Emergency Room Protocol for On-Call Ophthalmologists

By Kenneth C. Chern, MD

Argus, August, 1996

Many emergency room physicians receive little or no formal training in ophthalmology, yet they commonly see and treat acute ophthalmic injuries. As a consulting ophthalmologist, you may find yourself relying on an ER physician’s description of a patient’s condition and recommending treatment by phone without ever seeing the patient. Follow-up may not occur until days later, by which time the patient’s condition may have advanced beyond the window for optimal treatment. These factors increase the risk of ER-related claims.

The following is a typical scenario:

It is 10:00 on a Saturday night. A 35-year-old man comes to the ER with a red, painful right eye. The ER physician calls you at home:

“Hello, this is Dr. Jones, ophthalmology, on call.”

“This is Dr. Smith in the ER. I have a young man here for whom I want a sideline opinion. You don’t have to come in.”

“OK, what happened?”

“Mark wears extended wear contact lenses. He hasn’t worn them for the past 48 hours or so because of discomfort, although he regularly wears them continuously for up to two weeks. I think he may have scratched his cornea putting his lenses in since a small area of the cornea lights up with fluorescein. He says he has scratched his cornea several times before. What do you do for these corneal abrasions?

“Usually they heal with an antibiotic ointment and an overnight patch.”

“I’ll patch him up and have him see you on Monday morning.”

“That will be fine. Good night.”

On Monday morning, when the patient comes in, you find a dense stromal infiltrate and purulent material under the patch. The “scratched cornea” was the start of an infective corneal ulcer. With appropriate antibiotics, the cornea heals, leaving a residual scar and decreased vision.

With emergency rooms and urgent care centers fast becoming the first gateways for acute ophthalmic emergencies, a methodical and regimented routine is essential to ensure that the patient receives prompt and appropriate initial treatment.

It is not always necessary for the ophthalmologist to see the patient in the ER. Phone consultation may be sufficient and expedite care and treatment. However, when providing telephone consultation, a thorough history, vision test, and full physical exam are necessary to elicit other causes of the symptoms that the ER physician may not have considered. If you have any doubt about what has been described, there is no substitute for examining the patient yourself. Mentally run through a differential and treat the patient as if you were treating the most serious possibility. A corneal abrasion will heal even if it is treated as a bona fide infection with topical antibiotics.

Follow all emergencies closely until they are resolved. Referral follow-ups from the ER especially need to be re-evaluated in a timely fashion by an experienced ophthalmologist even if this means seeing the patient on a weekend or a holiday. This is part of appropriate patient management for an on-call physician.

Education is the best prevention against scenarios like the one described. Educate the ER physician and staff to recognize signs of serious ophthalmic problems, to express uncertainty, and to contact the on-call ophthalmologist immediately in complex cases. Encourage them to ask more probing questions when history and examination findings do not fit the diagnosis. When you are on call, report back to the ER physician about patient outcomes. This may be the only feedback and instruction they receive on ophthalmic emergencies. Their education is your best defense if a claim arises from care in the ER.

Ancillary Personnel Should Know Their Limits When Screening Patients

By Richard H. Birdsong, MD

Argus, Nov.-Dec., 1996

Increasingly, ophthalmologists are relying on ancillary personnel to screen patients, but as the following case history illustrates, ancillary personnel need to understand their clinical limitations. When faced with serious eye problems beyond their training and experience, they should know when to refer patients to an ophthalmologist.

A 15-year-old male was struck in the left eye with a dart-like projectile. After removing the projectile, the boy noted “tearing” and sought medical attention. He presented to the emergency room of a community hospital, where he was referred to the ophthalmology clinic within the same hospital. The patient initially was seen by a technician who, following the clinic’s protocol, took a brief history, obtained a visual acuity, and performed a non-contact tonometry (NCT). The patient noted that the “tearing” from the injured eye ceased after the NCT.

After these screening steps, one of the clinic’s ophthalmologists evaluated the patient, noting a central full thickness corneal laceration, air in the anterior chamber and lens damage. The patient was immediately referred to the nearby supporting medical center for emergent evaluation and repair.

At the medical center, the examination revealed VA of count fingers two and one-half feet OS. In addition to the corneal laceration, there was lens cortex and capsule to the wound. The patient underwent emergent repair of the corneal laceration, lensectomy and sulcus fixated posterior chamber intraocular (IOL) placement. Intravitreal hemorrhage was noted nasal to the disc, consistent with an exit wound. Systemic and subconjunctival antibiotics and subconjunctival steroids were given.

Two days later, the patient developed endophthalmitis and returned to surgery, at which time the IOL was removed, a core vitrectomy was performed, and intravitreal antibiotics were given. Cultures revealed gram positive cocci in chains and pairs, gram negative rods and gram positive rods.

Four days after the initial injury, the patient again returned to surgery for repeat intravitreal antibiotics and cultures, which revealed persistent gram positive cocci. The endophthalmitis resolved, but four weeks later there was a corneal wound melt, which was treated with cyanoacrylate glue. Two weeks later, further cortical vitrectomy was performed for a traction retinal detachment and nonclearing vitreal debris. Presently, the patient has VA of CF at three feet with +12 correction and a cloudy central cornea. VA by Potential Acuity Meter is 20/160, and a penetrating keratoplasty is planned for the future.

In this case, the proper use of screening procedures by ancillary clinic staff prior to patient evaluation by the ophthalmologist was called into question. While the dart was the likely source of bacterial contamination, introducing air into the anterior chamber during NCT was almost certainly a contributing factor. This could have been avoided if the technician had recognized the significance of the patient’s history and presenting complaints as well as the urgent need to consult the ophthalmologist before proceeding further.

Screening protocols are clearly an efficient time-saving tool since most patients present with common clinical problems that can be handled well by a division of labor between the ophthalmologist and the clinical staff. However, these protocols can contribute to adverse outcomes if they don’t include eye trauma and selected eye emergencies, particularly when clinic staff who are inadequately trained or unfamiliar with potentially serious eye conditions perform screening tests. In this case, the technician was unable to determine that the patient’s history indicated a very strong possibility of an open globe, which contraindicated NCT.

Screening procedures should allow for some flexibility, and technicians should be encouraged to ask the ophthalmologist to initially examine patients who present with non-routine problems.

Eyes, Lies and Videotape

By Jean Hausheer Ellis, MD, FACS

Argus, May 1997

For quite some time, ophthalmologists and other specialists have been videotaping surgical procedures, sometimes for educational purposes and sometimes to help keep operating personnel aware of the progress of a surgical procedure. Some ophthalmologists offer their patients a copy of the video to enhance patient education and strengthen the patient/physician relationship as well as to market a given surgical method or technique to a targeted audience. Considering, however, that about 70% of medical misadventures for all specialties occur in the operating room, a videotape can act as a shield and help diminish the chance of a paid claim or as a sword and increase exposure to a claim.

The Physicians Insurance Association of America (PIAA), an association of about 50 doctor-owned professional liability insurance companies, surveyed member companies and found that only 18% of respondents thought a videotape of the procedure would be helpful in making the decision to defend or settle a case. Some respondents felt the risks of using a videotape far outweighed the benefits. One member company reported that it had to make a settlement for $700,000 more than it thought a case was actually worth because the wrong instructions had been given to the surgeon and were recorded on the audio portion of the videotape.

PIAA also surveyed defense attorneys and found that 73% opposed videotaping surgical procedures. Some commented that videos present an inflammatory scene to an untrained eye in the jury box, and an appropriate procedure could appear otherwise to a layman, resulting in a frivolous or nuisance lawsuit. Another concern was that since fewer than 40% of iatrogenic injuries ever come to the attention of the patient, why send the patient home with a tape that might clearly show the surgeon making a mistake?

If an ophthalmologist does decide to videotape surgery, it is important to have policies and procedures in place. In most states, the videotape of a surgical procedure will likely be considered part of the patient’s medical record. As such, if a malpractice suit is filed, videotapes will be discoverable by the plaintiff and admissible at trial. Therefore, videotapes should be identified with the patient’s name, identification number and date of procedure. As with all medical records, videotapes should be properly stored to prevent loss, misfiling or damage. Videotapes should be stored under the proper conditions (i.e., humidity, temperature and darkness) to preserve their quality.

Obtain Separate Informed Consent Before Videotaping

Before videotaping a surgical procedure, obtain a separate informed consent which includes the reasons for taping the surgery, permission to tape the procedure in question, and the fee, if any, to be charged for taping the procedure. It also should include permission to use the videotape for educational or other purposes, and acknowledgment that the surgeon has the right to retain ownership and possession of the original tape. The form should include an explanation of the patient’s right to obtain a copy of the tape and the involved charges, if any, as well as a description of the physician’s policy regarding the length of time the tape will be preserved. It is recommended that the form include the scheduled date for destruction of the tape with an explanation that the patient should request a copy prior to that date if desired.

It is important to be consistent when videotaping. For example, some videotapes purposely contain only part of a procedure (especially if a problem arises during surgery). Generally, it is advisable to tape the entire procedure including difficult problems. If it becomes necessary to discontinue videotaping a surgical procedure, or if there is unintentional alteration or erasure of a videotape, the reason and a description of the discontinuance, alteration or erasure should be documented in the patient’s medical record. Intentional alteration, editing or erasure of a videotape without prior written consent of the patient is as improper as altering the written medical record. If there is any intention to edit, erase or destroy a tape (prior to the scheduled date of destruction on the informed consent), the ophthalmologist should advise the patient of this intention prior to doing so, and obtain the patient’s written consent. A dictated transcription of the designated videotape to be destroyed can be done prior to its destruction.

In conclusion, if the ophthalmologist has a specific protocol in place for videotaping surgery (informed consent and consistency when taping) and handling the videotape (storage and ultimate disposition), the possible legal risks of videotaping a surgical procedure can be minimized.

Ten Steps to Ensure that On-Call Coverage Doesn’t Put Your Patient on Hold

By B. Thomas Hutchinson, MD

Argus, September 1997

Medical call coverage, the transference of patient care responsibility from the “attending/treating” physician to a “covering” physician, is a necessary and integral part of contemporary ophthalmic practice. However, when patient care responsibility is transferred, there is greater risk exposure because of real or perceived undue delays in addressing the medical problem and lack of an established relationship between the patient and covering physician. If not carefully planned, effected and monitored, call coverage may be detrimental to the patient and result in a malpractice lawsuit, not only pitting patient against physician but, at times, physician against physician.

Establishing guidelines for coverage that ensures quality care for the patient will satisfy the risk management aspects of shared responsibility and enhance the image of the practice with patients. The following concepts are important to consider when evaluating existing or new call coverage.

Although most state licenses allow a physician to practice medicine and surgery in the broadest sense, a prudent course is to arrange coverage with an ophthalmologist who has similar training and experience, whenever possible. Practice patterns in call coverage must meet the standard of the community, which may vary between geographic areas of concentrated subspecialty care and areas of sparse medical coverage. In areas of concentrated subspecialty care, sharing coverage between different ophthalmic subspecialists and between comprehensive ophthalmologists and subspecialists may be appropriate only if each has maintained skills and practice patterns commensurate with the spectrum of care in the medical call coverage. Optometric and ophthalmological cross-coverage and that of different disciplines of medicine is an inappropriate policy and opens one to substantial legal risk.

Both the treating/attending and covering ophthalmologist should acknowledge the time the coverage starts and ends. The treating/attending ophthalmologist should advise the hospital, office and answering service of the name and telephone numbers of the covering physician. The covering ophthalmologist should advise the hospital, office and answering service of his/her availability and how to be reached.

The treating/attending ophthalmologist should provide covering physicians with information on patients with acute or anticipated problems; this should be documented in the patient’s medical record. The treating/attending ophthalmologist also should give these patients the covering ophthalmologist’s phone numbers and arrange for scheduled visits if the interval of coverage warrants it.

Instructions to the patient from the answering service or other facility must be clear and complete. If possible, an alternative referral source should be provided in case the ophthalmologist on call is unexpectedly unavailable. Access to the physician on call or the responsible facility must be given on the initial inquiry of the patient.

The medical records of the practice being covered should be available if needed.

Documentation

Recording the name, telephone number, identifying address, time of call, reason for call, disposition of the inquiry and follow-up arrangements is absolutely necessary. When returning the call coverage to the treating/attending ophthalmologist, the record of calls and care given will provide continuity of the patient’s care and establish for the written record the events of the on-call care provided.

If a patient’s concerns are not completely addressed during a telephone inquiry, the patient should be seen by the covering ophthalmologist, even if the patient is known to the covering ophthalmologist.

The treating/attending ophthalmologist should partner only with fellow ophthalmologists who share his/her own philosophy regarding prompt, high quality and ethical service to the patient.

Follow-up communication with both patients and any covering ophthalmologist should be a priority when the treating/attending ophthalmologist returns to cover the practice.

Although coverage arrangements are especially important for solo practitioners, it is also important for ophthalmologists in group practices to have clear policies defining coverage arrangements with their associates.

A timely response to a real or perceived emergency benefits not only the patient, but also the practice of both the attending and covering ophthalmologist. In summary, an effective, medically correct and responsive call coverage program is a necessity for every practicing ophthalmologist.

Risk Management Concerns of Satellite Offices

By E. Randy Craven, MD, and Kirk H. Packo, MD, Digest, Fall 1997

Ophthalmology is in a period of transition. With reimbursements steadily declining and competition steadily increasing, ophthalmologists are looking for ways to better position themselves in the market place. Satellite offices present an opportunity to increase patient access and volume, often with a minimal increase in overhead since staff and equipment may already be in place. Unfortunately, the physician working in a satellite office may be unfamiliar, and thus uncomfortable, with the equipment or staff and feel that the satellite office does not offer the same therapeutic and diagnostic capabilities as the main office. A “carpetbagger” mentality may evolve if the physician attempts to reap the benefits of a satellite patient volume with only a minimal outlay of overhead or time.

Managed care may create a carpetbagger mentality by its very nature: An ophthalmologist provides care through an insurance or managed care plan at a distant facility operated by the plan. Under the terms of the plan, procedures and operations must be done at this approved facility. The purchase of equipment, hiring of personnel, and management of medical records are handled by the plan. The arrangement feels “transient” and the ophthalmologist has less control over patient care. Patients, for their part, may feel restricted if all their care must be rendered at one facility.

New Risk Management Concerns

Some basic medical-legal concerns are common to all possible combinations of office locations and affiliations. Medical records, postop or emergency care, telephone coverage, equipment upkeep, and staff scheduling present potential problems in all types of satellite arrangements. Other concerns include business expenses, malpractice insurance costs, liability for employees traveling to satellite offices, office image, security and safety, and time-share liability.

Satellite offices can fragment a practice, resulting in two tiers of care if the practitioner does not work to avoid this pitfall. The ophthalmologist must apply the same standards and expectations to the care of satellite patients that exist in the main office, especially when patients are being comanaged. Strong leadership and frequent meetings between physician and staff are necessary to address problems related to emergency care, record keeping, and telephone coverage and to ensure a consistent level of care among various offices. Practice administrators should visit locations frequently to ensure that set office management protocols are followed even if the satellite staff is not employed by that administrator.

Telephone Coverage

The traditional office used one phone number, housed all records at one location, and followed one schedule. Now, the practice with satellite offices may use several phone numbers, house records at several locations, have numerous doctors visiting numerous locations, follow multiple schedules, and be staffed by personnel employed by multiple entities. A primary issue that arises is telephone coverage.

Many practices use a common phone number for all practice locations, often requiring a dedicated phone operator. Patients calling in have no idea the phone is actually being answered at a site distant to their treatment facility. Offices outside the immediate area provide a toll-free number so patients can easily touch base with their physician. In other instances, each location may have a different phone line but be able to forward calls to a main number.

The satellite patient or doctor should never feel out of touch, even when the office is unstaffed. Certain telephone principles help reduce potential liability. Call forwarding to the main office is an easy solution and gives patients a sense of security provided the staff remembers to activate the system at each day’s end. Sophisticated systems are available through local phone carriers that will transfer calls even after a power outage. Recorded messages and voice mail systems may be less costly but may frustrate patients and foster feelings of abandonment. Long voice prompt menus further frustrate patients and should always be kept to a minimum.

When sharing another practitioner’s office, the satellite physician may choose to use the existing phone line instead of installing a separate line forwarded to a main location. If this is the case, the satellite staff should be educated on how to handle calls for the visiting satellite practitioner, avoiding such responses as:

“Doctor Smith only comes here once a week. Please call back later.” Or, “We don’t know where Doctor Smith is today.”

Providing satellite offices with the physician’s main office number, cellular phone number, beeper number, daily schedule, and specific instructions for handling emergency calls is crucial when problems arise and patients need prompt care. Phone triage by the comanagement staff should be seamless for the visiting practitioner. If there are different staff at each location, acquaint them with each other to foster a single team mentality toward patient care. Turn the phone line into a valuable risk management tool rather than a potential liability.

Patients should be aware that their physician practices in a different location on a given day and that his or her scheduled presence in the satellite office may be limited. If a comanagement system is not in place at the satellite facility, provide patients with the addresses of the other office locations in case they need to travel to a distant location for urgent care. Giving patients pre-printed maps and driving directions helps foster a sense of caring and security.

Medical Records

Medical record management is probably the biggest consideration for the satellite office. Electronic medical record keeping offers the best solution for practices with multiple locations because it allows quick and up-to-date record access when a patient presents on an emergent basis. The electronic medical record is still an expensive solution requiring auxiliary hardware, computer expertise, and additional learning and set up time, but it may be well worth the effort for effective satellite office management.

If standard paper charts are used, a concerted effort must be made to check and double-check that records are coordinated from the various offices. A decision must be made about where to house paper charts for satellite office patients. Typically, charts are kept at the satellite facility when run by a managed care plan or hospital clinic. A duplicate record system (a “skin” chart) may be necessary to keep adequate information, but each chart needs to contain the same information. The duplicate record is then housed at the main facility and transported back and forth to the satellite. This is helpful in handling emergency calls from patients at the main facility when obtaining the original record from the satellite is difficult or impossible.

When charts are housed only at the main facility, special care is needed to make sure all records are packed and completed prior to being transported to the satellite. “Add-on” patients at the satellite create a special records problem. If possible, have someone at the main office available to fax the needed record information. If someone is not available at the main office, add-on patients are best seen as new patients so problem areas are not missed. Notes for each day should be refiled in the original chart in a timely fashion to avoid therapeutic mistakes. Filing loose notes out of chronological order is another potential pitfall and an invitation to mistakes.

The medical record is the single most important risk management document and all responsibility for its completeness falls upon the practitioner, not the housing agency. There is no defense in blaming a medical records department or other practitioner’s staff for lost notes or missing or incomplete charts.The use of a digital dictation system via phone line is one solution to directing notes to the appropriate chart location. Being able to dictate chart notes at night or during off-hours directly to a specific location minimizes the risk of lost or forgotten documentation.

Soliciting satellite patients to participate in their own care by providing them with a copy of their tests and records and mentioning what needs to be done at their next visit may be helpful. If they are then seen at a second facility or at a later time and know that a fundus photograph was needed at the time of their next visit, they can remind the ophthalmologist of this. This can be especially helpful with complicated ocular diagnoses. Still, the ultimate responsibility lies with the treating physician.

Photos and fluorescein angiography present a challenge for satellite record keeping since graphic images cannot be sent by ordinary fax lines. A patient presenting to one office for laser treatment when the needed fluorescein angiogram is in another location invites delays, courier expenses, or the urge to inappropriately treat the patient without the angiographic guidance. Further mistakes are invited if an angiogram ordered in one practice office is read by another practitioner who may not be as familiar with the patient’s clinical exam or history. When angiograms need quick attention such as in acute exudative macular degeneration, the satellite office should have a system in place for timely review or transfer of the film to the reading physician. A digital angiography system using telemedicine techniques is one solution, but its expense may be a deterrent.

Comanagement Arrangement

The comanagement arrangement is critical to the success of a satellite office. As a rule, it is wise to keep an arms-length distance when entering into a satellite comanagment arrangement. This allows you to maintain your objectivity and not be forced into financial arrangements or patient care scenarios that do not meet your approval. Research your comanagement partner’s education and training, malpractice claims history, and understanding of managing postop problems. While checking malpractice claims history may sound excessive, it is wise to protect your own liability. At the very least, you should confirm that your comanagement partner’s professional liability policy limits match your own so you are not the “deep pocket.” When working with providers where you provide satellite surgical coverage, it is very important that everyone involved has a clear understanding of who is responsible for what.

Case Study

A solo practitioner retinal surgeon maintains a satellite office 80 miles from his main office and once a week sees patients in a hospital time-share office. On one such visit, he performed an uncomplicated scleral buckle operation on a 65-year-old male in the early evening hours following completion of a routine patient day. After sleeping over night in the hospital call room, he examined the patient at bedside at 4:30 a.m. and observed the retina to be attached and tactile pressure to be normal. The surgeon then drove to his main facility to begin another scheduled day. The patient was discharged with instructions to follow-up at the satellite office in one week. No comanagement arrangement was set up; the patient was instructed to call if any problems arose. That evening, the patient called complaining of continued severe pain and nausea. Rather than drive back to re-examine the patient, the surgeon prescribed potent oral narcotics by telephone. The patient presented to his original ophthalmologist four days later still complaining of pain and was found to have no light perception with a pressure of 60. The patient filed suit against the retinal surgeon alleging negligent misdiagnosis of postop angle-closure glaucoma. He ultimately received a large settlement.

This case study demonstrates the dangers of a satellite setup in which there are no provisions for handling postop problems. Successful comanagement, particularly in rural or distant satellite situations, is critically important when postop problems arise. It would not have been necessary for the retinal surgeon to drive back to the satellite office if a defined comanagement setup had been in place. Some geographic areas use visiting nurse practitioners for this as a standard of care.

When a patient is referred by the comanaging provider, it is important to discuss the patient’s expectations of surgery. An open and honest discussion before surgery will help avoid problems later. The visiting provider needs to let the patient know what to expect during and after surgery, including where the patient will have to travel in the event of a complication. Some practitioners continue to see patients postoperatively at intervals whether or not a comanagement fee is billed by the referring ophthalmologist or optometrist, primarily as a risk management tool.

Conclusion

The basic principle in caring for patients at a satellite office is to strive at all times to provide a single consistent level of care throughout the entire practice regardless of facility location. Effective use of comanagement, careful record keeping, and phone planning remain powerful tools in the creation of a low liability satellite facility. (A sample form, Confirmation of Postoperative Comanagement Arrangement, is included in the Appendix.)