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Midwest Medical Liability Management Association Medical Liability Webinar October 2012

Midwest Medical Liability Management Association Medical Liability Webinar October 2012. W elcome to the first Midwest Medical Liability Management Association medical liability webinar. We trust the convenience of this presentation via the internet will be beneficial to you.

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Midwest Medical Liability Management Association Medical Liability Webinar October 2012

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  1. Midwest Medical Liability Management AssociationMedical Liability WebinarOctober 2012 Welcome to the first Midwest Medical Liability Management Association medical liability webinar. We trust the convenience of this presentation via the internet will be beneficial to you. As mentioned in our recent communiqué this production is intended to replace our traditional live seminars enabling you to receive this valuable information without having to travel far; saving you time and money. Your attendance will earn payment of Professional Protective risk management incentive fees upon your completion of the short quiz at the end of the presentation. Please take advantage of this generous benefit. It will help you in your practice, help you to avoid claims, and help in supporting your Midwest Medical Liability Management Association’s sponsored insurance carrier. Given this is our first webinar it goes without saying there may be glitches along the way. After participating please share your thoughts concerning the convenience, the material, and if there are any problems you experience. We will do our best to help. Thanks for your membership. We hope you enjoy this presentation and look forward to hearing from you. Please email replies to risk manager Jim Olsen at: jdonlm@cablespeed.com

  2. Midwest Medical Liability Management Association • Agenda • Part I Case Presentation • Part II Diabetic Foot Ulcer Care • Part III Loss Prevention– Discharging a Patient • Part IV PPI Chairman’s Report • Part V PPI Claims Report

  3. Midwest Medical Liability Management Association Part ICase Presentation

  4. Midwest Medical Liability Management Association Case ReportProfessional Protective Insurance, Ltd. Risk Management Presentation October 2012

  5. Midwest Medical Liability Management AssociationCase Presentation As is done every year at our live seminars we are presenting a case for your review. This case was gleaned from information provided at a national podiatric seminar. It pertains to a type of problem many of you see and treat with regularity, and is being presented because a claim resulted. Review it and consider each step along the way. At the end of this session you’ll be asked to complete a short quiz that will address medical and management issues pertaining to the highlights of the case. Your comments concerning this presentation will be welcomed.

  6. Midwest Medical Liability Management Association The Patient • 59 year old male • Postal worker • Hx. excision of left calcaneal exostosis • C/O recurrent pain left heel, increasing in severity

  7. 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

  8. Midwest Medical Liability Management Association 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

  9. Midwest Medical Liability Management Association 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.

  10. Midwest Medical Liability Management Association 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 • When was Ibuprofen prescribed? • Why was cephalexin prescribed?

  11. Midwest Medical Liability Management Association 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 • Why diathermy through cast when cast was later removed?

  12. Midwest Medical Liability Management Association 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?

  13. Midwest Medical Liability Management Association Course of Treatment (continued) • Pt. returned weekly for next 2 weeks • Same documentation and same treatment • Weight bearing status? • Home instructions?

  14. Midwest Medical Liability Management Association 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?

  15. 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?

  16. Midwest Medical Liability Management Association 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?

  17. Midwest Medical Liability Management Association 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

  18. Midwest Medical Liability Management Association 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?)

  19. Midwest Medical Liability Management Association 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.

  20. 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

  21. Midwest Medical Liability Management Association 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?

  22. Midwest Medical Liability Management Association 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.”

  23. 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?

  24. Midwest Medical Liability Management Association Progress Patient returned every 3 days for next 2 visits

  25. 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?

  26. Midwest Medical Liability Management AssociationProgress 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 – 1st mention of systemic symptoms - PT. not admitted. Why? - Pt. not following with ID. Why? • 7/23/07 – Finally sent to hospital

  27. Midwest Medical Liability Management Association 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

  28. Midwest Medical Liability Management Association 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)

  29. Midwest Medical Liability Management Association 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

  30. Midwest Medical Liability Management Association Outcome Settled during mediation

  31. Midwest Medical Liability Management Association 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

  32. Midwest Medical Liability Management Association Part IIDiabetic Foot Ulcer Care

  33. APMA National Convention Presented by PPI with cooperation and credit to APMA National Convention Aug 16-19, 2012 Washington DC Midwest Medical Liability Management AssociationDiabetic Foot Ulcer Update

  34. Midwest Medical Liability Management Association Diabetic Facts 2011 • 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.

  35. Midwest Medical Liability Management Association Diabetic Facts 2011 • 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.

  36. Midwest Medical Liability Management Association Order of PriorityIn Treating Diabetic Acute Ulcer • Treat the Infection First: Patient Can Die! • Treat Vascular Status next. • Function and Structure come next. • Cosmetic consideration should come last.

  37. Midwest Medical Liability Management Association Suggested Debridement Goals: • 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.

  38. Midwest Medical Liability Management Association Today’s Care • 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.

  39. Midwest Medical Liability Management Association When Using Cam Walkers...Studies Show • 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.

  40. Midwest Medical Liability Management Association New Standard of Ulcer Care • 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.

  41. Midwest Medical Liability Management Association BUT MOST IMPORTANT OF ALL! • 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.

  42. Midwest Medical Liability Management Association REMEMBER…FOOTLAW.COM 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.

  43. Midwest Medical Liability Management Association Note of recommendation... 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.

  44. Midwest Medical Liability Management Association Part IIIRisk Management Tips & Ideas“Discharging a Patient”

  45. Midwest Medical Liability Management Association Risk Management Tips & ideas 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.

  46. 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 jdonlm@cablespeed.com

  47. Midwest Medical Liability Management Association Part IVReport from the Chairman of:Professional Protective Insurance, Ltd.

  48. Midwest Medical Liability Management Association Some information from professional protective Report from the Chairman of the Board Dr. James H. Simonds, Sr., DPM “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.”

  49. Midwest Medical Liability Management Association Part VReport from the Claims Committee of:Professional Protective Insurance, Ltd.

  50. Midwest Medical Liability Management Association More information from professional protective Report from the Chairman of the PPI Claims Committee Dr. James H. Simonds, Sr., DPM 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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