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Midwest Medical Liability Management Association

Medical Liability Webinar

October 2012

Midwest Medical Liability Management Association

The Patient

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59 year old male Postal worker Hx. excision of left calcaneal exostosis C/O recurrent pain left heel, increasing in severity

Midwest Medical Liability Management Association

Course of Treatment



11/4/06 – initial evaluation Pt. reported trial of different shoe types and padding provided no pain relief. Requested surgical intervention.

Erythema circumferentially around the posterior superior aspect of left heel.

Dorsalis pedis and posterior tibial pulses +2/4 bilat Patellar and Achilles deep tendon reflexes +2/4 bilat

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Course of Treatment (continued)

X-ray, L foot showed hypertrophic bone formation at the posterior and superior aspect of calcaneus. Kager’s triangle is intact and the Archilles tendon appears normal. Increased soft tissue density is noted just posterior to the area of bone hypertrophy.

Diagnosis = Left foot retrocalcaneal hypertrophy of bone with pain Plan = Left foot retrocalcaneal ostectomy



Surgery scheduled for next day

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Course of Treatment (continued)

11/5/06 – Surgery Dx. L retrocalcaneal hypertrophy of bone Procedure: L retrocalcaneal partial ostectomy with partial detachment and reattachment of the Achilles tendon with internal fixation Pt. tolerated procedure and anesthesia well and left OR with all VSS and good perfusion to the L foot.

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Course of Treatment (continued)

• • • • • • •

11/8/06: 3 days post-op SOAP Notes: (S) Pt. presents for F/U of L foot- he had discomfort but not unbearable. Was Ibuprofen taken during waking hours?

(O) & (A) Satisfactory progressive post-op healing. Sutures intact. 0 signs of infection.

(P) Sterile scrub done to L foot X-ray taken L foot, DP&LAT – Pt. wore lead apron X-ray reviewed EGS directed to L foot @ 300v X 15 MIN.

Sterile dressing with polysporin powder applied to L foot BK cast applied to L foot with Fiberglass material Return to office 5-7 days Rx. Cephalexin 500mg. Disp. #40 (forty) Take 1 tab.Q6H w/food

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When was Ibuprofen prescribed?

Why was cephalexin prescribed?

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Course of Treatment (continued)

11/15/06: 1 week 3 days post-op (S) Pt. presents for F/U of L foot surgery. Reports his foot feels good except when it swells. He can feel it tight in the cast.

(O) & (A) Satisfactory progressive post-op healing. Cast intact.

(P) Diathermy directed to L heel through cast @ 50% X 15 min.

Cast checked-cast removed Sterile scrub done to L foot Sterile dressing with polysporin powder applied to L foot Cast reapplied Return to office 10 days

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Why diathermy through cast when cast was later removed?

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Course of Treatment (continued)

• • • • • •

11/24/06: 2 weeks 5 days post-op (S) Pt. presents for F/U L foot. Reports he only has discomfort when foot swells (O) & (A) Satisfactory progressive post-op healing. Sutures intact. Cast intact.

(P) Cast removed Sterile scrub done to L foot EGS directed to L foot @ 200V X 15 min.

Surgical site debrided Sterile dressing w/polysporin & zinc applied to L foot surgical site Cast applied with fiberglass Return to office 1 week

 

Surgical site debrided, polysporin applied – why?

Were sutures removed?

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Course of Treatment (continued)

• •

Pt. returned weekly for next 2 weeks Same documentation and same treatment

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Weight bearing status?

Home instructions?

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Course of Treatment (continued)

• • • • • •

12/16/06: 5 weeks 6 days post-op (S) Pt. presents for F/U L foot surgery. Reports pain.

(O) & (A) Satisfactory progressive post-op healing.

(P) Sterile scrub done to L foot L foot examined Sterile dressing with polysporin applied to L foot surgical site with Desitin EGS directed to L foot @ 200V X 15 min.

Pt. advised to take Motrin Pt. advised to wear open-backed shoes for right now Return to office Monday (3 days)

  

Why was polysporin & sterile dsg. Applied at 6 wks. post-op?

Desitin?

Why was patient instructed to return in 3 days?

Midwest Medical Liability Management Association

Course of Treatment (continued)

12/20/06: 6 weeks 3 days post-op (S) Pt. presents for L foot surgery F/U. Reports no pain.

(O) & (A) Satisfactory progressive post-op healing (P) Sterile scrub done to L foot EGS directed to L foot @ 400V X 15 min.

Sterile dressing with Desitin and polysporin applied to L foot surgical site

 

“Satisfactory progressive post-op healing”, but still applying dressing?

No description of surgical site?

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Course of Treatment (continued)

12/23/06: 6 weeks 6 days post-op (S) Pt. presents for F/U L foot surgery. Reports little pain.

(O) & (A) Satisfactory progressive post-op healing with capsulitis (P) Sterile scrub done on L foot

  

EGS directed L foot @ 400 V X 15 min.

Sterile dressing with polysporin applied to L foot Return to office 1 week

 

Return 3 days after previous visit-why such frequent visits at almost 7 weeks post-op?

Still applying sterile dressing?

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Progress

    

Pt.. Returned weekly for the next 6 weeks No documentation of capsulitis No wound description Same treatment : surgical scrub, sterile dressing, ointment Still obvious wound, but no documentation of such

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Progress

2/18/07 (S) Pt. reports increased drainage from L foot surgical site for 3-4-days. He also has c/o increased pain. He stopped doing the stretching exercises due to pain.

(O) & (A) retrocalcaneal surgical scar with mild deshiscence of incision. Drainage noted-mild erythema.

(P) L foot surgical site cleansed with H2O2.

EGS directed t L heel at 200 V X 15 mins.

Wound culture taken L heel. Sent to lab.

Pt. to use compresses on heel To ease off on stretching Rx Cephalexin 500 mg. Dispense #40 (forty), Take 1 tab. Q6H with food RTC 1 week



No documentation of systemic review?



(Notes getting better – foot getting worse?)

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Progress

• • No mention of culture results in subsequent notes Patient returned every 3-4 weeks for next 4 visits, then weekly for the next 3 weeks.

Midwest Medical Liability Management Association

Progress

4/1/07 (S) Pt. presents for F/U L heel. Reports his heel has been hurting a lot and the wound is open again.

(O) & (A) S/P L heel resection with wound dehiscence.

(P)EGS directed to L heel at 200 V X 15 mins.

Sterile scrub done to L heel L heel examined Cultures taken-sent to lab Pt. should still soak foot Rx Cipro 500 mg. Disp. #20 (Twenty), 1 Tab. BID with food.

  

Dehiscence does not equal infection Antibiotic changed to Cipro-why? Was Cephalexin d/c’d?

Now 5 months post op

• •

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Progress

Pt. seen every 3-4 days for next 3 visits.

Again, no mention of culture results in notes 4/14/04 (S) Pt. reports his foot is feeling much better (O) & (A) L foot retrocalcaneal suture rejection site 90% cleared.

(P) Sterile scrub EGS X 15 min. at 120 V Sterile dressing with polysporin and zinc oxide to L foot Rx Septra DS, #20, BID with food RTC 4 days  

Antibiotic changed to Septra-why?

Are the Cipro and Cephalexin still being used?

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Progress

• • Pt. seen every 3-4 days for next 4 visits At visit on 5/2/07, the Podiatrist advised the patient “of the need for an X-ray to evaluate osseous involvement in recurrence of pain.”

Midwest Medical Liability Management Association

Progress

5/6/07 (S) Pt. presents for F/U L heel- still draining and has “puffy” spot-blister-yesterday was bigger need Rx for MRI written (O) & (A) L retrocalcaneal resection (P) Sterile scrub done EGS directed to L heel at 250 V X 15 min.

L heel examined C&S taken L ankle. Specimen sent to lab Sterile dressing with polysporin to L heel Rx Cephalexin 500 mg. #40, Take 1 tab q 6H with food.

Rx MRI L ankle, 3mm cuts, without contrast RTC 3 days   

Still no description of culture results, but pt. prescribed Cephalexin No mention of X-ray results?

No description of wound?

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Progress

Patient returned every 3 days for next 2 visits

Midwest Medical Liability Management Association

Progress

5/24/07     (S) Pt. presents for F/U L heel. Feels a little better (O) & (A) L foot retrocalcaneal aspect resection (P) Sterile scrub done to L ft.

EGS directed too L heel at 200 V X 15 mins.

L heel examined C&S results discussed with Pt. from 5-06-07 C&S taken, Specimen sent to lab.

ID specialist discussed with Pt. if problem persists Sterile dressing with polysporin to L heel RTC 3 days

No mention of MRI results Discussed culture results, but no mention of what the results were Was antibiotic prescribed?

Finally thinks of ID consult-was “discussion” enough?

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Progress

Returned every 3-7 days over the next 2 months • 6/3/07 – Septra DS ordered • • 6/8/07 – More cultures taken 6/15/07 – Pt. reported he saw ID doctor and he started new antibiotic -Zyvox. (ID doctor recommended removal of hardware from heel) • • • • 6/27/07 – Another culture taken-no mention of results. No acknowledgement of ID doctor’s recommendation to remove hardware .

7/11/07 – Another culture taken – no mention of culture results – chasing cultures 7/21/07 – 1 st mention of systemic symptoms

- PT. not admitted. Why?

- Pt. not following with ID. Why?

7/23/07 – Finally sent to hospital

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Subsequent Treatment

Hospital

• Hardware removed in ED • Admitted • Surgical debridement • ID consult • Bone cultures + for MRSA • IV antibiotics started Post Discharge • 6 wks. Home IV Vancomycin & oral Rifampin

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Lawsuit

Allegations against podiatrist: • Negligence in managing post-operative infection • • Failure to prescribe the correct antibiotics Failure to refer to specialist in a timely manner • Failure to remove hardware after the infectious disease specialist recommended that it be removed

(Continued)

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Problems for Defense

   Failure to perform appropriate examination - No description of wound - No rationale for prescribing antibiotics - No mention of C&S results in progress notes - No rationale for not adhering to ID recommendations Failure to timely refer to specialist Failure to treat appropriately - Multiple cultures were + for MRSA, but was never addressed by podiatrist - Did not follow the recommendations of the infectious disease specialist (hardware removal & antibiotic) - Infection developed into osteomyelitis

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Outcome

Settled during mediation

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Common Allegations in Infection Claims

• • • • • • • • • • Failure to perform appropriate examination Failure to obtain appropriate diagnostic testing: (X-rays, lab work, cultures) Failure to timely refer to specialist Failure to timely treat Failure to diagnose infection Failure to document the wound condition and size Failure to document the treatment plan Failure to timely admit to hospital Failure to treat appropriately (antibiotics) Failure to reappoint or follow up in a timely fashion

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APMA National Convention Presented by PPI with cooperation and credit to APMA National Convention Aug 16-19, 2012 Washington DC

Midwest Medical Liability Management Association

• • • • • 25% of Diabetics will have an ulcer.

Currently, the standard is to call a wound chronic if it is still open > 4 weeks.

We are seeing more ulcers as Diabetics are living longer and we se more end stage Disease.

There is a 5 year survival rate for people following a leg amputation.

With any neuropathy caused ulcer, there is a 45% 5 year survival rate.

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•

There is an 8 fold increased chance of infection for ulcers older than 30 days.

•

You need to convert a chronic wound to an acute wound for it to heal.

•

24% of Foot Ulcer patients go to the hospital.

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Treat the Infection First: Patient Can Die!

Treat Vascular Status next.

Function and Structure come next.

Cosmetic consideration should come last.

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• • • • • • Remove hyperkeratosis Remove Necrosis to healthy margins Curette the base, remove undermining Remove Fiber Wet to Moist no longer used; now the standard is on of the synthetic, such as Calcium Alginates, Foams, Collagens, Hydrocolloids or Hydrogels.

Consider taking two wound margin samples on a serious case. Send one to micro and the other to Pathology for confirmation if clean margins. Results may cause a change in treatment plan.

Midwest Medical Liability Management Association

• • • • Negative pressure is becoming the standard of care.

Off Loading is standard of care but can be inadequate.

Use: total Contact Cast (there are kits available called ITCC); crutches for the young; if the patient is able to use adequately, a roll about is to be used, but these can be dangerous. Patients could find fault if you suggested something that is a challenge to them.

Use cam walkers, rocker type, such as air cast; ½ shoes; short shoes to float toes if necessary. Be creative.

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•

NOTE: 82% of people in a removable Cam walker remove it and walk without it.

•

It may be necessary to use cable ties around the Cam walker or to wrap it with Coban so the patient is less likely to remove it.

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• • • • • Look for 50% improvement in sq mm by 4 weeks, many feel if not 25% healed by two weeks, you need to make changes in: off loading, vascularity, bacteria burden, dressings, etc.

The rule of 1mm a week of healing has been an old standard; for large wounds and unusual wounds this may not apply.

If not healed in 4 weeks, you need assistance with advanced wound healing techniques.

Only Dermagraft and Apligraf have pre-marketing approval from the FDA. Others like Theraskin which is a less costly choice) has a 510K status (under study).

There is an art to billing these dressings and as you know some require reapplications.

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• • • • • • Go to www.Footlaw.com

and browse the sight.

The new trial attorney push is Diabetic foot ulcers that lead to amputation.

Read the Blogs and cases and see top 10 reasons Podiatrists are sued.

#7 is Diabetic Complications #2 is RSDS/CRPS Read about the Podiatrist who did not treat the heel pain conservatively; had an $85,000 settlement.

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Wonder who the 21 Podiatrists are that offer their services to this firm? They only charge $800 to $1,200 to look at a case.

Midwest Medical Liability Management Association

Download and look at this paper from

www.podiatrytoday.com

“Consensus Recommendations on Advancing the Standard of Care For Treating Neuropathic Foot Ulcers In Patients with Diabetes” - 2010 It is 24 pages long, but an easy pdf download. Very informative document.

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DISCHARGING A PATIENT

Occasionally you encounter a patient that you know could be troublesome. It may be best to discharge them from your care. Those displaying

confrontational behavior

or who are insistent on receiving treatment or procedures you know are not in their best interest are dangerous from a liability standpoint, and great care should be taken prior to performing any procedure; especially surgery. In the event you feel you must continue to treat such patients obtaining second opinions prior to surgery is a good idea. Having support going in can be very helpful in the event the patient becomes disgruntled...legitimately or not. Provided you aren’t

abandoning

a patient, there is no obligation to treat them. If you are concerned to the extent you feel you’re going to be at risk you may wish to recommend they continue treatment with another doctor. To properly discharge a patient from your care you must take the following steps.

Be certain they are notified in writing Advise them of the reason you are recommending they seek treatment elsewhere Offer to continue necessary care until they have found another doctor, or for thirty-days (30); whichever is shorter Offer to recommend the names of other doctors in the area

A sample letter used to discharge a patient is on the following page.

The following is a sample letter used to discharge a patient.

Dear M. ______________ I find it necessary to inform you that I am withdrawing from further professional treatment of you

for the reason that you have persisted in refusing to follow my medical advice and treatment

. You are suffering from a very serious disease and your failure to follow my advice jeopardizes your health. Since your condition requires medical attention, I suggest that you place yourself under the care of another physician without delay. If you so desire, I will be available to attend you for a reasonable time after you have received this letter, but in no event for more than 30-days.

This should give you ample time to select a physician of your choice from the many competent practitioners in this area. With your approval, I will make available to the physician your case history and information regarding the diagnosis and treatment which you have received from me.

Very truly yours,

**You may substitute the appropriate reason for that which is highlighted above. It may be that they are demanding treatment you feel is inappropriate, they seem dissatisfied with the way your practice operates, refuse to pay for treatment, etc.

Any questions in this regard should be directed to our Risk Manager...Jim Olsen at: 800 955-2840 or [email protected]

Midwest Medical Liability Management Association

“Your company continues to be financially sound. The total number of Insureds had dropped to 90 members, but we are now back up to 95. The Board’s efforts continue to be toward finding a way for the Company to market in Michigan. We have approached, and have been in negotiations with two different companies. We hope to have news in this regard soon.

Our premiums have remained the same for several years in spite of increased costs. Thus the importance of obtaining new members to enable us to keep our premiums very competitive and to retain further profits to continue to build policyholder funds.”

Midwest Medical Liability Management Association

Since some PPI members will read this who have never been to a risk seminar, certain definitions are necessary: Incident - Doctor receives a request for records or has an unhappy patient. You should call Jim Olsen, 1-800-955-2840.

NOI - A legal Notice of Intent from a patient that they are going to file a malpractice claim against a doctor.

Claim - The patient has actually filed a claim against a doctor.

As of 8/1/12 PPI has 3 claims, 1 NOI and 1 incident as pending cases.

The incident involves a patient’s death following surgery, yet to be determined, but we believe unrelated to the surgery. One of the claims involves the death of a patient immediately following surgery; the other involves a patient losing toes and part of foot and claiming negligence on the part of our doctor. The third claim relates to a poor result following bunion surgery. The NOI alleges improper implant surgery.

We remind you that for all procedures requiring the use of a consent form after 1/1/11 must have used our approved form or a $2500 deductible may apply to any claim.

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We appreciate you participating in our first webinar. We trust the information was useful and the method of presentation was convenient. Do let us know if you had any trouble with accessing the webinar. Your input will aid us in improving future presentations.

To confirm that you have carefully reviewing the information we’ll ask that you complete the following questionnaire. We’ll ask some questions that will determine whether the points we attempted to make were understood. It is not difficult, but will confirm that our message got through.

Again, you comments and input will be appreciated. Simply follow the instructions on the screen.

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Follow the instructions on the screen. If you have any trouble contact us at: [email protected]

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  

1. What was patient’s diagnosis and treatment?

2. Name three allegations against doctor.

3. List three problems the defense faced.

4. What is the most common cause of lawsuits?

Have you attended 1 or more of our annual risk management meetings?

Do you prefer the Webinar format or an annual meeting?

Comments:

Midwest Medical Liability Management Association 1) Ulcers that stagnate do so because of which following potential causes:

a) Vascular issues b) Lack of offloading c) The patient's nutritional status, smoking, obesity, and deconditioning d) Bacterial burden e) All of the above

2) When writing the first orders for managing an acute fetid foot, the most important priority is:

a) Determine if pt needs just medial rays versus a total trans met amp.

b) Planning for scar position c) Get ID consult and do an aggressive I&D d) Get vascular/cardiology consult if no palpable pulses e) None of above

Midwest Medical Liability Management Association 3) What is the most inadequate off loading management technique you could recommend to a neuropathic patient with a forefoot ulcer who cannot stay on crutches?

a) Pad on foot b) Air cast cam walker with plazitote and felt off loading for surface c) TCC commercial type or office created d) Tell patient to not walk too much and use their heel and anterior muscle group and float his/her forefoot e) Try 4 wheel roll-about if the patient has the strength for this and agility that they can maneuver the cart and they live on one floor in the home.

f) Flat surgical shoe with no off loading, or padding.

Midwest Medical Liability Management Association 4) These are ideas about wound healing that are appearing in Publications and National Meetings. Select all below that makes sense to you.

a) You need to change a number of your approaches to getting the wound healed if it is not progressing steadily.

b) An ulcer that was 20x30mm on Nov 1st and now is 300mm in size Dec.1st is good progress.

c) Consider referral to wound center or second opinion from fellow PPI insured etc if you are managing an unhealed ulcer for more than 60-90 days.

d) There are law firms searching for amputation claims involving Podiatrists.

e) All of the above

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1. True or False; it is permissible to discharge a patient from your care provided you are not abandoning the patient?

2. When discharging a patient the proper procedure, or requirements include: a.

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There are no questions for this section of the presentation as it was to inform the participants of the state of their sponsored malpractice insurer. Please proceed to the next section concerning claims.

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1. Define the following: 1. Incident 2. NOI 3. Claim or Suit 2. What should you do in the event you receive notice of any of the above?