If surgery patients call back following discharge, do staff know their limits?

Nonphysicians must know expected and normal reactions

An outpatient surgery patient called back after discharge with complaints that indicated significant internal bleeding, but the staff member who answered the phone didn’t recognize the signs and didn’t refer the person to emergency care or a physician. By the next day, the patient had died.

Another patient called back after discharge with symptoms indicating a heart- or aneurysm-related problem. No one who responded to the patient, including a physician, recognized the symptoms or referred the patient to emergency care. He went to an emergency department the next day and died.

"We have seen lawsuits because staff incorrectly assessed the situation over the phone and gave advice that led to injury of or a bad outcome for the patient," says Waldene K. Drake, RN, MBA, vice president of risk management for Cooperative of American Physicians — Mutual Protection Trust in Los Angeles.

Stephen Trosty, JD, MHA, CPHRM, director of risk management and CME for American Physicians Assurance Corp. in East Lansing, MI, says, "It’s the exception, but it becomes important that someone taking the call can make an evaluation about whether this is an expected or normal reaction."

Tell patients they can call the surgery center, as well as the physician, after surgery, Drake and others suggests. "A licensed nurse could reinforce the discharge instructions and precautions," she says.

Patients who are discharged early in the day may be unable to reach their physicians that day, because their surgeons still may be operating, says Linda Kirk, RN, MPA, director of ambulatory perioperative services at Spectrum Health Hospital in Grand Rapids, MI.

"If the issue is medication, and the surgeon needs to talk to them, we connect them if the surgeon’s here," Kirk says. "If they’re not available, we get them in contact with appropriate medical care."

One downside of taking calls from patients is that same-day surgery programs generally are not open at night or on weekends. Programs can have an after-hours call service, but physicians need to be available for backup, Drake says.

In most states, outpatient surgery programs do have an obligation to respond in emergency situations, Trosty warns. "If a call comes in, say it’s from a person having a critical or emergency situation, and the surgery center or hospital doesn’t advise the person to go to the ED, there is potential liability there," he says.

Start with good discharge instructions

To avoid liability and poor outcomes concerning post-op patient calls, follow these steps:

  • Send the patient home with detailed discharge instructions that include the physician’s contact information.

"The key for this whole issue is that the facility has good discharge instructions that are reviewed with the patient and/or responsible adult that will be with the patient at home," Drake says.

In the case of a bad patient outcome, discharge instructions play an important part and help provide a defense for a surgeon or facility, she says. "Thus, written/printed discharge instructions should have both general postoperative instructions and instructions specific to the procedure the patient had," Drake advises. "They should include when/what the patient may eat; activity level on discharge and for successive days; possible symptoms of complications; when/who they should call if there is a problem/question; minor symptoms/complications that they may expect during the immediate postoperative period; precautions they should take; and when they should make an appointment to see the doctor for a postoperative checkup."

Also, ensure handouts include space to write in any specific instructions from the surgeon, sources advise.

Document in the medical record who gave the patient/caregivers the discharge instructions, their apparent level of understanding, and a copy of the instructions or a reference to a standard (for example, No. 14 At-Home Care After Cataract Surgery), Drake says.

Before discharge instructions are handed to patients, it should be clearly spelled out when the patient should call the facility and when the patient should call the physician, say sources interviewed by Same-Day Surgery. Kirk says.

"We let them know they can call us back with any issues or questions," she says. "It it’s a medical concern following the day of surgery, we suggest they call physicians directly." These directions are written on the discharge instructions, with the physician’s name and office number as well as contact information for the surgery center.

Verify contact information with the surgeons to ensure calls from patients will be answered, sources suggest.

Education should start in the physician’s office when the surgery is scheduled, Kirk maintains. "Education and instruction of patients and family need to start early, not the day of or after surgery," she says.

Also, if the surgeon moves to a new office, ensure the contact information is changed on the handouts, sources advise.

  • Specify what types of questions can be answered by nonphysicians.

Give staff specific directives on what issues are appropriate to be handled by nonphysicians, what responses to give, and which ones must be handed off to physicians, Trosty says. Your policies and procedures also should specify the appropriate way to handle patient calls, he says.

Look to your state’s licensing laws to determine what questions can be answered by nonphysicians, Trosty suggests. "Usually, the rule of thumb is that anything that has to do with the practice of medicine, anything to do with diagnosing or providing emergency treatment should be for the physician," he says.

Job descriptions should clearly spell out whose responsibility it is to answer what types of questions, Trosty notes. "That includes the physicians," he adds.

Nurses should limit their answers to the discharge instructions that the patient was given, Drake says.

"They may answer questions and give advice in line with their experience and training or within standardized protocols set by physicians in the facility," she explains. "However, they do have responsibility, and perhaps liability, for their assessment and advice should it be wrong."

Some calls, such as ones from patients who have lost their postoperative education sheet or who aren’t sure when to return to activities of daily living, don’t need to be forwarded to a physician, Trosty emphasizes.

Staff must be able to differentiate between these calls vs. patients who are not responding normally or who have something that went wrong in surgery.

"If a nonphysician is answering questions and is inappropriately answering questions, liability will rest there on the facility," he says.

  • Know when to refer the patient to the physician or emergency care.

The discharge instructions should outline when and for what conditions patient should seek help or call, sources says. Some problems, such as mild or moderate pain, are expected after surgery, Trosty says.

"You need to be able to determine whether the pain is at a level expected, or it is far greater pain that is indicative of another problem," he says.

If patients indicate serious bleeding, heart-related problems, or aneurysm-related problems, direct them to seek emergency care, Trosty says.

At The Surgery Center of Nacogdoches (TX), "Nurses help the patient understand the doctor’s discharge instructions and questions about pain management," says Janice Williams, RN, BSN, regulatory manager.

If the patient reports fever, drainage, nausea/ vomiting, inability to urinate, or similar complications, the patient is referred to the physician or the emergency department, she notes.

"Nurses also encourage the patient to call the doctor if the patient feels he or she is not progressing as he or she should," Williams says.

The night answering service or recorded message should inform patients to dial 911 if it is an emergency, sources suggest. Patients who are not experiencing an emergency should be directed to contact their surgeon, they say.

The safest approach for postoperative patient calls is to refer serious questions to physicians as long as the physicians take the calls, Trosty points out.

"If doctors don’t take the calls or don’t call back in a timely manner, and this is a question that could indicate a potential emergency problem, [outpatient surgery staff] need to indicate to people to go to the nearest ED to seek care, at least," he says. (For information on following up on patient calls, see "Follow up and track patient complications".)

Sources

For more information on postoperative calls from patients, contact:

  • Waldene K. Drake, RN, MBA, Vice President, Risk Management, Cooperative of American Physicians-Mutual Protection Trust (CAP-MPT), 333 S. Hope St., Eighth Floor, Los Angeles, CA 90071. E-mail: wdrake@cap-mpt.com.
  • Linda Kirk, RN, MPA, Director, Ambulatory Perioperative Services, Spectrum Health Hospital, 4069 Lake Drive S.E., Grand Rapids, MI 49546. Phone: (616) 285-1053. Fax: (616) 285-1065.
  • Stephen Trosty, JD, MHA, CPHRM, Director, Risk Management and CME, American Physicians Assurance Corp., East Lansing, MI. Phone: (800) 748-0465, ext. 6808 or (517) 324-6808. Fax: (517) 332-0262. E-mail: strosty@apassurance.com.
  • Janice Williams, RN, BSN, Regulatory Manager, The Surgery Center of Nacogdoches, 4948 N.E. Stallings Drive, Nacogdoches, TX 75963. Phone (936) 558-3658. Fax: (936) 568-3591. E-mail: janice-NMC.williams@tenethealth.com.