Midlevel Operations: Exploring New Expsoures with Allied Health Providers
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Transcript of Midlevel Operations: Exploring New Expsoures with Allied Health Providers
Midlevel Operations: Exploring New Exposures
with Allied Health Providers
Jayme T. VaccaroSedgwick
Learning Objectives
Identify professional liability risks unique to Midlevels and their Supervising Physicians
Discuss Risk Reduction Techniques
Review and take lessons from actual malpractice cases involving Midlevels
The World of Midlevels
Who are they?• PA’s, Nurse Practitioners, Midwives, Nurse
Anesthetist, etc. 6,723 PA’s, 8.1% of US 83,466
15,766 NP’s, 9.4% of US 167,857• (see statehealthfacts.org)
What do they do?• Walks, talks, acts…
• Lower Acuity Patients?
Where do they practice?• Everywhere!
Hot Topics for Midlevels
• Scope of Practice
• Supervisory Role of Physician
• Statutory Governance
• Tracking Midlevel Participation
• Credentialing
• Basic Professional Liability Considerations
Scope of Practice
What is Scope of Practice and How is it Determined? • Healthcare Providers
• State Law
• Hospital Credentialing
• Employment Contract
Reasonableness• Jury will use common sense
Lower Acuity• If you want to be a doctor, go to medical school
Effective Triage• Consulting or Referring to Physician
Case #1
Who did the Jury Believe?
Scope of Practice?
Case #1 - Scope of Practice
45 Year Old Male seen by PA & ED Physician for c/o Headache Hx of sinus cancer CT ordered Radiologist Read Film = No Pathologies Present=Body of Report
discusses other possible findings At issue:
- did ED Physician & PA also read CT - PA says yes, MD says doesn’t remember- if ED Physician read CT was he the ―last chance‖ for this patient?
Patient Discharged 4 Days Later returns in semi-conscious state Craniotomy, Stroke due to Untreated Brain Infection
Case #1 - Scope of Practice
ED Physician, PA, ED Group, Radiologist & Hospital Sued
PA dismissed on Statute of Limitations
Radiologist: Defense Verdict (causation)
ED Physician: $11M, Reduced to $6M
Jury embraced PA’s testimony that ED Physician read the CT and should have further acted notwithstanding the initial radiology findings and thereby could have further aided the patient
Case #1
Witness Abilities
• Nexus between Physician and PA
Does this lead to credibility?
• PA made better witness and was believed
• The PA defined the scope of practice of an ED physician for the jury
Supervising Role of Physician
Vicarious Liability• What if Physician Disagrees with care?
Communication• Open Door Policy• Physician too busy to review, oversee, interact with
midlevel• Patient Volume
Chart Sign Off• Timing of sign off • Did the Physician read the chart?• Is the Physician required to sign the chart?
Case #2
Is Anyone Supervising?
Case #2 Supervisory Role of Physician
40 Year Old Male with brain tumor Both Neurosurgeon and ENT perform surgery ENT hits cribiform ENT takes 4 hours to do 45 minute approach Neurosurgeon suspects complication No Anesthesiologist, Nurse Anesthetist Nurse Anesthetist does not recognize significance of
complication Neurosurgeon takes over surgery Brain Damage to patient Sues ENT, Neurosurgeon, Anesthesiologist, Nurse
Anesthetist, Anesthesiology Group and Hospital
Case #2 Supervisory Role of Physician
Nurse Anesthesis not licensed
Anesthesiologist supervising 8 Nurse Anthesesis at a time during surgeries
Anthesiolgist present at start of surgery and did not return for the next 8 hours
Nurse Anthesthesis missed warning signs on monitors that patient was in distress
Case settled by all defendants
Case #2 Supervisory Role of Physician
Anesthesiologist/Group Exposure
• Reality of Supervising
Surgical Team Exposure
Hospital Exposure
• Who Credentials?
• Reliance?
Statutory Requirements
Awareness
• PA’s
• Nurse Mid Wives
Compliance
Effect on Cases and License
What do the Statutes say?
Unique to each state & revised periodically - State PA laws –CAPA or www.aapa.org - NP & PA state licensing boards websites
Compliance- Delegation of Services Agreements- Protocols- Schedule II drugs- Chart documentation- Sign offs - EMTALA-Cross reference statutes
Impact on Cases - Negligence Per Se- elements:• There is a statute designed to protect a class of people (i.e. statutory scope of practice
requirement or supervision requirement)• Plaintiff was a member of the class to be protected (i.e. general public)• Plaintiff was injured due to a violation of the statute (fail to supervise, fail to stay within
scope of practice, etc.• Standard of Care Breached, Left with causation
Case #3
Did Anyone Review the Application?
Case Study #3
50 Year Old Male
PA takes Hx, Hired by the ED Group
Nausea, Headache, Dizziness, Confusion & Double Vision
―Pop‖ in Head
Hx of Hypertension, Diabetes, High Cholesterol and Family Hx of Stroke
MD examines and orders 2 CT’s
Dx Sinusitis
Antibiotics RX
Pt. Discharged Home
Case Study #3
Next Morning
Severe Headache, Slurred Speech
Patient returns to Hospital ED and transferred in the PM to Different Facility
2nd Hospital Dx Stroke
Patient now suffering major brain damage and paralysis
Case Study #3
Plaintiff’s alleged MD Missed Dx of Impending Stroke—MRI instead of CT?
2nd Visit Missed Dx of Stroke
Delay in Transfer
PA unlicensed, failed exams 4X—must have taken poor history
Case #3
Jury Verdict Award of $217M
50% of verdict on MD and PA
50% of verdict on MD Groups
Punitive Damages of $100M due to Unlicensed PA
ED Group BK’d
Hospital dismissed prior to trial
Case #3
Tracking this case as a PA case
Back to Basics: Licensing and Credentials
When juries get mad, they get mad…
Basic PL Considerations
Documentation
Witness Abilities
Communication/Relationships with other Healthcare Providers
Bedside Manner
Medical Training and Knowledge
Case #4
The Basics of Pregnancy
Basic PL Considerations: Case 4
35 year old female patient seen in ED for abdominal pain
Ultra Sound done, fetal demise (wet read) Patient told miscarried, follow-up with OB-GYN Patient seen 2 times by OB-GYN PA No repeat pregnancy test done Patient realizes she is still pregnant at 25 weeks Does not want Amnio Down Syndrome Baby Sues ED, Hospital, OB
Basis PL Considerations: Case 4
Final Read on Ultra Sound shows viable fetus
Final Read not relayed to ED but sent to OB’s office
Standard of Care of OB-PA, retest to confirm miscarriage and read Ultra Sound
Case is settled by ED, Hospital and OB
Case #4
Training and Knowledge
• The PA did not know to retest
• The PA did not think to review ED records
• The PA did not recognize on physical exam that the patient was still pregnant
• The PA did not confer with their supervising OB
• PA is held to the standard of an OB
Potpourri
Medicine, Statutes, Supervision and Contracts
The Basics and Then Some:Case # 5
Triage Nurse: 44 Year Old Male Fever Headache x four days Pain 10/10 Temp @ exam 98.8 BP 91/60 Pulse 90 Respiratory Rate 20 Skin Warm, Dry, Awake &
Oriented x4 No notation of skin rash
PA:
Fever, chills & body ache 4 to 5 days
Mild congestion & cough
No neck stiffness
Lips, teeth & gums dry
Tenderness L side of Neck
Dx viral syndrome
RX Vicodin
Seek further care if symptoms not better in 2 days or sooner
The Basics and More: Case #5 Allegations
Medical Issues:• Pulse & Blood pressure: dehydration• If dehydrated, labs? If labs, further testing which
would have led to proper dx?• Proper dx, leading to antibiotics?
Statutory Issues:• MD/PA Contracts—Not in Order, negligence per se• Rx Vicodin—Against Code, negligence per se• Code Allowed Physician off site but electronically
available
The Basics and Then Some:Case #5 Allegations
Contract Issues:
• Hospital, Group and PA Contracts at Issue
• Hospital Contract did not allow PA to be supervised by off site Physician
• Unilateral Indemnification Clause
• Financial Incentive
Group and Hospital Used PA because financially Beneficial
Putting It All Together
Medical Knowledge
Statutes
Supervisory Role
Check-List for the Risk Manager
Headcount
Scope of Practice
Supervision by Physicians
Statutes
Credentialing
Contractual Issues
Thank you