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When comanagement is mismanagement

November 2011
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Published in the November 2011 issue of Today’s Hospitalist

MANY HOSPITALIST GROUPS have rushed into surgical comanagement arrangements, making surgeons and hospital administrators happy. But given how many details need to be ironed out in these arrangements as to which service will take charge of what, it’s no surprise that comanagement can go terribly wrong. The result can be not only enormous liability for physicians, but patient harm.

That was the situation in the following case, in which a patient died as the result of errors and omissions that added up to gross mismanagement, not comanagement. Here are the facts of the case.

CASE
A 31-YEAR-OLD OBESE FEMALE presented to the insured hospital emergency department with multiple trauma after a car accident. She was taken to surgery two days after admission for intramedullary rodding of the right femur; open reduction internal fixation of the right ulnar fracture, left humerus fracture and left olecranon fracture; external fixation of the right pilon fracture; and incision and drainage with closure of a severe forehead laceration.

The patient was then placed on an orthopedic floor to be comanaged with the hospitalist service. Initial orders included heparin 5,000 units subcutaneously every 12 hours, and the patient was seen on daily rounds by the orthopedic medical team and the hospitalist service.

During her hospital stay, the patient remained on complete bed rest; no orders were written for physical therapy or to advance the patient’s activity level. Despite this, the orthopedic residents on several occasions noted “continue transfers” and “continue PT” in the progress notes. None of the floor nurses questioned any of the doctors about the fact that the patient’s activity level was not being increased or that she hadn’t been referred to physical therapy.

After consulting with the hospitalists, the orthopedic team decided a week after admission to begin plans for discharge. But instead of going to a subacute facility, the patient was adamant about wanting to be discharged home to be near her children, even though the discharge planning nurse repeatedly counseled the patient and her family about how difficult it would be to care for her there. These discussions were well-documented, and the patient’s mother “a certified nurse assistant “agreed to care for the patient at home.

Nine days after admission, the patient was discharged. The chart contained no documentation of an exam on that day. The discharge orders, which were written by the orthopedic attending, included PRN Percocet, no weight-bearing on right lower extremity, weight-bearing as tolerated on left lower extremity and follow-up in the orthopedic clinic in one week. No orders were written for anticoagulants.

The discharge nurse did a very poor job documenting discharge instructions and apparently didn’t educate the family about the possibility or signs and symptoms of DVT. (The discharge sheet was almost entirely blank.) The discharge nurse also did not question the doctors about not continuing anticoagulation, apparently did not reconcile the patient’s medications, and did not mention to either the orthopedists or hospitalists that the patient had not been out of bed since admission.

Five days after discharge, the patient began experiencing acute shortness of breath. An ambulance that was already at the scene to take her to a scheduled doctor appointment transported her to the hospital, where she died shortly thereafter. The autopsy revealed massive pulmonary emboli.
The claimant alleged that the patient’s premature discharge (before she was out of bed and able to move) and the physicians’ failure to order anticoagulation at discharge led to the pulmonary emboli.

Hard to defend
In the courtroom, the plaintiff produced several expert orthopedic surgeons who testified that the patient should have received physical therapy and that her activity level should have been increased before discharge to include pivot transfers. These experts also felt the patient should have been continued on anticoagulation post-discharge, particularly because she was completely bedridden.

One expert felt the hospital had a “system deficit” due to the fact that the patient seemed to “fall through the cracks.” That expert emphasized the poor communication among the attending orthopedist, the orthopedic residents and the hospitalist comanager, as well as between the doctors and nurses regarding the patient’s care. The plaintiff also produced a nursing expert who was highly critical of the nursing care the patient received.

A hospitalist who was one of the codefendants stated that he was not aware that the patient had continued on complete bed rest and that, had he known she was immobile, he would certainly have ordered anticoagulants at discharge. Two orthopedic residents both testified that they also thought the patient was mobile to some extent. They had no explanation for why anticoagulants were not continued at home.

The defense did produce one orthopedic surgeon who claimed that ordering anticoagulants at discharge would have made no difference to the outcome. He also stated that it is not cost effective to order anticoagulants for trauma patients after discharge and that studies do not confirm the efficacy of doing so.

The defense also found a orthopedic surgeon who testified that at the time of this incident, requiring post-discharge anticoagulation for multiple-trauma patients was not the standard of care. That doctor gave no opinion as to whether the discharge was premature.

Overall, the defense felt that the testimony in its behalf was weak, and it decided to settle the case in the high six figures.

What went wrong
Many factors contributed to this woman’s death. The lack of appropriate patient assessment was certainly one of them. The fact that all the doctors involved failed to order physical therapy and monitor the patient’s mobility directly contributed to the poor outcome.

The lack of communication among the providers also played a big role. The nurses failed to communicate the patient’s bedridden status, for instance, or point out that no anticoagulation was ordered at discharge.

But underlying all these problems is one central failure: Neither the orthopedists nor the hospitalists delineated their respective roles and responsibilities in terms of patient management. As this case demonstrates, the result too often is that neither service is really in charge “and both think the other has critical elements of patient care under control.

Before beginning any comanagement arrangement, these two teams should have hammered out which one would be responsible for ordering physical therapy and monitoring that progress, completing discharge planning and orders, and reconciling all medications.

Part of that advance planning includes deciding what to use for DVT, both for prophylaxis in the hospital and after discharge. This is particularly critical because orthopedists and hospitalists can fall on different sides of that fence. Orthopedists, who may worry more about bleeding risk, often take a less aggressive approach to DVT prophylaxis than hospitalists. Whose approach should prevail for patients being comanaged? That’s something to work out in advance.

Without clearly delineated roles, nurses are left wondering who to call when problems arise. The discharge documentation in this case was so abysmal that it’s unclear whether the discharge nurse even questioned the fact that post-discharge anticoagulation hadn’t been ordered. But if she had questioned it, she may not have known which of the two services to contact.

A bigger team?
While the actions of both the orthopedists and the hospitalists in this scenario weren’t defensible, the case also makes a strong argument for having more team members involved in patient care. This discharge nurse apparently didn’t reconcile the patient’s anticoagulation at discharge. Would it have helped to have a pharmacist doing medication reconciliation, particularly for a complicated patient being discharged home?

Would having a discharge planner or social worker involved ensure that this patient had a better chance of being discharged to a skilled nursing facility, as she needed to be? Clearly, leaving the care of this immobile patient to the patient’s mother ” a certified nurse assistant, who does not begin to have the training to deal with this type of patient ” was a major error, compounded by the fact that no one ordered home health services.

Social workers can also help with cost issues that may arise. While the providers were at fault for not ordering anticoagulation, insurers sometimes don’t cover the cost of Lovenox post-discharge. As a result, patients don’t always fill prescriptions for post-discharge prophylaxis.
This case also makes a strong argument for developing standard orders and protocols for conditions being comanaged.

And it speaks to the need for clear and concise documentation of all aspects of patient care. Not only was such documentation missing in this case, but misleading notations “such as “continue PT” in the progress notes and “physical therapy was consulted” in the discharge summary “made the decision to discharge the patient virtually impossible to defend.

Robin Diamond, JD, RN, is a senior vice president of The Doctors Company, a national medical malpractice insurer that is based in Napa, Calif.