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Plastic Surgery and Anesthesia: A Claims and Risk Reduction Workshop

Findings from two workshops recently held at The Doctors Company headquarters in Napa, California, were combined to offer a broad perspective on claims and risk reduction in plastic surgery and anesthesia.

Plastic surgeons and anesthesiologists met separately but focused on the same eight cases involving plastic surgery procedures with general anesthesia. This enabled The Doctors Company to address similar issues from two different specialty perspectives. In each case reviewed, the insured was either the plastic surgeon or the anesthesiologist. In no case were both specialists insured by The Doctors Company.

Anesthesiologists, who have historically had secondary liability exposure to surgeons, now play center stage in surgical dramas along with plastic surgeons.

All Eight Cases Reviewed Were Evaluated on the Following Criteria for the Plastic Surgeons:

• Patient Education—Did the medical record contain evidence of first-visit patient education and discussion of the procedure to be performed?
• Informed-consent Documentation—Was the informed-consent process adequate, with sufficient documentation to protect the physician?
• Smoker—If the patient was a smoker, does the medical record reflect advising the patient of the detrimental effects of smoking on scarring and healing?
• History and Physical Examination—Were a complete physical examination and assessment of the patient performed? Did the history and physical examination include a complete medical history, especially as related to surgery, anesthesia, and allergies?
• Facility—If it was an outpatient procedure, was the facility appropriate?
• Operating Time—Was surgical operating time appropriate for an outpatient setting?
• Recovery and Monitoring—What was the status of ancillary personnel who remained with the patient during the recovery period?
• Dictation—Does the surgical dictation match the operation? Was it dictated late? Was it appropriate for what was performed?
• Discharge —Was the patient discharged home? If not, where was the patient sent?
   

Anesthesiologists’ Review Criteria Were Adapted to Their Specialty:

• Patient Education —Did the medical record contain evidence of initial patient education and discussion of the anesthesia to be used?
• Appropriate Anesthetic Techniques and Agents—Was the anesthesia appropriate for this procedure? Did the patient meet selection criteria?
• Informed-consent Documentation—Was the informed-consent process documented, with sufficient information to protect the anesthesiologist? Was there a separate anesthesia consent document?
• History and Physical Examination —Were a complete preoperative examination and assessment of the patient performed, including oral inspection? Did the history and physical examination include a complete medical history, especially as related to surgery, anesthesia, and allergies?
• Facility—If it was an outpatient procedure, was the facility appropriate?
• Operating Time—What were the operating time and duration of anesthesia?
• Recovery and Monitoring —What was the status of each of the ancillary personnel who remained with the patient during the recovery period?
• Anesthesia Record Documentation—Are the preoperative, intraoperative, and postoperative notes timely and appropriate? Are the notes legible?
• Discharge—Was the patient discharged home? If not, where was the patient sent?
   

Selection of Review Criteria

Our selection of criteria for medical record review was based on two premises: (1) that the presence of these elements in a medical record significantly improves The Doctors Company’s ability to successfully defend an action against a policyholder, and (2) that review of these criteria enhances The Doctors Company’s ability to formulate effective loss prevention recommendations. For example, choosing the facility means the physician is responsible for selecting the correct venue for the planned procedure. Should an anticipated 12-hour surgery be performed under general anesthesia in a standalone surgicenter, or should the surgeon opt for an operating room in a hospital? What is the standard of care in determining whether inpatient or outpatient surgery is appropriate? Should the operating time be longer than a certain number of hours?

In addition to the fact that all eight cases were plastic surgeries with general anesthesia, there were several other significant similarities within the eight cases reviewed. Most of the procedures were performed in outpatient facilities. Six of the eight patients died, some within moments of transfer to an emergency room or within two weeks postoperatively. The two who survived surgery remain in poor general health.

The surgeries included: two dental reconstructions (asymmetrical jaw and a Class III malocclusion, accompanied by a cosmetic procedure); full and complete face-lifts; breast augmentation (with and without abdominal liposuction); and liposuction as a single procedure.

Surgery times varied by procedure, but were in the range of two-and-a-quarter to nine-and-a-half hours. Patient ages ranged from 25 to 74 years.

Case Record Reviews Were Based on the Criteria Previously Discussed:

• Evidence of patient education was found deficient in six cases by both groups of specialists.
• Plastic surgeons identified five records as either poor patient or procedure selection, while the anesthesiologists felt that four records did not meet the criteria for the type of anesthesia used.
• The informed-consent process was well documented in only two records by the plastic surgeons’ standards and in only one by the anesthesiologists’ standards.
• Physicians of both specialties felt that six of the eight records lacked complete physical examinations, medical histories, and lab work.
• Five records contained some form of anesthesia consent, but none of the records contained a separate anesthesia consent document, as recommended by The Doctors Company.
• All but two of the cases were appropriately venued, meaning that the surgical procedures for six cases could and should have been performed in an outpatient facility.
• The surgeons were critical of the length of surgery in three cases, while the anesthesiologists felt the general anesthetic was extended and problematic in only two cases.
• Both specialty groups were critical of recovery care in three cases.
• Dictation was well-timed and adequate in six of the eight records.
• Discharge data was requested to evaluate postoperative care and follow up, however, all eight patients were directly transferred to a hospital.
• Smoking history and current status were documented in five of the eight patient records.

Additional Reviewer Comments by Case

Plastic surgeons’ comments with loss prevention and defense implications:

• The patient experienced a drop in hemoglobin of 7.4 gms and did not receive adequate treatment.
• The patient was admitted to a hospital for continued care with complaints of shortness of breath and dyspnea, yet no chest x-ray or blood gases were ordered, and no pulmonary consultation was requested.
• Even though the procedure was appropriate for an outpatient facility, the surgical time was too long.
• In one case, it was the first surgery performed under general anesthesia in an unaccredited facility. In addition, the anesthesiologist carried no professional liability insurance and administered anesthesia on a revoked license. A law in this particular state requires state-approved agency accreditation for outpatient facilities in which anesthetic drugs that have the probability of placing a patient at risk for loss of life-preserving protective reflexes are administered.
• The patient contributed to complications by not providing a full medical history of a brachial cephalic occlusion with placement of a shunt from left subclavian artery to right carotid artery, and five years later, a revision of the graft. (One observer’s question: Did no one see the scars?)
• There is a strong possibility that this patient experienced an anaphylactic drug reaction that was not recognized by recovery room personnel.
• The patient was observed in recovery for two-and-a-half hours with face and neck edema, but no investigation and workup were performed to identify the cause, and treatment was not given.
• Inadequate information about the patient’s surgical procedure was transferred to the receiving facility, creating extended complications.
  

Anesthesiologists’ comments with loss prevention and defense implications:

• Patients with known asthma histories should be preventively medicated.
• Should jaw surgeries be performed in an outpatient facility?
• Anesthesiologist’s notes in the intraoperative record were difficult to follow, and drugs were given without rationale.
• The possibility of esophageal intubation was unrecognized as the patient’s reaction occurred within 30 minutes of induction.
• There was an unrecognized anaphylactic reaction without appropriate treatment.
• There was an unrecognized fluid overload without adjusted treatment.
• The patient had two previous surgeries not noted by the surgeon.
• Multiple medications were given without rationale (including four doses of verapamil).
• Pulse oximetry was not available in the recovery area.
• There were documentation discrepancies for the same patient by two recovery room personnel during the same time period.
• Seizure activity was not handled well by the anesthesiologist.
• Transfer notes were very poor, without follow up by the surgeon or anesthesiologist.
• There was inadequate fluid management: 8,000 cc crystalloid administered by anesthesia, with 7,000 cc tumescent input countered by only 1,000 cc suctioned output and 600 cc urine.

The Doctors Company Risk Management Observations of the Medical Records Were Mixed:

• Record contained adequate diagrams and drawings of intended surgical outcomes.
• Record showed good use of drawings to obtain informed consent.
• The record contained good informed-consent notes, with reference to risks, complications, and questions answered.
• The record showed questionable use of the patient health questionnaire.
• The record showed positive patient responses (high blood pressure, asthma with wheeze, bleeding tendency, and loose or chipped teeth) without follow up by the surgeon or anesthesiologist (blood pressure was 160/114 at start of procedure without treatment).
• Lab results were filed without indication that they were seen by the physician.
• The record contained illegible handwriting.
• There were inadequate record notes (e.g., “past treatment and medicines” were recorded illegibly).
• Incomplete or no responses were given on entire pages of questions on the patient health questionnaire.
• Three- to four-page consent forms are too lengthy for patient comprehension during time of stress.

Seven of the eight plastic surgeons reviewed were board certified, and one was board eligible at the time of the surgeries. Four cases were attended by board-certified anesthesiologists, and three by CRNAs. One anesthesiologist had neither a valid medical license nor professional liability insurance.

Loss Prevention Lessons

• Develop and apply proper patient-selection criteria; not everyone is a candidate for the surgery sought.
• Develop and apply facility-selection criteria. Determine the appropriate facility (hospital or outpatient) by rating the anticipated length of the procedure against the patient’s present condition.
• Develop or purchase and use up-to-date patient education literature on the procedure to be performed. Assess the patient’s level of understanding of the materials and the procedure, and address the patient accordingly.
• Develop a uniform surgical informed-consent process to be utilized in the facility.
  1. Condense the informed-consent document to one page if possible; research shows that one page is the full extent of the average patient’s understanding and retention.
  2. If additional information is necessary for patient education (i.e., smoking), prepare a special disclosure documenting the physician’s discussion with the patient.
• Develop a separate anesthesia informed-consent document and process. A single sentence related to anesthesia buried in the surgical consent form may not offer the anesthesiologist adequate coverage if an adverse anesthesia-related event occurs.
• Perform a full and complete physical examination, using the patient health questionnaire; review lab work.
  1. Ask about scars that are not included in the patient’s history, and follow up on any positive response; consider referring the patient elsewhere for surgical clearance.
  2. Pay attention to the patient’s medical history. If there were prior surgeries, ask about and record any anesthesia reactions.
• Always ask about and document medication allergies.
• Develop standard-of-care protocols for the recovery phase.
  1. A physician must remain in the facility and be readily available during the full recovery period, until the last patient is discharged.
  2. If a CRNA administers the anesthesia, the surgeon should remain available.
  3. Anytime a patient is placed under anesthesia, someone with advanced life support training should be on-site.
• Develop and apply facility standards for patient discharge.
• Provide complete patient information for transfer to a receiving facility when transfer is necessary.
• Develop and use a postoperative follow-up telephone call routine when patients are discharged home.
• Preoperatively, determine if the patient can go home or will need professional care for the first night. If professional care is required, arrange for hospital admission, a visiting nurse, or home health care.
• Be sure of all of your coworkers’ credentials.
  1. Confirm licensure and insurance coverage.
  2. Review state regulations that pertain to outpatient facilities, and limit yourself to those that meet the standards.
• Maintain a complete, legible medical record.
  

Although these recommendations are not guaranteed to keep you litigation-free, they will help a great deal to make any claim against you more defensible.

Other Issues

In addition to claims reviews, our panels of specialists discussed a number of other issues pertinent to their medical specialties.

Plastic Surgery Procedures Performed By Ancillary Personnel

There are currently many procedures offered in plastic surgery suites that are performed by ancillary personnel: collagen injections, endermology, cosmetology, acupuncture, micropeel, make-up, tattoo removal, and botox injections. While there are no strict guidelines for limiting these procedures, our plastic surgery panel members suggested the following questions to provide criteria for loss prevention:

• Does the ancillary health care provider have the training and education to perform these procedures?
• Does the state have specific regulations governing procedures performed by nonphysicians?
• Is the provider supervised on-site by a physician?
• Will the patient be evaluated by a physician before the procedure?
• Is the patient aware that the person treating him or her may not be a physician?
• Is a physician-approved informed-consent process in place?
• Is the informed-consent process performed by the service provider or the physician?
• If procedures are performed in a satellite facility, is the physician present? If not, does the patient know?

Miscellaneous

Addendum programs are also available in many plastic surgery suites, including: body wellness, weight loss (with and without drugs), nutritional wellness, nonsurgical face-lift, herbal therapy, skin care, vitamin supplement regimes, and personal trainers. Do all concerned understand their potential exposure and how it affects the physician?

These questions will guide practitioners to safer practices for addendum programs:

• Is the program offered as an optional addition?
• Has the program received FDA approval?
• Will the program interfere with surgery?
• Will the program extend the patient/physician relationship beyond the customary postoperative period?
• Are patients offered a choice beyond the physician’s program?
• Is there an informed-consent process for the program?
• Does the office have complete medical and allergy histories on the patient?
• Has a physician performed a physical examination on the patient if needed to clear him or her for the program?
• Does the physician have a financial interest in the program (stream of commerce considerations)? Note: HCFA’s Stark regulations may apply when products and programs are sold in a physician’s office. It is wise to learn how Stark rules may affect your practice.
  

Operating Room Distractions for Anesthesiologists

Distractions for anesthesiologists in the operating room appear to be increasing in both volume and frequency. Although The Doctors Company has not yet experienced associated claims activity in this area, we remind anesthesiologists that external distractions should be kept to a minimum during procedures. It is outside the standard of care for the anesthesiologist to combine reading, watching TV, or sleeping during his or her monitoring responsibilities. Just as it is unacceptable to abandon the patient by stepping out of the operating room, it can also be considered abandonment when the anesthesiologist is distracted and gives less than full attention to the patient.

Our panelist authors urge you to carefully re-evaluate all aspects of your surgical and anesthetic practices, with special focus on the issues we have addressed. They can make the difference between a high-quality, successful practice and a career shattering disaster. The Doctors Company remains committed to the protection of the policyholder.

As always, we are available to address your risk management and patient safety questions or concerns at (800) 421-2368, extension 1243.

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