Liability and High ratio supervision

[caligas]

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can anybody with a TRUE understanding of the law comment on liability issues with medical supervision in anesthesia? I am NOT talking about medical direction which has a max ratio of 1:4 and where the MD sees every patient prior to induction. I’m taking about the 1:10 or 1:12 where they just call you to put out fires.

Specifically when does your DUTY to the patient begin? As a totally made up example: you are in a 1:10 model and a patient that you never met is induced. They have a known full stomach nevertheless an LMA is placed by CRNA. You are called to assist when the patient has already aspirated. You manage appropriately from that point forward but patient dies. According to the LAW (I get that liability is always possible due to emotional aspects with juries) have you committed malpractice?

 

[deleted171991]

can anybody with a TRUE understanding of the law comment on liability issues with medical supervision in anesthesia? I am NOT talking about medical direction which has a max ratio of 1:4 and where the MD sees every patient prior to induction. I’m taking about the 1:10 or 1:12 where they just call you to put out fires.

Specifically when does your DUTY to the patient begin? As a totally made up example: you are in a 1:10 model and a patient that you never met is induced. They have a known full stomach nevertheless an LMA is placed by CRNA. You are called to assist when the patient has already aspirated. You manage appropriately from that point forward but patient dies. According to the LAW (I get that liability is always possible due to emotional aspects with juries) have you committed malpractice?

Probably not, but you'll have to prove it in court, where everybody will try to blame everybody else. And, as you mentioned, you can be found liable even when you shouldn't. The jury may not understand the "medical supervision" concept.

I would rather do another residency than work in a supervision setting.

 

[sevoflurane]

I’ve never been involved in any sort of malpractice case. I know many that have been however. These cases can go on for years. It’s the type of stress I’d try to avoid at all costs.

 

[IMGASMD]

I certainly don’t have the TRUE understanding of it, nor do I ever want to. From I’ve gathered, the patient’s side will comb through every single record and get everyone who is ever invovled onto their suit first. Surgeon, Anesthesiologists, residents, CRNA, nurse, scrub and of course hospital. Then comes the fun time of determining who has the deepest pockets. If this thing is going to be dragged on for years, I as a “victim”, why would I go after CNRA when the anesthesiologist has better insurance?

Then as previous posters have pointed out, you also have to convince the jury, who probably have average IQ less than medical professionals, the differences between anesthesiologist solo/supervision/direction practices. Why the guideline was followed or not. You already lost 90% of the battle when the lawyers showing a video of a vegetable that needed long term care.

 

[Man o War]

You are equally on the hook for either model. We used a mix of both models in my old practice (OB vs the ORs), and this was the final word from an attorney I asked.

 

[San Marzano]

You are equally on the hook for either model. We used a mix of both models in my old practice (OB vs the ORs), and this was the final word from an attorney I asked.

JFC that’s terrifying.

 

[Man o War]

JFC that’s terrifying.

This is why supervision ratios are so important, we must not allow AMCs and hospitals to hang us out to dry making us supervise 8 nurses. At the end of they day, WE are the ones who have to endure the stress of a lawsuit. One of my friends had a huge lawsuit against him that took 3 years to conclude. It was horrific and took a toll on him. Amniotic fluid embolus, woman died. CRNA released from liability fairly early on even though she was there the whole time. The OB and my friend were taken all the way to the bitter end.
@IMGASMD is absolutely right. They decided the nurse wasn’t worth going after but the doctors were.

 

[skypilot]

This is why supervision ratios are so important, we must not allow AMCs and hospitals to hang us out to dry making us supervise 8 nurses. At the end of they day, WE are the ones who have to endure the stress of a lawsuit. One of my friends had a huge lawsuit against him that took 3 years to conclude. It was horrific and took a toll on him. Amniotic fluid embolus, woman died. CRNA released from liability fairly early on even though she was there the whole time. The OB and my friend were taken all the way to the bitter end.
@IMGASMD is absolutely right. They decided the nurse wasn’t worth going after but the doctors were.

Doing your own cases you have a 95% chance of getting sued during your career. If you supervise at 4:1 you probably have a 99.9999999 percent chance. 8:1 gives you an even more excellent chance of getting sued.

It is your license and your career on the line when you are lining the pockets of the CEOs. Nobody is going to come to court with you and defend you even though they exploited you for years.

 

[IMGASMD]

Doing your own cases you have a 95% chance of getting sued during your career. If you supervise at 4:1 you probably have a 99.9999999 percent chance. 8:1 gives you an even more excellent chance of getting sued.

It is your license and your career on the line when you are lining the pockets of the CEOs. Nobody is going to come to court with you and defend you even though they exploited you for years.

Do you have that statistics somewhere, or just your best guesstimate? The problems, we don’t ever get to know any of this, as residents, as associates or even as junior partners, maybe even as partner before they sell to AMCs. It’s too shameful, it’s too embarrassing, it’s just not talked about?

Then AMC comes and feel hiring nurses are much cheaper than Anesthesiologists.... rest is history. But I’d like to see if anyone actually has any data on that?

 

[Mman]

Doing your own cases you have a 95% chance of getting sued during your career. If you supervise at 4:1 you probably have a 99.9999999 percent chance. 8:1 gives you an even more excellent chance of getting sued.

It is your license and your career on the line when you are lining the pockets of the CEOs. Nobody is going to come to court with you and defend you even though they exploited you for years.

OK that's just not true. I think we've had 4 or 5 lawsuits in our group in the last 30 years and that probably covers a combined 500+ years of physician practice in an ACT model. Your odds of getting sued are more dependent on what state you work in than on what model you work in.

 

[hypnosMD]

Is this where all the care team superpartners/amc player-owners come in and tell us that there is no increased liability, it’s all overblown, outcomes are the same, and lawsuits settle at or below your limits? Drink that kool aid right down, just don’t look behind the curtain.

 

[skypilot]

OK that's just not true. I think we've had 4 or 5 lawsuits in our group in the last 30 years and that probably covers a combined 500+ years of physician practice in an ACT model. Your odds of getting sued are more dependent on what state you work in than on what model you work in.

Cumulative Career Malpractice Risk
Figure 4.

Figure 4. Cumulative Career Probability of Facing a Malpractice Claim or Indemnity Payment, According to Risk of Specialty and Age of Physician.
Cumulative probabilities were estimated from a multivariate linear regression model with adjustment for physician random effects, physician specialty, state of practice, and county demographic characteristics.

The projected proportion of physicians facing a malpractice claim by the age of 65 years was high (Figure 4). Among physicians in low-risk specialties, 36% were projected to face their first claim by the age of 45 years, as compared with 88% of physicians in high-risk specialties. By the age of 65 years, 75% of physicians in low-risk specialties and 99% of those in high-risk specialties were projected to face a claim. The projected career risk of making an indemnity payment was also large. Roughly 5% of physicians in low-risk specialties and 33% in high-risk specialties were projected to make their first indemnity payment by the age of 45 years; by the age of 65 years, the risks had increased to 19% and 71%, respectively.

Maybe my stats are off but almost 100% of doctors in high risk specialties will get sued by the age of 65! You don't always hear about the lawsuits either. Many of them settle, and no doc is going to advertise their lawsuits. They still may suffer years of angst waiting for a resolution.

 

[Mman]

Maybe my stats are off but almost 100% of doctors in high risk specialties will get sued by the age of 65! You don't always hear about the lawsuits either. Many of them settle, and no doc is going to advertise their lawsuits. They still may suffer years of angst waiting for a resolution.

Like I said, it's a state dependent issue. Some states see all kinds of lawsuits. In other states they are very rare.

 

[BLADEMDA]

can anybody with a TRUE understanding of the law comment on liability issues with medical supervision in anesthesia? I am NOT talking about medical direction which has a max ratio of 1:4 and where the MD sees every patient prior to induction. I’m taking about the 1:10 or 1:12 where they just call you to put out fires.

Specifically when does your DUTY to the patient begin? As a totally made up example: you are in a 1:10 model and a patient that you never met is induced. They have a known full stomach nevertheless an LMA is placed by CRNA. You are called to assist when the patient has already aspirated. You manage appropriately from that point forward but patient dies. According to the LAW (I get that liability is always possible due to emotional aspects with juries) have you committed malpractice?

Let me explain this to you very clearly: when you "supervise" 5, 6 or 8 CRNAs that means the liability falls on you. So, even if you don't preop the patient your responsibility includes a chart review and/or a brief discussion with the CRNA. Anything which gets missed that later leads to a poor outcome will likely result in a legal settlement on your behalf by the malpractice carrier. I have seen these types of practices "pin" the settlement on a CRNA for $200K but typically the amount of malpractice that CRNAs carry in a supervisory practice is far less than the MD covering them.

There are some practices where the CRNAs are "independent" and assume the first $200-$300K of liability; the supervision is indirect and the malpractice carrier understands your role as "back-up" only. This helps in limiting any legal claim against you but no guarantee the jury will see it that way.

A model of 1:5 or greater is best left as a CRNA Independent model where the CRNAS carry their own $500K (or more) malpractice policy. The hospital bylaws and State laws would need to note "Independent CRNA" practice is allowable by law. Then, the Anesthesiologists' role is truly limited to consultant level only. Again, no guarantees in court but this model would likely hold up.

Finally, I've seen "non opt out" hospitals employee all the anesthesia personnel and insure them. This means the hospital could settle any claim under the CRNAs name as long as the insurance policy covers the damages.

 

[It's lupus!]

I find it kind of hypocritical for CRNAs and associated admin to believe they can do the job without a physician but in both cases feel perfectly ok shirking the responsibility to the physician when something goes wrong. It really seems like they got their cake and even get to eat it.

Sent from my Pixel XL using SDN mobile

 

[BLADEMDA]

I find it kind of hypocritical for CRNAs and associated admin to believe they can do the job without a physician but in both cases feel perfectly ok shirking the responsibility to the physician when something goes wrong. It really seems like they got their cake and even get to eat it.

Sent from my Pixel XL using SDN mobile

It's a good gig for them.

 

[BLADEMDA]

 

[BLADEMDA]

 

[MirrorTodd]

This is why supervision ratios are so important, we must not allow AMCs and hospitals to hang us out to dry making us supervise 8 nurses. At the end of they day, WE are the ones who have to endure the stress of a lawsuit. One of my friends had a huge lawsuit against him that took 3 years to conclude. It was horrific and took a toll on him. Amniotic fluid embolus, woman died. CRNA released from liability fairly early on even though she was there the whole time. The OB and my friend were taken all the way to the bitter end.
@IMGASMD is absolutely right. They decided the nurse wasn’t worth going after but the doctors were.

Don't those have like an 85% mortality rate and isn't there really no way to prevent them? How did they sue for a known side effect of birth? My knowledge is limited so perhaps there's something I missed. Was the resuscitation horribly mismanaged or something?

 

[Mman]

How did they sue for a known side effect of birth?

The only thing you need for a lawsuit is a lawyer willing to take the case. That doesn't mean it will be successful, but even lawsuits that lead to nothing are still painful to deal with.

 

[Man o War]

Don't those have like an 85% mortality rate and isn't there really no way to prevent them? How did they sue for a known side effect of birth? My knowledge is limited so perhaps there's something I missed. Was the resuscitation horribly mismanaged or something?

I’m not sure what the official rate is, I’ve always thought it was about 50/50.
In this case, nothing was done wrong. Ultimately my friend and the OB won. But it was 3 years of hell and stress. Thankfully the insurance company never even suggested settling because they did nothing wrong.
But, the plaintiffs lawyer thought he could parade a widower and 3 kids without a mother in front of a jury and win. And sometimes they do even when we do everything right.
The system is so screwed up.

 

[BLADEMDA]

Don't those have like an 85% mortality rate and isn't there really no way to prevent them? How did they sue for a known side effect of birth? My knowledge is limited so perhaps there's something I missed. Was the resuscitation horribly mismanaged or something?

Did the MD or CRNA attempt Rx with the appropriate medications?

AOK treatment:

• Atropine: vagolysis
• Ondansetron to block serotonin receptors and for vagolysis
• Ketorolac 30mg to block throboxane production

Clinical Update on Amniotic Fluid Embolism

Rezai S1, Hughes AC2, Larsen TB3, Fuller PN1, Henderson CE4. Atypical Amniotic Fluid Embolism Managed with a Novel Therapeutic Regimen. Case Rep Obstet Gynecol. 2017;2017:8458375. doi: 10.1155/2017/8458375. Epub 2017 Dec 21.

P. L. Copper, M. P. Otto, and B. L. Leighton, “Successful management of cardiac arrest from amniotic fluid embolism with ondansetron, metoclopramide, atropine, and ketorolac: a case report,” SOAP 2013, 2013. View at Google Scholar

 

[BLADEMDA]

 

[pgg]

Don't those have like an 85% mortality rate and isn't there really no way to prevent them? How did they sue for a known side effect of birth? My knowledge is limited so perhaps there's something I missed. Was the resuscitation horribly mismanaged or something?

There's a case report of using intralipid, of all things, to treat it. The idea goes that since AFE isn't really an "embolism" per se, that some of the cytokines, platelet activating factor, or other evil humors might lipid soluble and sinkable.

http://www.csen.com/AFE.pdf

I don't know. Someone should do an animal study and get famous (if it works).

 

[IMGASMD]

There's a case report of using intralipid, of all things, to treat it. The idea goes that since AFE isn't really an "embolism" per se, that some of the cytokines, platelet activating factor, or other evil humors might lipid soluble and sinkable.

http://www.csen.com/AFE.pdf

I don't know. Someone should do an animal study and get famous (if it works).

Or intralipid manufacturer.

 

[Man o War]

Well, here’s how this worked at least in the case of his lawsuit. His side hired expert witnesses (multiple) who said he did everything according to standard of care, and what any reasonable person would expect.
Then the plaintiff’s witnesses came in and picked apart the 8 hour rescucitation efforts. As we all know, we all may choose different drugs, approaches, etc. while still operating within standard of care in any anesthetic......little details that really probably don’t make a difference in the overall outcome, but are just individual preference.
Thankfully the jury agreed with the doctors here, and found that standard of care was not breached even though maybe you, I, or the plaintiff’s expert witnesses may have done something different.

 

[skypilot]

The only thing you need for a lawsuit is a lawyer willing to take the case. That doesn't mean it will be successful, but even lawsuits that lead to nothing are still painful to deal with.

Yes, it is the years of depositions and continuances while the case is hanging over your head. Then once the insurance company settles with the plaintiff, you have to report that case for the rest of your career.

If you supervise 4 CRNAs you will have 4 times as many cases over the course of your career, and 4 times the chance of being sued.

That is how the math works in my brain. I am sure there are more complexities that I am not considering.

 

[CRNA ANSWERS]

Hello

If you are interested in my perspective (and our legal opinions) from a group where we had 1 Physician and 15-20 CRNAs or where 16 CRNAs own a group and work without physicians I can help with that.

I do not want to hijack the thread but offer it as informational only. Best way is probably just to PM me here and not reply to this post.

 

[deleted171991]

Hello

If you are interested in my perspective (and our legal opinions) from a group where we had 1 Physician and 15-20 CRNAs or where 16 CRNAs own a group and work without physicians I can help with that.

I do not want to hijack the thread but offer it as informational only. Best way is probably just to PM me here and not reply to this post.

Have you been sued yet? All legal opinions don't matter crap until verified in court.

 

[CRNA ANSWERS]

Have you been sued yet? All legal opinions don't matter crap until verified in court.

Over the last 15 years there have only been 2 lawsuits between those 2 practices. We are not in an opt out state (not that opt out has anything to do with liability)

1) one was at the practice with an MD and 15-20 CRNAs

2) second one was in the CRNA only group

The MD was named and dropped from the first and the surgeon was named and dropped from the second.

The lawyer explained to us it was because of 3 factors:

1) how the hospital policy was written in regard to the MD in the 1:15 where it specifically says “consultant”

2) the surgeon was not found liable because of how we had written the hospital policy related to CRNAs.

3) neither the MD or the surgeon “exerted control” over the CRNA in either case

Hope this helps. If you have additional questions probably best to PM me. I do not want to derail this thread.

 

[GravelRider]

Hello

If you are interested in my perspective (and our legal opinions) from a group where we had 1 Physician and 15-20 CRNAs or where 16 CRNAs own a group and work without physicians I can help with that.

I do not want to hijack the thread but offer it as informational only. Best way is probably just to PM me here and not reply to this post.

Why a PM? Why not add to the discussion about high supervision ratios? Having more experienced and critical eyes read and review a response is more helpful anyway.

 

[Man o War]

Why a PM? Why not add to the discussion about high supervision ratios? Having more experienced and critical eyes read and review a response is more helpful anyway.

Agreed.
I am not trustful of the CRNAs’ final word on liability because of how they approach the surgeons in regard to this topic. Making broad, sweeping statements assuring them there’s no way they will be held liable for a CRNA’s actions. That is just blatantly untrue.
Any of us who have been practicing any length of time know that in general if something goes badly in the OR, everybody is getting named who has any sort of pocket for them to dig into.
So the surgeons are concerned, and rightly so, that there is a lesser trained provider at the head of the bed with no anesthesiologist backup.
Liability is also a fluid concept; just because one jury ruled one way doesn’t mean another won’t rule the opposite. New precedent is set all the time.

 

[deleted171991]

Over the last 15 years there have only been 2 lawsuits between those 2 practices. We are not in an opt out state (not that opt out has anything to do with liability)

1) one was at the practice with an MD and 15-20 CRNAs

2) second one was in the CRNA only group

The MD was named and dropped from the first and the surgeon was named and dropped from the second.

The lawyer explained to us it was because of 3 factors:

1) how the hospital policy was written in regard to the MD in the 1:15 where it specifically says “consultant”

2) the surgeon was not found liable because of how we had written the hospital policy related to CRNAs.

3) neither the MD or the surgeon “exerted control” over the CRNA in either case

Hope this helps. If you have additional questions probably best to PM me. I do not want to derail this thread.

Thank you. I would appreciate actual links to the case precedents, because otherwise it is hearsay, no offense.

 

[CRNA ANSWERS]

Why a PM? Why not add to the discussion about high supervision ratios? Having more experienced and critical eyes read and review a response is more helpful anyway.

Hello

I was told I would be banned if I derailed a thread. I did not come here to get into political arguments or derail threads just to be a resource about what I do and I can only speak as it relates to my specific state and federal rules/laws because every state may be different. So I’m not sure if I am allowed to post much. I am trying to be respectful as this is a physician forum and follow the rules.

Honestly I am not sure how I should proceed.

 

[CRNA ANSWERS]

Thank you. I would appreciate actual links to the case precedents, because otherwise it is hearsay, no offense.

Hello

No offense taken. Both were settled out of court before ever going to trial. I do not ahve links to these.. not sure how I would get them or if they exist?

But I will answer whatever I can.

 

[Mman]

I can only speak as it relates to my specific state and federal rules/laws because every state may be different.

If you are interested in discussing lawsuits, I suppose telling us what state you are referring to is the bare minimum since federal laws really aren't coming into play, although at that point you are still just adding anecdotal nonlegal advice for that particular state.

 

[Consigliere]

Hello

Honestly I am not sure how I should proceed.

I do....right through the door with the EXIT sign above it. Don't let the door hit ya' where the good Lord split ya'.

 

[AdmiralChz]

Hello

No offense taken. Both were settled out of court before ever going to trial. I do not ahve links to these.. not sure how I would get them or if they exist?

But I will answer whatever I can.

I mean, without any evidence you could be some rando in a web cafe making up stuff. Or a high school student in class. Or the Russians meddling again?

 

[CRNA ANSWERS]

Hey

I am in Arizona. As for state law etc. here I am well aware of it as I have been involved at every level to help shape statue for APRNs as a group.

Other states you would need an expert from there.

I will not respond to any attacks to avoid derailing the thread. I can answer direct questions here or in PM.

 

[okayplayer]

Hey

I am in Arizona. As for state law etc. here I am well aware of it as I have been involved at every level to help shape statue for APRNs as a group.

Other states you would need an expert from there.

I will not respond to any attacks to avoid derailing the thread. I can answer direct questions here or in PM.

I don't think anyone was asking for you to come here. We are well aware of you and your colleagues' agenda. You are unlikely to find interested people here, considering you are part of a group trying to falsely claim equivalency and take work from us in spite of your inferior training and skillset. Good day.

 

[AdmiralChz]

Hey

I am in Arizona. As for state law etc. here I am well aware of it as I have been involved at every level to help shape statue for APRNs as a group.

Other states you would need an expert from there.

I will not respond to any attacks to avoid derailing the thread. I can answer direct questions here or in PM.

You aren’t going to get very positive responses if you are working “at every level” to advance “APRN” practice, especially on a physician forum. Particularly one where nearly everyone is wary and suspicious of APRNs, some from personal experience. Just a heads up. Be part of the solution, not the problem

 

[deleted126335]

@CRNA ANSWERS is at least partly correct. But State law is only one factor that comes into play when determining physician liability for CRNA actions. Other factors play a role in increasing or decreasing physician liability: Contracts, Hospital Bylaws, Department policy and procedure manual can all increase or decrease physician liability for CRNA actions. State law is a floor, not a ceiling. Hospitals and employers can require a higher standard. In my state CRNAs need to be supervised by a physician (not necessarily an anesthesiologist). But the hospital bylaws where I practice require CRNAs (AND ALL APPS) to be supervised BY A PHYSICIAN credentialed in the specialty and the procedure that the APP practices. Even in a totally independent CRNA practice state, physicians can be held responsible for CRNA actions depending on the contracts and the bylaws. Something that the AANA never mentions.

 

[Arch Guillotti]

Closing.

The OP is a well-known troll and militant CRNA.