Risk Management

Managing Medical Emergencies in the Office

Anne M. Menke, RN, PhD, OMIC Risk Manager

Digest, Summer 2012

Ophthalmologists and staff who work in an ambulatory surgery center or hospital operating room know that patients may have life-threatening cardiac or respiratory problems during a procedure. In these settings, emergency equipment and personnel with advanced training in the management of medical emergencies are on hand. Office-based eye surgeons and staff rarely have to confront such situations and may find themselves unprepared to provide safe patient care in the event of a life-threatening emergency. OMIC has had several cases related to death in the office setting. Lessons learned from these cases may provide assistance to our policyholders.

Q  We perform fluorescein angiography (FA) in our office. I know that, in rare cases, patients have died from anaphylactic reactions. What should we have on hand when performing FA?

A  FA is arguably the riskiest office-based procedure in ophthalmology. Based upon a review of expert witness testimony in related claims, it is clear that there is no need for a full “crash cart.” Ophthalmologists do not have the current competency to use most of the drugs and equipment found in crash carts, which are usually located in emergency rooms, intensive care units, and hospital wards. Moreover, few eye surgeons maintain Advanced Cardiac Life Support (ACLS) certification, and so should not attempt intubation or IV administration of emergency drugs. Both plaintiff and defense expert witnesses have opined that an “emergency kit” containing key drugs, such as Benadryl and epinephrine, along with oxygen and equipment to assist breathing (e.g., Ambubag and age-appropriate airways tubing), were adequate. They also recommended maintaining IV access until after the procedure was completed. There was disagreement about the need for an AED as these are only effective in treating arrhythmias.

Q  What were the main criticisms?

A  Rather than focusing on equipment, concerns centered on the lack of preparedness for a medical emergency. In two separate cases, family members were present and later testified that staff seemed harried and confused. They did not know where the oxygen tank and emergency kit were located and lost valuable time. In one case, there was disagreement about protocol and whether to call the anesthesia practice in the building, the code team from the adjacent hospital, or 911. When the anesthesia practice did not respond, they called 911, only to learn that only one of the building’s three elevators was large enough to accommodate a stretcher to the 10th floor, leading to a longer delay in getting emergency treatment. Neither practice kept the drug kit and oxygen in the room where the FAs were performed. And, clearly, neither had conducted emergency drills.

Q  What is the best way to prepare a protocol for an ophthalmic office?

A  Evaluate your patient population to determine the most likely and riskiest type of emergency situations, and review the types of procedures performed and anesthesia administered in the office. Offices that administer moderate sedation or perform procedures with a high risk of bleeding need more medications and equipment (see “Office-Based Surgery for Adults” at www.omic.com). Take into consideration the skill level of the physician and staff, the distance to the nearest emergency room, and 911 response time. This evaluation will help determine the materials needed in an “emergency kit.” Offices that do not offer FAs, moderate sedation, or higher risk procedures mainly need to know and recognize the signs and symptoms of medical problems common in adult patients, such as heart and lung conditions that put patients at risk for heart attacks and strokes. All physicians and staff members should have current certification in basic life support (BLS) for health care providers, which will allow them to do CPR if needed while awaiting the ambulance. Diabetic patients may also have hypoglycemic conditions, so a form of glucose should be available. Two persons, including a physician, should be available at all times when patients are in the office.

Q  What is an emergency protocol?

A  This is a document that describes the roles of the physician and staff members in the event of an emergency. Here are some common elements. One staff member should stay with the patient while another goes to notify the physician so that the patient’s condition may be evaluated. The physician should quickly determine if 911 needs to be called. The caller should give precise information about the patient’s condition and location and watch for the arrival of the ambulance. The physician should ask one person to document the patient’s condition and the exact sequence of steps taken to treat it (have a form available in the emergency kit). Family members, if present, may be able to assist by providing comfort to the patient. If not present, they should be notified as soon as possible. The protocol should also provide for a staff “debriefing” to collect information and provide support, as well as a plan for staying in contact with the patient and family.