SPA Annual Meeting Reviews
Session III: PEDx: Error Traps in Communication: Medico-legal Concerns
Reviewed by Sean Flack, MBChB, FCA
Seattle Children’s Hospital
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Dr. Flack |
Mr. Scott Bentivenga, a Chicago-based trial lawyer shared his experience and insights based on 20-plus years expertise in medico-legal concerns. He began by advising the audience that, if served with a lawsuit, do not go into the electronic medical record. This leaves an electronic footprint that you have done so after the lawsuit was filed.
Common allegations include inadequate history and physical, lack of informed consent and unclear, erroneous or incomplete orders. A complete history and physical should include a review of existing records, accompanied by careful listening and open-ended questions. One should drill down on potential problems and perform a full or focused physical examination. When language barriers arise, always note in the record who assisted with translation. When concerns for proceeding with a case arise, take a time-out and talk it out with the surgeon, the family, other providers and the patient. Always document these discussions.
To minimize risk, develop a process of questions and how you go about performing an exam and requesting records. Two years later, when deposed, you do not have to rely solely on memory and the record, but you know your customary practice and can testify that you followed it for this patient. In real estate, the most important thing is location; for medical records, it is documentation because memories fade. Good records may deter a patient from suing you.
Consent for surgery and anesthesia is another contentious issue. When a bad outcome occurs, the plaintiff’s attorney questions whether informed consent was obtained, was the risk known and discussed and who presented the consent to the patient. Also, if there was enough time for the patient/family to consider the risks. Error traps in consent can be avoided by communicating thoroughly about general and patient specific risks and following the same practice every time. Again, document in detail and amend or supplement the consent form when appropriate.
Orders can be an area of contention. Clear communication and documentation along with follow up and confirmation that orders were followed can help limit issues. There are a lot of challenges with electronic medical records. Be careful and accurate with drop down boxes. If you add or change things later, document why along with date and time so it does not appear that you are changing records to cover tracks. Again, if served, do not enter the record, rather wait for your attorney to obtain a copy for you. Do not change the records, the audit trail will show all.
PEDx: Error Traps in Congenital Cardiac Anesthesia
Megan Albertz, MD (Children’s Hospital, Colorado) discussed errors in congenital cardiac anesthesia. Layers of protection are built into our healthcare systems to prevent errors turning into bad outcomes; however, due to provider practice and patient variability, these layers are imperfect. More patients are living with repaired or palliated congenital cardiac disease and as they live longer, they are more likely to present for non-cardiac procedures. Importantly, they may prove more difficult to resuscitate after adverse events; therefore, prevention and early treatment are important.
The first error trap in these patients is being singularly focused on completing the surgery. As anesthesiologists, we should always assess risk and determine the need to proceed with any surgery. Data in the POCA registry demonstrate that mortality is higher in patients with heart disease (33%) compared to those without (23%). Patient risk factors include young age (<2 years), single ventricle physiology, aortic stenosis and cardiomyopathy. Children with minor cardiac disease have the same mortality risk as matched controls. Conversely, those with major or severe disease have significantly higher mortality risk.
Communication with procedural colleagues is critical. Is the surgery elective or urgent? Does the primary care team consider the patient optimized? Can a non-sedated CT provide the same information as an MRI with anesthesia? Can the procedure be scheduled early in the day when resources and support are most available? Discuss risks frankly with the family.
Patients with congenital heart disease (CHD) tolerate typical anesthesia induction practices poorly. Volatile anesthetics depress myocardial contraction in a dose-dependent fashion and reduce cardiac output. Neonatal myocardium is particularly susceptible to reduction in myocardial contraction. Propofol significantly decreases MAP and SVR and this persists in infants. This could significantly worsen coronary perfusion pressure leading to cardiac arrest if not promptly treated.
Helpful hints include turning sevoflurane down immediately after the IV is placed. Prepare propofol in appropriate-sized syringes to avoid overdosing. Consider using rocuronium to facilitate intubation and other induction agents such as ketamine and etomidate.
Careful attention to ventilation strategies is critical. There is no “one size fits all” model. Children with superior cavopulmonary anastomoses benefit from mild hypoventilation. Patients with Fontan circulation prefer spontaneous ventilation and negative intrathoracic pressure. Positive pressure ventilation and PEEP can reduce, stagnate or reverse Fontan flow. For Fontan patients, use I:E ratios of 1:3 or 1:4 and lowest amount of PEEP to minimize atelectasis without overdistending alveoli. Extubate patients with CHD early whenever possible.
Pulmonary hypertension (PHT) can be a scary disease process for any anesthesiologist. Airway choice is critical as laryngoscopy stimulation can trigger PHT if not blunted appropriately. Likewise, hypoxemia and hypercarbia can have similar effects in a spontaneously breathing patient. Appropriate PEEP is important to maintain FRC without overdistending alveoli. Avoid acidosis and deliver oxygen to maintain saturation ideally >90%. Monitor ETCO2 closely and consider having inhaled nitric oxide in-line in the event of a pulmonary hypertensive crisis.
