Study: Many surgical claims involve postoperative care
Several years ago, The Doctors Company conducted a study of surgical specialties, looking at preoperative, intraoperative, and postoperative phases of surgical care.
"We were surprised by the number of life-threatening complications that manifest themselves in the postoperative period. In the past, many assumed that the majority of risks to patients were during surgery," says Donald J. Palmisano, MD, JD, FACS, a member of the Board of Governors of The Doctors Company.
The postoperative phase of patient care then became the focus of a March 2013 study conducted by The Doctors Company of medical liability claims filed against general surgeons.1A review of individual claims revealed that many patient injuries resulted from delayed discovery of surgical complications such as punctures of bowel, bladder, and blood vessels. Patients experienced complications such as deep vein thrombosis, pulmonary embolus, pneumonia, infections, and brain damage from hypoxemia.
Based on the claims in the analysis, Palmisano gives these risk-reducing strategies:
• Assess patients prior to surgery to determine whether they are candidates for the recommended procedure.
"Some patients don't survive successful surgical procedures due to co-morbidities," he notes.
• Train nursing staff who provide care to patients in the postoperative phase to recognize symptoms of complications, including bleeding or drops in hemoglobin; increased respiratory rate; increased heart rate; temperature increase above a designated degree; more pain than is anticipated for the type of surgery; any changes to neurological assessment including patient complaints of inability to move an extremity; any changes to mental status; unexpected inability to urinate; and low urine output.
• Screen patients for sleep apnea due to the effects of narcotic analgesics on the respiratory system.
• Administer prophylaxis to patients at risk of developing deep vein thrombosis.
In reviewing documentation of cases involving postoperative complications, it often becomes very clear that physicians have not communicated with the nurses, says Phyllis Miller, RN, a legal nurse analyst in the Minneapolis office of Robins, Kaplan, Miller & Ciresi.
"If the nurses are documenting that the patient was up all night with terrible pain and bloating, and the physician says the patient is looking good and ready to go home, that is not helpful either to the patient or to defend a potential claim," says Miller.
Many of the claims involving postop complications in The Doctor's Company were rooted in poor communication, says Palmisano. Here are some examples:
• Physicians did not read the medical record or did not communicate about a patient's aortic and pulmonary stenosis. This issue resulted in complications postoperatively and the patient's death. "In several cases, patients were known to have cardiac problems, but the surgeon did not receive the information prior to surgery," says Palmisano. "Some reports were filed before being reviewed by the surgeon."
In some cases, the problem was not identified in the pre-operative history and physical, or was not communicated by the referring physician. "There were situations where the patient's cardiac condition was documented in the patient's medical record, but was not read by the surgeon and not factored into the plan for surgery," adds Palmisano.
• Nurses observed elevated patient temperature but did not call the surgeon prior to discharging the patient, who later was found to be septic.
• Nurses notified a surgeon that the patient complained that they could not move their legs, and the surgeon delayed referring the patients to a neurologist. The patient suffered paralysis from an epidural hematoma.
• A patient's low sodium level was not communicated by the surgeon to the nephrologist, and the patient suffered stroke-like symptoms that were attributed to hyponatremia.
• A patient's abdominal pain was treated by a family physician, who failed to communicate to the surgeon that he was seeing blood following enemas. The patient died of sepsis due to a perforated bowel.
In this case, the patient presented to the emergency department with abdominal pain, and the emergency physician ordered a surgical consult. The surgeon examined the patient and found guarding, hypoactive bowel sounds, and impacted fecal material. An enema was ordered, but no diagnostic tests were ordered. The patient was admitted to the hospital.
"The patient continued to have pain, so the family practice physician ordered another enema. No fecal material returned, but blood was seen in the enema fluid," says Palmisano. "The family physician attempted to contact a surgeon, without success."
The patient's pain was intense and treated with morphine, but no other attempts to reach the surgeon were made throughout the night. The following morning, the surgeon ordered an X-ray. "The interpretation was perforated viscous with significant free air. The surgeon took the patient to surgery and found a perforated sigmoid colon with fecal peritonitis," says Palmisano. "The patient later expired from septic shock."
No explanation was made for why the surgeon was unavailable when called by the family physician, says Palmisano, and it was also unclear why the nurses did not contact the surgeon when the patient's intense pain persisted. "Blood in the bowel indicates possible perforation and warrants further investigation. Continued intense pain should have prompted further diagnostic workup and should have caused the nurses to notify the surgeon of the patient's condition," says Palmisano. The delay in diagnosing the patient's condition decreased the chance that the patient would survive, he says.
Protocols should require nurses to call surgeons with elevated heart rates and temperatures prior to discharging patients, says Palmisano, and discharge instructions need to clearly outline situations when patients should seek care. "Patients need instructions about when they should seek further care. This is often dependent on the type of surgery," he adds. Palmisano says patients should seek care if they are bleeding, have a fever, have pain that is not controlled by their medications, have shortness of breath, have a rapid heart rate, or experience any significant change in their status.
"This especially true for patients who are discharged right after surgery," says Palmisano. "Even serious complications may not manifest themselves until later." (See related story, below, on documentation that makes claims more defensible.)
Postoperative complication? Tip to help defense
In the event a malpractice lawsuit is filed alleging failure to diagnose and treat a surgical complication, Donald J. Palmisano, MD, JD, FACS, a member of the Board of Governors at The Doctors Company, says this documentation can make the claim more defensible:
• evidence that assessments and vital signs that are performed at regular intervals according to hospital policies or physician orders, providing a clear picture of the care received by the patient;
"Some complications or other conditions don't become evident until later," explains Palmisano. "Documentation of vital signs may show that earlier interventions were not required."
• documentation of physicians' responses to nurses' calls demonstrates that surgeons or other physicians were giving appropriate attention to the patients' changing conditions;
• documentation of clinical rationale for conducting surgery, despite the fact that a patient has co-morbidities;
• documentation of informed consent discussions;
• compliance with protocols. "This helps to demonstrate that an appropriate level of care was provided," Palmisano says.
1. Palmisano DJ, Ranum D. Symptoms of normal recovery or complication: The risks of postoperative care. Bulletin ACS 2013; 98(6):28-32.