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Midlevel Operations:
Exploring New Exposures
with Allied Health Providers
Jayme T. Vaccaro
Sedgwick
Learning Objectives
 Identify professional liability risks unique
to Midlevels and their Supervising
Physicians
 Discuss...
The World of Midlevels
 Who are they?
• PA’s, Nurse Practitioners, Midwives, Nurse
Anesthetist, etc.
 6,723 PA’s, 8.1% o...
Hot Topics for Midlevels
• Scope of Practice
• Supervisory Role of Physician
• Statutory Governance
• Tracking Midlevel Pa...
Scope of Practice
 What is Scope of Practice and How is it Determined?
• Healthcare Providers
• State Law
• Hospital Cred...
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 ordere...
Case #1 - Scope of Practice
 ED Physician, PA, ED Group, Radiologist &
Hospital Sued
 PA dismissed on Statute of Limitat...
Case #1
 Witness Abilities
• Nexus between Physician and PA
 Does this lead to credibility?
• PA made better witness and...
Supervising Role of Physician
 Vicarious Liability
• What if Physician Disagrees with care?
 Communication
• Open Door P...
Case #2
Is Anyone Supervising?
Case #2 Supervisory Role of
Physician
 40 Year Old Male with brain tumor
 Both Neurosurgeon and ENT perform surgery
 EN...
Case #2 Supervisory Role of
Physician
 Nurse Anesthesis not licensed
 Anesthesiologist supervising 8 Nurse
Anthesesis at...
Case #2 Supervisory Role of
Physician
 Anesthesiologist/Group Exposure
• Reality of Supervising
 Surgical Team Exposure
...
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 st...
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 Vi...
Case Study #3
 Next Morning
 Severe Headache,
Slurred Speech
 Patient returns to
Hospital ED and
transferred in the PM
...
Case Study #3
 Plaintiff’s alleged MD Missed Dx of
Impending Stroke—MRI instead of CT?
 2nd Visit Missed Dx of Stroke
 ...
Case #3
 Jury Verdict Award of $217M
 50% of verdict on MD and PA
 50% of verdict on MD Groups
 Punitive Damages of $1...
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
...
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 demis...
Basis PL Considerations: Case 4
 Final Read on Ultra Sound shows viable
fetus
 Final Read not relayed to ED but sent to
...
Case #4
 Training and Knowledge
• The PA did not know to retest
• The PA did not think to review ED records
• The PA did ...
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 @...
The Basics and More:
Case #5 Allegations
 Medical Issues:
• Pulse & Blood pressure: dehydration
• If dehydrated, labs? If...
The Basics and Then Some:
Case #5 Allegations
 Contract Issues:
• Hospital, Group and PA Contracts at Issue
• Hospital Co...
Putting It All Together
 Medical Knowledge
 Statutes
 Supervisory Role
Check-List for the Risk Manager
 Headcount
 Scope of Practice
 Supervision by Physicians
 Statutes
 Credentialing
 C...
Thank you
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Midlevel Operations: Exploring New Expsoures with Allied Health Providers

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Jayme T. Vaccaro, J.D.
Director, Professional Liability Claims
Sedgwick Claims Management Services, Inc.
Jayme.Vaccaro@sedgwickcms.com
www.sedgwick.com

Published in: Health & Medicine, Business
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Transcript of "Midlevel Operations: Exploring New Expsoures with Allied Health Providers"

  1. 1. Midlevel Operations: Exploring New Exposures with Allied Health Providers Jayme T. Vaccaro Sedgwick
  2. 2. 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
  3. 3. 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!
  4. 4. Hot Topics for Midlevels • Scope of Practice • Supervisory Role of Physician • Statutory Governance • Tracking Midlevel Participation • Credentialing • Basic Professional Liability Considerations
  5. 5. 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
  6. 6. Case #1 Who did the Jury Believe? Scope of Practice?
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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?
  11. 11. Case #2 Is Anyone Supervising?
  12. 12. 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
  13. 13. 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
  14. 14. Case #2 Supervisory Role of Physician  Anesthesiologist/Group Exposure • Reality of Supervising  Surgical Team Exposure  Hospital Exposure • Who Credentials? • Reliance?
  15. 15. Statutory Requirements  Awareness • PA’s • Nurse Mid Wives  Compliance  Effect on Cases and License
  16. 16. 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
  17. 17. Case #3 Did Anyone Review the Application?
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. Case #3  Tracking this case as a PA case  Back to Basics: Licensing and Credentials  When juries get mad, they get mad…
  23. 23. Basic PL Considerations  Documentation  Witness Abilities  Communication/Relationships with other Healthcare Providers  Bedside Manner  Medical Training and Knowledge
  24. 24. Case #4 The Basics of Pregnancy
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. Potpourri Medicine, Statutes, Supervision and Contracts
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. Putting It All Together  Medical Knowledge  Statutes  Supervisory Role
  33. 33. Check-List for the Risk Manager  Headcount  Scope of Practice  Supervision by Physicians  Statutes  Credentialing  Contractual Issues
  34. 34. Thank you
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