no action or inaction by its staff caused or contributed to the displacement of the instrumentation screws implanted in the plaintiff’s spine. Interestingly, the hospital argued that the displacement of the instrumentation screws was caused by a less-than-optimal screw fixation at the C5, C6, and C7 levels during the initial spinal fusion surgery. Moreover, the rods used during the surgery were shown to be too stiff relative to the anchoring ability of the bone, exerting additional pressure on the screws.

The physician assistant similarly defended himself on the basis that he complied with the standard of care for pain management and medication administration and adjustments. The assistant contended his work was reviewed by supervising physicians as part of a team overseeing the patient’s pain management. He further claimed that the administration of the medication did not result in a code blue situation requiring CPR. The assistant also claimed a chin tilt could not cause the loss of fixation of the patient’s spinal hardware, and the Narcan did not cause side effects that could generate the requisite force to dislodge the screws.

On Aug. 17, 2017, the trial court entered a judgment in favor of the defendants, reflecting the jury’s special verdict finding no negligence by the hospital or the physician assistant.

What this means to you: This case offers insight into proper postoperative care in difficult situations. The hospital conformed to the appropriate standard of care throughout these events, including teams on standby and available to respond quickly, by properly monitoring medication, by establishing a treatment approval process, by maintaining a good medical record, and by maintaining a knowledge of medications and their side effects. While it is difficult to quantify which of these measures are necessary and which are best practices, the cumulative effect of the hospital’s extensive care satisfied the applicable standard.

Rapid response teams are imperative in any hospital. Stabilization of patients in rapidly deteriorating conditions can be a deciding factor in whether a patient recovers. These rapid response teams are becoming more commonplace in hospitals, and they can offer nurses and physician assistants a chance to address problems in a patient’s condition that otherwise is not immediately reported to physicians. If hospitals fail to institute procedures that enable medical professionals to report symptoms amounting to an undefined condition or fail to adhere to their own standards, rapid response teams can act as a safeguard. The creation of rapid response teams can reduce the number of code blues, intensive care bed days, patient deaths, lawsuits, and the duration of patient stays.

The procedure of the hospital in this case to require supervision of physician assistant treatment by a physician — with appropriate documentation of that oversight — helps reduce treatment errors that negatively affect the patient’s health. Close collaboration between medical professionals encourages communication and transparency, and hospitals should strive to foster mutual respect between physicians and supporting medical staff. Physicians should be encouraged to set forth clear procedures for medical staff, and the staff should be empowered to respectfully negotiate those procedures, where appropriate, to produce efficient and actionable courses for any given circumstance.

Hospitals should establish specific and detailed procedures for rapid response teams and those who work with the teams. Thorough and appropriate training and documentation is critical not only to the success of the teams and to a patient’s safety, but also aids in defense if a patient alleges medical malpractice.

This case also provides some guidance concerning prospective procedures for rapid response teams. Objective criteria should be listed to define situations where staff should call for a rapid response team. Such circumstances may include low respiration rate, wet lungs, shortness of breath, elevated heart rate, chest pain, mental status change, and reduced blood pressure. Calls for rapid response should be made through the hospital’s designated emergency phone line. The teams must arrive equipped and prepared to stabilize patients quickly, as the emergent nature of their services is expected. On-duty nurses and physician assistants must be trained on how to integrate into, and work closely alongside, the rapid response to team to provide comprehensive treatment. Thorough and accurate documentation is critical; staff must be trained and instructed on how to properly document events.

Whether a medical record is helpful or harmful, clear information and knowledge enable hospitals and physicians to later evaluate the circumstances when a patient alleges malpractice. Unfortunately, it may be the case that the standard of care was not met. If the medical record unequivocally demonstrates such a case, a defendant hospital or physician, working with an attorney, may wish to take the necessary steps to settle the matter rather than engage in arduous, expensive, and lengthy court proceedings.

Finally, this case presents an interesting catch-22 in the form of arguing its non-defendant physicians performed the surgery in a less-than-ideal fashion. Arguing that its physicians operated, to some degree, negligently opens the hospital to a determination that it failed to conform to the standard of care. In any event, the hospital’s argument does well to show that a hospital is only as strong as its weakest link, and as such, constant internal oversight is essential.

REFERENCE

Decided on Aug. 17, 2017, in the Superior Court, Orange County, California; Docket No. 30-2014-00754443-CU-MM-CJC.