Commentary

The development of an electronic health care system has revolutionized the way in which patients receive medical treatment. Every physician in practice is familiar with how EHRs have changed the way we record and retrieve information and even interact with patients.

Many of us are just beginning to become aware of a new trend: telemedicine. Proponents of telemedicine believe that it will give patients increased ease of access to trained health care professionals at low cost and skeptics feel that the quality of care will be low without either a physical exam or an ongoing relationship to help guide care. One thing, unfortunately, is for certain, with the evolution of health care comes the evolution of health care litigation. Physicians who are considering seeing patients through a telemedicine service should be aware of liability issues that may arise when seeing patients without actually seeing patients.

In 2009, Congress enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act to develop a national health care infrastructure fueled by modern technology. In addition to offering health care providers financial incentives to replace patient medical charts with EHRs, leading over 400,000 health care providers to participate in the Medicaid and Medicare incentive programs, the HITECH Act also has encouraged the advancement of telemedicine through the use of virtual visits and electronic doctor/patient communication.

Telemedicine allows physicians and patients to exchange health information through telecommunication technologies while in different geographic locations (Model policy for appropriate use of telemedicine technologies in the practice of medicine, Federation of State Medical Boards, April 2014). Telemedicine emerged in the 1960s after NASA funded early research to allow astronauts to communicate with physicians while traveling in space. In recent years, telemedical practice has evolved into a much more practical and convenient method of practicing medicine.

Virtual visits now allow a patient to use a computer or other videoconference device to have a virtual visit with a doctor in lieu of having an in-person physical examination. Jason Gorevic, CEO of Teladoc, a leading telemedicine company, expects Teladoc to conduct a half a million telemedicine visits in 2015 (“Video visits, telemedicine today are like retail clinics were in the 1990s,” mobihealthnews, Nov. 4, 2014). The increase in the use of virtual visits comes largely from the high use of telemedicine in rural areas, where long distances exists between a patient and his/her physician.

Telemedicine has expanded rapidly, and state licensure requirements and regulation of telemedicine have not caught up with its use, leading regulations to vary from state to state. In an attempt to eliminate the state regulation disparities, the Federation of State Medical Boards (FSMB) has provided a framework for standards of care in regulating the practice of telemedicine, but each state still has its own requirements for telemedical practice (50 State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure, American Telemedicine Association, September 2014).

Only nine states offer a conditional or telemedicine license that allows out-of-state physicians to practice telemedicine, and Maryland, New York, and Virginia are the only states that offer reciprocity to licensed physicians in bordering states. In California, a Colorado doctor was criminally prosecuted for prescribing medication via the web to a patient in California (Hageseth v. Superior Court). The California Court of Appeals found that jurisdiction was proper in California because the doctor willfully practiced medicine in that state by agreeing to prescribe medication to a California resident online.

Physicians also should be aware of the need to obtain informed consent from the patient before conducting any telemedicine visit or examination. Most states require a physician to obtain written or verbal informed consent from a telehealth patient. Although research is slowly establishing the reliability of telemedicine, there are inherent risks associated with receiving a consultation via telecommunication of which a patient should be aware, such as the limits of the evaluation given that a complete physical exam cannot be performed. The physician should inform the patient when the visit is being recorded and receive his/her consent before proceeding.

The physician also should be very careful when selecting telemedical technology to ensure that the technology is HIPAA/HITECH certified and permitted under the state regulations in the state in which the doctor is practicing. In Oklahoma, a physician was sanctioned by the state’s medical board for conducting a virtual visit via Skype. (“Oklahoma state medical board adopts policy following Skype case,” The Oklahoman, Sept. 25, 2013). Although Oklahoma permits the use of virtual visits, the state prohibits a physician from conducting these visits via Skype. The Oklahoma doctor turned out to not be subject to a HIPAA violation because the Skype website is encrypted.

Given telemedicine’s rapid expansion, experience and litigation in this area are limited. The one thing that the current litigation trend shows is that physicians must be particularly careful when treating patients outside of the state in which they practice, both with regard to entering into a patient-physician relationship, making a diagnosis, and particularly when prescribing medication. As patients and physicians enjoy the benefits of this new method of providing medical care, they must be careful to follow the evolving telemedicine litigation and legislative landscape.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Jones and Ms. Dandy are both attorneys at Marks, O’Neill, O’Brien, Doherty & Kelly, P.C. in Philadelphia.

Note: An earlier version of this article incorrectly stated that the FSMB had recommended a national licensure and practice standard.

The development of an electronic health care system has revolutionized the way in which patients receive medical treatment. Every physician in practice is familiar with how EHRs have changed the way we record and retrieve information and even interact with patients.

Many of us are just beginning to become aware of a new trend: telemedicine. Proponents of telemedicine believe that it will give patients increased ease of access to trained health care professionals at low cost and skeptics feel that the quality of care will be low without either a physical exam or an ongoing relationship to help guide care. One thing, unfortunately, is for certain, with the evolution of health care comes the evolution of health care litigation. Physicians who are considering seeing patients through a telemedicine service should be aware of liability issues that may arise when seeing patients without actually seeing patients.

In 2009, Congress enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act to develop a national health care infrastructure fueled by modern technology. In addition to offering health care providers financial incentives to replace patient medical charts with EHRs, leading over 400,000 health care providers to participate in the Medicaid and Medicare incentive programs, the HITECH Act also has encouraged the advancement of telemedicine through the use of virtual visits and electronic doctor/patient communication.

Telemedicine allows physicians and patients to exchange health information through telecommunication technologies while in different geographic locations (Model policy for appropriate use of telemedicine technologies in the practice of medicine, Federation of State Medical Boards, April 2014). Telemedicine emerged in the 1960s after NASA funded early research to allow astronauts to communicate with physicians while traveling in space. In recent years, telemedical practice has evolved into a much more practical and convenient method of practicing medicine.

Virtual visits now allow a patient to use a computer or other videoconference device to have a virtual visit with a doctor in lieu of having an in-person physical examination. Jason Gorevic, CEO of Teladoc, a leading telemedicine company, expects Teladoc to conduct a half a million telemedicine visits in 2015 (“Video visits, telemedicine today are like retail clinics were in the 1990s,” mobihealthnews, Nov. 4, 2014). The increase in the use of virtual visits comes largely from the high use of telemedicine in rural areas, where long distances exists between a patient and his/her physician.

Telemedicine has expanded rapidly, and state licensure requirements and regulation of telemedicine have not caught up with its use, leading regulations to vary from state to state. In an attempt to eliminate the state regulation disparities, the Federation of State Medical Boards (FSMB) has provided a framework for standards of care in regulating the practice of telemedicine, but each state still has its own requirements for telemedical practice (50 State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure, American Telemedicine Association, September 2014).

Only nine states offer a conditional or telemedicine license that allows out-of-state physicians to practice telemedicine, and Maryland, New York, and Virginia are the only states that offer reciprocity to licensed physicians in bordering states. In California, a Colorado doctor was criminally prosecuted for prescribing medication via the web to a patient in California (Hageseth v. Superior Court). The California Court of Appeals found that jurisdiction was proper in California because the doctor willfully practiced medicine in that state by agreeing to prescribe medication to a California resident online.

Physicians also should be aware of the need to obtain informed consent from the patient before conducting any telemedicine visit or examination. Most states require a physician to obtain written or verbal informed consent from a telehealth patient. Although research is slowly establishing the reliability of telemedicine, there are inherent risks associated with receiving a consultation via telecommunication of which a patient should be aware, such as the limits of the evaluation given that a complete physical exam cannot be performed. The physician should inform the patient when the visit is being recorded and receive his/her consent before proceeding.

The physician also should be very careful when selecting telemedical technology to ensure that the technology is HIPAA/HITECH certified and permitted under the state regulations in the state in which the doctor is practicing. In Oklahoma, a physician was sanctioned by the state’s medical board for conducting a virtual visit via Skype. (“Oklahoma state medical board adopts policy following Skype case,” The Oklahoman, Sept. 25, 2013). Although Oklahoma permits the use of virtual visits, the state prohibits a physician from conducting these visits via Skype. The Oklahoma doctor turned out to not be subject to a HIPAA violation because the Skype website is encrypted.

Given telemedicine’s rapid expansion, experience and litigation in this area are limited. The one thing that the current litigation trend shows is that physicians must be particularly careful when treating patients outside of the state in which they practice, both with regard to entering into a patient-physician relationship, making a diagnosis, and particularly when prescribing medication. As patients and physicians enjoy the benefits of this new method of providing medical care, they must be careful to follow the evolving telemedicine litigation and legislative landscape.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Jones and Ms. Dandy are both attorneys at Marks, O’Neill, O’Brien, Doherty & Kelly, P.C. in Philadelphia.

Note: An earlier version of this article incorrectly stated that the FSMB had recommended a national licensure and practice standard.

The development of an electronic health care system has revolutionized the way in which patients receive medical treatment. Every physician in practice is familiar with how EHRs have changed the way we record and retrieve information and even interact with patients.

Many of us are just beginning to become aware of a new trend: telemedicine. Proponents of telemedicine believe that it will give patients increased ease of access to trained health care professionals at low cost and skeptics feel that the quality of care will be low without either a physical exam or an ongoing relationship to help guide care. One thing, unfortunately, is for certain, with the evolution of health care comes the evolution of health care litigation. Physicians who are considering seeing patients through a telemedicine service should be aware of liability issues that may arise when seeing patients without actually seeing patients.

In 2009, Congress enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act to develop a national health care infrastructure fueled by modern technology. In addition to offering health care providers financial incentives to replace patient medical charts with EHRs, leading over 400,000 health care providers to participate in the Medicaid and Medicare incentive programs, the HITECH Act also has encouraged the advancement of telemedicine through the use of virtual visits and electronic doctor/patient communication.

Telemedicine allows physicians and patients to exchange health information through telecommunication technologies while in different geographic locations (Model policy for appropriate use of telemedicine technologies in the practice of medicine, Federation of State Medical Boards, April 2014). Telemedicine emerged in the 1960s after NASA funded early research to allow astronauts to communicate with physicians while traveling in space. In recent years, telemedical practice has evolved into a much more practical and convenient method of practicing medicine.

Virtual visits now allow a patient to use a computer or other videoconference device to have a virtual visit with a doctor in lieu of having an in-person physical examination. Jason Gorevic, CEO of Teladoc, a leading telemedicine company, expects Teladoc to conduct a half a million telemedicine visits in 2015 (“Video visits, telemedicine today are like retail clinics were in the 1990s,” mobihealthnews, Nov. 4, 2014). The increase in the use of virtual visits comes largely from the high use of telemedicine in rural areas, where long distances exists between a patient and his/her physician.

Telemedicine has expanded rapidly, and state licensure requirements and regulation of telemedicine have not caught up with its use, leading regulations to vary from state to state. In an attempt to eliminate the state regulation disparities, the Federation of State Medical Boards (FSMB) has provided a framework for standards of care in regulating the practice of telemedicine, but each state still has its own requirements for telemedical practice (50 State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure, American Telemedicine Association, September 2014).

Only nine states offer a conditional or telemedicine license that allows out-of-state physicians to practice telemedicine, and Maryland, New York, and Virginia are the only states that offer reciprocity to licensed physicians in bordering states. In California, a Colorado doctor was criminally prosecuted for prescribing medication via the web to a patient in California (Hageseth v. Superior Court). The California Court of Appeals found that jurisdiction was proper in California because the doctor willfully practiced medicine in that state by agreeing to prescribe medication to a California resident online.

Physicians also should be aware of the need to obtain informed consent from the patient before conducting any telemedicine visit or examination. Most states require a physician to obtain written or verbal informed consent from a telehealth patient. Although research is slowly establishing the reliability of telemedicine, there are inherent risks associated with receiving a consultation via telecommunication of which a patient should be aware, such as the limits of the evaluation given that a complete physical exam cannot be performed. The physician should inform the patient when the visit is being recorded and receive his/her consent before proceeding.

The physician also should be very careful when selecting telemedical technology to ensure that the technology is HIPAA/HITECH certified and permitted under the state regulations in the state in which the doctor is practicing. In Oklahoma, a physician was sanctioned by the state’s medical board for conducting a virtual visit via Skype. (“Oklahoma state medical board adopts policy following Skype case,” The Oklahoman, Sept. 25, 2013). Although Oklahoma permits the use of virtual visits, the state prohibits a physician from conducting these visits via Skype. The Oklahoma doctor turned out to not be subject to a HIPAA violation because the Skype website is encrypted.

Given telemedicine’s rapid expansion, experience and litigation in this area are limited. The one thing that the current litigation trend shows is that physicians must be particularly careful when treating patients outside of the state in which they practice, both with regard to entering into a patient-physician relationship, making a diagnosis, and particularly when prescribing medication. As patients and physicians enjoy the benefits of this new method of providing medical care, they must be careful to follow the evolving telemedicine litigation and legislative landscape.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Jones and Ms. Dandy are both attorneys at Marks, O’Neill, O’Brien, Doherty & Kelly, P.C. in Philadelphia.

Note: An earlier version of this article incorrectly stated that the FSMB had recommended a national licensure and practice standard.

Note from NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP: Recently, the authors of this column and I started discussing the decision by the Drug Enforcement Administration (DEA) to reschedule hydrocodone and the resulting barriers to care. By the end of the conversation, it was evident that my colleagues needed to “get the word out” to our readers—so I afforded them this opportunity to do so.

On October 6, 2014, hydrocodone combination products were reclassified from Schedule III to Schedule II of the Controlled Substances Act, per a final ruling issued by the DEA’s Office of Diversion Control. The DEA’s ruling was the result of an evaluation of scientific and medical evidence supplied by multiple agencies, as well as considerations related to the FDA Safety and Innovation Act of 2012.¹ The rationale for rescheduling hydrocodone preparations was based on evidence of high potential for abuse, high rates of dependency, and epidemic levels of drug diversion related to these products.

Our purpose in this editorial is not to debate the DEA’s decision to reschedule hydrocodone preparations but rather to demonstrate that all policy changes have consequences. In this case, these include substantial limitations on the ability of NPs in several states to adequately manage acute and chronic pain for their patients. As a result, NPs may be prevented from delivering comprehensive care to patients with certain conditions. (We are aware that our PA colleagues may be similarly affected by this ruling but will restrict our commentary to NPs, as we are most familiar with our profession’s circumstances.)

Each state grants specific prescriptive privileges to advanced practice registered nurses (APRNs), resulting in wide variation across the country. Therefore, the effect of this ruling on patients’ access to care and providers’ ability to treat certain conditions differs by state. The states in which APRNs have prescriptive privileges for Schedule III but not Schedule II medications—those most impacted by this rule change—include Arkansas, Georgia, Missouri, Nebraska, Oklahoma, South Carolina, Texas, and West Virginia.² Prior to the effective date of this ruling, NPs in these states had hydrocodone and codeine preparations, as well as the nonnarcotic tramadol, in their armamentaria to treat pain.

The DEA ruling—coupled with restrictive state regulations—reduces the options for pain management in these states. The only other Schedule III narcotic treatment options are codeine preparations; for patients with codeine sensitivities or allergies, NPs are now unable to adequately manage acute or chronic pain. Besides inconvenience, this change results in additional costs, since patients will also need to be assessed by a provider with Schedule II prescriptive privileges if they hope to achieve adequate pain management. This is particularly burdensome in underserved or rural populations, which many of the affected states have.

In response to this (presumably) unintended consequence, legislatures need to consider the impact this ruling will have on patient care and move to modernize prescriptive authority for APRNs, especially in the most affected states. The Future of Nursing report³ from the Institute of Medicine (IOM) recommends that APRNs’ scope of practice be reformed to conform with the model rules and regulations established by the National Council of State Boards of Nursing (NCSBN). The NCSBN’s consensus model report supports full scope of practice for all APRNs, as well as collaboration among all health care disciplines as a professional norm, instead of the current restrictive practices.⁴

Continued on next page >>

Historically, APRNs have struggled to gain total support from state legislators in the quest for full practice authority, including prescriptive privileges. Our professional organizations, with support from the IOM, the National Governors Association, and the Federal Trade Commission, must be ready to provide accurate data on safety and outcomes to state and federal legislators. This evidence would support efforts to modernize NP scope of practice acts, including prescribing regulations, that are currently outdated and prevent APRNs from providing optimal care.⁵

This year (2015) marks the 50th anniversary of the NP role. Thus, it is the proper time for state legislatures to recognize and support the role of the NP in the delivery of comprehensive, cost-effective health care in the United States. With millions of previously uninsured Americans seeking primary care and the increasing shortage of primary care physicians, NPs are part of the answer to the problem of access to acute and chronic care in both urban and rural communities. With NPs available to close this gap, it is imperative that both state and federal legislatures support initiatives that will eliminate barriers to care and promote legislation that offers full scope of practice to NPs.

We welcome your feedback on this topic. Please send your comments to NPEditor@frontline medcom.com.

REFERENCES
1. Drug Enforcement Administration. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II (document no: 2014-19922). Federal Register. https://federalregister.gov/a/2014-19922. Accessed February 13, 2015.
2. Drug Enforcement Administration Office of Diversion. Mid-level practitioners authorization by state. www.deadiversion.usdoj.gov/drugreg/practioners. Accessed February 13, 2015.
3. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
4. National Council of State Boards of Nursing. The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education (2008). www.ncsbn.org/Consen sus_Model_for_APRN_Regulation_July_2008.pdf. Accessed February 13, 2015.
5. National Council of State Boards of Nursing. Changes In Healthcare Professions’ Scope of Practice: Legislative Considerations (2009). www.ncsbn.org/ScopeofPractice_09.pdf. Accessed February 13, 2015.

Note from NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP: Recently, the authors of this column and I started discussing the decision by the Drug Enforcement Administration (DEA) to reschedule hydrocodone and the resulting barriers to care. By the end of the conversation, it was evident that my colleagues needed to “get the word out” to our readers—so I afforded them this opportunity to do so.

On October 6, 2014, hydrocodone combination products were reclassified from Schedule III to Schedule II of the Controlled Substances Act, per a final ruling issued by the DEA’s Office of Diversion Control. The DEA’s ruling was the result of an evaluation of scientific and medical evidence supplied by multiple agencies, as well as considerations related to the FDA Safety and Innovation Act of 2012.¹ The rationale for rescheduling hydrocodone preparations was based on evidence of high potential for abuse, high rates of dependency, and epidemic levels of drug diversion related to these products.

Our purpose in this editorial is not to debate the DEA’s decision to reschedule hydrocodone preparations but rather to demonstrate that all policy changes have consequences. In this case, these include substantial limitations on the ability of NPs in several states to adequately manage acute and chronic pain for their patients. As a result, NPs may be prevented from delivering comprehensive care to patients with certain conditions. (We are aware that our PA colleagues may be similarly affected by this ruling but will restrict our commentary to NPs, as we are most familiar with our profession’s circumstances.)

Each state grants specific prescriptive privileges to advanced practice registered nurses (APRNs), resulting in wide variation across the country. Therefore, the effect of this ruling on patients’ access to care and providers’ ability to treat certain conditions differs by state. The states in which APRNs have prescriptive privileges for Schedule III but not Schedule II medications—those most impacted by this rule change—include Arkansas, Georgia, Missouri, Nebraska, Oklahoma, South Carolina, Texas, and West Virginia.² Prior to the effective date of this ruling, NPs in these states had hydrocodone and codeine preparations, as well as the nonnarcotic tramadol, in their armamentaria to treat pain.

The DEA ruling—coupled with restrictive state regulations—reduces the options for pain management in these states. The only other Schedule III narcotic treatment options are codeine preparations; for patients with codeine sensitivities or allergies, NPs are now unable to adequately manage acute or chronic pain. Besides inconvenience, this change results in additional costs, since patients will also need to be assessed by a provider with Schedule II prescriptive privileges if they hope to achieve adequate pain management. This is particularly burdensome in underserved or rural populations, which many of the affected states have.

In response to this (presumably) unintended consequence, legislatures need to consider the impact this ruling will have on patient care and move to modernize prescriptive authority for APRNs, especially in the most affected states. The Future of Nursing report³ from the Institute of Medicine (IOM) recommends that APRNs’ scope of practice be reformed to conform with the model rules and regulations established by the National Council of State Boards of Nursing (NCSBN). The NCSBN’s consensus model report supports full scope of practice for all APRNs, as well as collaboration among all health care disciplines as a professional norm, instead of the current restrictive practices.⁴

Continued on next page >>

Historically, APRNs have struggled to gain total support from state legislators in the quest for full practice authority, including prescriptive privileges. Our professional organizations, with support from the IOM, the National Governors Association, and the Federal Trade Commission, must be ready to provide accurate data on safety and outcomes to state and federal legislators. This evidence would support efforts to modernize NP scope of practice acts, including prescribing regulations, that are currently outdated and prevent APRNs from providing optimal care.⁵

This year (2015) marks the 50th anniversary of the NP role. Thus, it is the proper time for state legislatures to recognize and support the role of the NP in the delivery of comprehensive, cost-effective health care in the United States. With millions of previously uninsured Americans seeking primary care and the increasing shortage of primary care physicians, NPs are part of the answer to the problem of access to acute and chronic care in both urban and rural communities. With NPs available to close this gap, it is imperative that both state and federal legislatures support initiatives that will eliminate barriers to care and promote legislation that offers full scope of practice to NPs.

We welcome your feedback on this topic. Please send your comments to NPEditor@frontline medcom.com.

REFERENCES
1. Drug Enforcement Administration. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II (document no: 2014-19922). Federal Register. https://federalregister.gov/a/2014-19922. Accessed February 13, 2015.
2. Drug Enforcement Administration Office of Diversion. Mid-level practitioners authorization by state. www.deadiversion.usdoj.gov/drugreg/practioners. Accessed February 13, 2015.
3. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
4. National Council of State Boards of Nursing. The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education (2008). www.ncsbn.org/Consen sus_Model_for_APRN_Regulation_July_2008.pdf. Accessed February 13, 2015.
5. National Council of State Boards of Nursing. Changes In Healthcare Professions’ Scope of Practice: Legislative Considerations (2009). www.ncsbn.org/ScopeofPractice_09.pdf. Accessed February 13, 2015.

Note from NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP: Recently, the authors of this column and I started discussing the decision by the Drug Enforcement Administration (DEA) to reschedule hydrocodone and the resulting barriers to care. By the end of the conversation, it was evident that my colleagues needed to “get the word out” to our readers—so I afforded them this opportunity to do so.

On October 6, 2014, hydrocodone combination products were reclassified from Schedule III to Schedule II of the Controlled Substances Act, per a final ruling issued by the DEA’s Office of Diversion Control. The DEA’s ruling was the result of an evaluation of scientific and medical evidence supplied by multiple agencies, as well as considerations related to the FDA Safety and Innovation Act of 2012.¹ The rationale for rescheduling hydrocodone preparations was based on evidence of high potential for abuse, high rates of dependency, and epidemic levels of drug diversion related to these products.

Our purpose in this editorial is not to debate the DEA’s decision to reschedule hydrocodone preparations but rather to demonstrate that all policy changes have consequences. In this case, these include substantial limitations on the ability of NPs in several states to adequately manage acute and chronic pain for their patients. As a result, NPs may be prevented from delivering comprehensive care to patients with certain conditions. (We are aware that our PA colleagues may be similarly affected by this ruling but will restrict our commentary to NPs, as we are most familiar with our profession’s circumstances.)

Each state grants specific prescriptive privileges to advanced practice registered nurses (APRNs), resulting in wide variation across the country. Therefore, the effect of this ruling on patients’ access to care and providers’ ability to treat certain conditions differs by state. The states in which APRNs have prescriptive privileges for Schedule III but not Schedule II medications—those most impacted by this rule change—include Arkansas, Georgia, Missouri, Nebraska, Oklahoma, South Carolina, Texas, and West Virginia.² Prior to the effective date of this ruling, NPs in these states had hydrocodone and codeine preparations, as well as the nonnarcotic tramadol, in their armamentaria to treat pain.

The DEA ruling—coupled with restrictive state regulations—reduces the options for pain management in these states. The only other Schedule III narcotic treatment options are codeine preparations; for patients with codeine sensitivities or allergies, NPs are now unable to adequately manage acute or chronic pain. Besides inconvenience, this change results in additional costs, since patients will also need to be assessed by a provider with Schedule II prescriptive privileges if they hope to achieve adequate pain management. This is particularly burdensome in underserved or rural populations, which many of the affected states have.

In response to this (presumably) unintended consequence, legislatures need to consider the impact this ruling will have on patient care and move to modernize prescriptive authority for APRNs, especially in the most affected states. The Future of Nursing report³ from the Institute of Medicine (IOM) recommends that APRNs’ scope of practice be reformed to conform with the model rules and regulations established by the National Council of State Boards of Nursing (NCSBN). The NCSBN’s consensus model report supports full scope of practice for all APRNs, as well as collaboration among all health care disciplines as a professional norm, instead of the current restrictive practices.⁴

Continued on next page >>

Historically, APRNs have struggled to gain total support from state legislators in the quest for full practice authority, including prescriptive privileges. Our professional organizations, with support from the IOM, the National Governors Association, and the Federal Trade Commission, must be ready to provide accurate data on safety and outcomes to state and federal legislators. This evidence would support efforts to modernize NP scope of practice acts, including prescribing regulations, that are currently outdated and prevent APRNs from providing optimal care.⁵

This year (2015) marks the 50th anniversary of the NP role. Thus, it is the proper time for state legislatures to recognize and support the role of the NP in the delivery of comprehensive, cost-effective health care in the United States. With millions of previously uninsured Americans seeking primary care and the increasing shortage of primary care physicians, NPs are part of the answer to the problem of access to acute and chronic care in both urban and rural communities. With NPs available to close this gap, it is imperative that both state and federal legislatures support initiatives that will eliminate barriers to care and promote legislation that offers full scope of practice to NPs.

We welcome your feedback on this topic. Please send your comments to NPEditor@frontline medcom.com.

REFERENCES
1. Drug Enforcement Administration. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II (document no: 2014-19922). Federal Register. https://federalregister.gov/a/2014-19922. Accessed February 13, 2015.
2. Drug Enforcement Administration Office of Diversion. Mid-level practitioners authorization by state. www.deadiversion.usdoj.gov/drugreg/practioners. Accessed February 13, 2015.
3. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
4. National Council of State Boards of Nursing. The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education (2008). www.ncsbn.org/Consen sus_Model_for_APRN_Regulation_July_2008.pdf. Accessed February 13, 2015.
5. National Council of State Boards of Nursing. Changes In Healthcare Professions’ Scope of Practice: Legislative Considerations (2009). www.ncsbn.org/ScopeofPractice_09.pdf. Accessed February 13, 2015.

This month we are introducing a new feature in Vascular Specialist – a column on medicolegal matters. After all there are few issues that we face as vascular surgeons that can so negatively affect our lives. For a malpractice suit can cause great financial loss even if the verdict is in our favor. Attending various depositions, trials, and meetings with attorneys is nonproductive. Not to mention the emotional toll of self-doubt, embarrassment from negative press, or resentment of a frivolous suit.

Vascular surgeons pay some of the highest insurance premiums because we deal with critical issues which may have the potential for catastrophic outcomes. Lawsuits can occur when we perform a CEA and the patient suffers a stroke or a nerve injury, or after we save a ruptured aneurysm but the patient wakes up paralyzed. We can be sued for doing too much or too little. Do a bypass for critical limb ischemic that fails or attempt a thrombectomy and ultimately perform an amputation, and we are sued for not doing a primary amputation.

Decide that a limb is beyond salvage and perform a primary amputation, and we are sued for not attempting a bypass. Further, we are often called to the operating room to save a patient who suffered an inadvertent vascular injury during a procedure by another specialist. When the lawsuit arrives, we are the ones named. In some states, lawsuits are so common and juries so biased that insurance premiums have become unaffordable. Many vascular surgeons have gone without, risking their livelihood.I believe that much can be learned from prior malpractice suits and so I have turned to Dr. O. William Brown to help develop a column dealing with lessons learned from these claims. Bill has been a President of the Society for Clinical Vascular Surgery and is an accomplished physician and educator. He is also a lawyer with a huge experience in medicolegal issues. Together we have written the first column, dealing with the issue of retroperitoneal bleeds after femoral access for endovascular procedures.

By evaluating the cases that will be presented, you will notice that there are many traps that could lead a vascular surgeon to be involved in a suit especially if the patient suffers a lethal or life-altering complication. Importantly, for newer surgeons and those in training, these cases may also be informative as to how to best manage these situations. It is possible that textbooks might not be as instructive! The cases will obviously be modified to preserve confidentiality but this information is freely available for review in the legal literature. However, since some aspects may be fictional and since there are always extenuating circumstances that these scenarios may not reflect, trial lawyers should not expect that the cases are meant to define standard of care.

A further issue with malpractice litigation is the role of the “expert witness.” Since the legal system in the United States mostly requires a trial by jury and since these so-called peers do not have our knowledge or expertise, someone must take on the responsibility of educating jurors as to the merits or demerits of the case. This is a responsibility that must not be taken lightly. The honesty and integrity of the expert needs be paramount and so we support respected authorities performing legal reviews. This requires a great deal of time and so their time should be compensated. However, all too often the expert becomes a hired gun for the attorney supporting a specious plaintiff or defense argument simply for financial gain. Such “experts” should be shunned. When their testimony becomes egregious, they should be reported to the SVS Professional Conduct committee for investigation and possible sanction. Guidelines for experts have been published by the SVS (http://www.vascularweb.org/about/policies/Pages/expert-witness-guidelines.aspx).While Dr. Brown and I hope to be able to write these columns every other month, we invite any member to contribute. You could write the column or provide us with details of a suit, or a disease process or procedure that results in complications that could land a surgeon in trouble. We would be happy to research this and, if needed, write the column for you. You may also comment on a prior column by submitting a letter to the editor. Your contribution could save a colleague from a lawsuit. More importantly it could help prevent a complication occurring in one of your patients.

Dr. Samson is the medical editor of Vascular Specialist.

This month we are introducing a new feature in Vascular Specialist – a column on medicolegal matters. After all there are few issues that we face as vascular surgeons that can so negatively affect our lives. For a malpractice suit can cause great financial loss even if the verdict is in our favor. Attending various depositions, trials, and meetings with attorneys is nonproductive. Not to mention the emotional toll of self-doubt, embarrassment from negative press, or resentment of a frivolous suit.

Vascular surgeons pay some of the highest insurance premiums because we deal with critical issues which may have the potential for catastrophic outcomes. Lawsuits can occur when we perform a CEA and the patient suffers a stroke or a nerve injury, or after we save a ruptured aneurysm but the patient wakes up paralyzed. We can be sued for doing too much or too little. Do a bypass for critical limb ischemic that fails or attempt a thrombectomy and ultimately perform an amputation, and we are sued for not doing a primary amputation.

Decide that a limb is beyond salvage and perform a primary amputation, and we are sued for not attempting a bypass. Further, we are often called to the operating room to save a patient who suffered an inadvertent vascular injury during a procedure by another specialist. When the lawsuit arrives, we are the ones named. In some states, lawsuits are so common and juries so biased that insurance premiums have become unaffordable. Many vascular surgeons have gone without, risking their livelihood.I believe that much can be learned from prior malpractice suits and so I have turned to Dr. O. William Brown to help develop a column dealing with lessons learned from these claims. Bill has been a President of the Society for Clinical Vascular Surgery and is an accomplished physician and educator. He is also a lawyer with a huge experience in medicolegal issues. Together we have written the first column, dealing with the issue of retroperitoneal bleeds after femoral access for endovascular procedures.

By evaluating the cases that will be presented, you will notice that there are many traps that could lead a vascular surgeon to be involved in a suit especially if the patient suffers a lethal or life-altering complication. Importantly, for newer surgeons and those in training, these cases may also be informative as to how to best manage these situations. It is possible that textbooks might not be as instructive! The cases will obviously be modified to preserve confidentiality but this information is freely available for review in the legal literature. However, since some aspects may be fictional and since there are always extenuating circumstances that these scenarios may not reflect, trial lawyers should not expect that the cases are meant to define standard of care.

A further issue with malpractice litigation is the role of the “expert witness.” Since the legal system in the United States mostly requires a trial by jury and since these so-called peers do not have our knowledge or expertise, someone must take on the responsibility of educating jurors as to the merits or demerits of the case. This is a responsibility that must not be taken lightly. The honesty and integrity of the expert needs be paramount and so we support respected authorities performing legal reviews. This requires a great deal of time and so their time should be compensated. However, all too often the expert becomes a hired gun for the attorney supporting a specious plaintiff or defense argument simply for financial gain. Such “experts” should be shunned. When their testimony becomes egregious, they should be reported to the SVS Professional Conduct committee for investigation and possible sanction. Guidelines for experts have been published by the SVS (http://www.vascularweb.org/about/policies/Pages/expert-witness-guidelines.aspx).While Dr. Brown and I hope to be able to write these columns every other month, we invite any member to contribute. You could write the column or provide us with details of a suit, or a disease process or procedure that results in complications that could land a surgeon in trouble. We would be happy to research this and, if needed, write the column for you. You may also comment on a prior column by submitting a letter to the editor. Your contribution could save a colleague from a lawsuit. More importantly it could help prevent a complication occurring in one of your patients.

Dr. Samson is the medical editor of Vascular Specialist.

This month we are introducing a new feature in Vascular Specialist – a column on medicolegal matters. After all there are few issues that we face as vascular surgeons that can so negatively affect our lives. For a malpractice suit can cause great financial loss even if the verdict is in our favor. Attending various depositions, trials, and meetings with attorneys is nonproductive. Not to mention the emotional toll of self-doubt, embarrassment from negative press, or resentment of a frivolous suit.

Vascular surgeons pay some of the highest insurance premiums because we deal with critical issues which may have the potential for catastrophic outcomes. Lawsuits can occur when we perform a CEA and the patient suffers a stroke or a nerve injury, or after we save a ruptured aneurysm but the patient wakes up paralyzed. We can be sued for doing too much or too little. Do a bypass for critical limb ischemic that fails or attempt a thrombectomy and ultimately perform an amputation, and we are sued for not doing a primary amputation.

Decide that a limb is beyond salvage and perform a primary amputation, and we are sued for not attempting a bypass. Further, we are often called to the operating room to save a patient who suffered an inadvertent vascular injury during a procedure by another specialist. When the lawsuit arrives, we are the ones named. In some states, lawsuits are so common and juries so biased that insurance premiums have become unaffordable. Many vascular surgeons have gone without, risking their livelihood.I believe that much can be learned from prior malpractice suits and so I have turned to Dr. O. William Brown to help develop a column dealing with lessons learned from these claims. Bill has been a President of the Society for Clinical Vascular Surgery and is an accomplished physician and educator. He is also a lawyer with a huge experience in medicolegal issues. Together we have written the first column, dealing with the issue of retroperitoneal bleeds after femoral access for endovascular procedures.

By evaluating the cases that will be presented, you will notice that there are many traps that could lead a vascular surgeon to be involved in a suit especially if the patient suffers a lethal or life-altering complication. Importantly, for newer surgeons and those in training, these cases may also be informative as to how to best manage these situations. It is possible that textbooks might not be as instructive! The cases will obviously be modified to preserve confidentiality but this information is freely available for review in the legal literature. However, since some aspects may be fictional and since there are always extenuating circumstances that these scenarios may not reflect, trial lawyers should not expect that the cases are meant to define standard of care.

A further issue with malpractice litigation is the role of the “expert witness.” Since the legal system in the United States mostly requires a trial by jury and since these so-called peers do not have our knowledge or expertise, someone must take on the responsibility of educating jurors as to the merits or demerits of the case. This is a responsibility that must not be taken lightly. The honesty and integrity of the expert needs be paramount and so we support respected authorities performing legal reviews. This requires a great deal of time and so their time should be compensated. However, all too often the expert becomes a hired gun for the attorney supporting a specious plaintiff or defense argument simply for financial gain. Such “experts” should be shunned. When their testimony becomes egregious, they should be reported to the SVS Professional Conduct committee for investigation and possible sanction. Guidelines for experts have been published by the SVS (http://www.vascularweb.org/about/policies/Pages/expert-witness-guidelines.aspx).While Dr. Brown and I hope to be able to write these columns every other month, we invite any member to contribute. You could write the column or provide us with details of a suit, or a disease process or procedure that results in complications that could land a surgeon in trouble. We would be happy to research this and, if needed, write the column for you. You may also comment on a prior column by submitting a letter to the editor. Your contribution could save a colleague from a lawsuit. More importantly it could help prevent a complication occurring in one of your patients.

Dr. Samson is the medical editor of Vascular Specialist.

Deferring management of a postop complication to the surgery team resulted in treatment delay with a serious adverse outcome.

History:

RR is a 54 year-old man with a medical history of hypertension, hyperlipidemia, obesity, and chronic left knee pain from osteoarthritis. He was admitted to the hospital and underwent an elective left total knee replacement with monitored anesthesia care, combined with a left femoral nerve block. There were no intraoperative complications. When RR awoke in the recovery unit, he was in excruciating pain. He received another femoral nerve block and was sent to the regular nursing floor around 4 p.m. By early evening, the pain in his left leg remained poorly controlled and was consistently rated as 10/10. In addition, RR’s heart rates were elevated (130-140 bpm). The orthopedic surgeon was notified of the uncontrolled pain and elevated heart rates and he requested a hospitalist consult.

©Alliance/Fotolia.com

Dr. Hospitalist saw RR sometime before 9 p.m. that evening. RR was somewhat sedated by opiate analgesics, and his wife was at the bedside. During the interview, she related that her husband had been taking nightly benzodiazepines for sleep for several months leading up to the surgery. Dr. Hospitalist did not examine RR’s left foot and leg, and he documented in his consult that he was deferring left leg issues such as bleeding and swelling to the orthopedic surgery team. Dr. Hospitalist’s impression was that RR had sinus tachycardia, possibly because of the benzodiazepine withdrawal. Fluids were ordered along with low-dose benzodiazepines.

Throughout the night, RR awakened and complained of severe pain. The evening nurse charted that RR was having difficulty moving the toes on his left foot and that the pulses in his foot were barely palpable. By the early morning, RR’s pulses were no longer palpable but could still be detected by Doppler. Examination by the surgical team the following morning documented that RR had decreased sensation in his left lower extremity as well. An ultrasound of the left leg was ordered and revealed a large left popliteal pseudoaneurysm with complete occlusion of the left popliteal, tibial, and peroneal arteries below the knee. The patient went to the operating room three times over the next 4 days in an attempt to revascularize the leg. Unfortunately, RR ultimately had an above-the-knee amputation (AKA) performed 9 days after his elective total knee replacement.

Complaint:

RR sought a “quality of life”–enhancing procedure for his chronic left knee pain. What he ended up with was an AKA and a significant decrease in his overall quality of life. RR was angry that his postoperative pain, which was out of proportion to what should have been expected for this type of surgery, was essentially ignored until it was too late. He blamed the surgeon and the hospitalist for failing to diagnose his condition while his leg was still salvageable.

Scientific principles:

Complications during and after total knee replacement are generally uncommon and can often be prevented with meticulous surgical technique and with attentive postoperative management. Vascular injuries in total knee arthroplasty are exceedingly rare, but careful examination of the limbs is necessary to detect signs of acute limb ischemia. The six P’s of acute ischemia include paresthesia, pain, pallor, pulselessness, poikilothermia, and paralysis. A diagnosis of acute lower extremity ischemia can generally be made based upon the history and physical examination. Once the diagnosis of acute arterial occlusion has been made, anticoagulation should be initiated. Subsequent treatment varies depending upon the classification of acute ischemia. The initial options include catheter-directed thrombolytic therapy with or without percutaneous intervention or surgery.

Complaint rebuttal and discussion:

Dr. Hospitalist defended himself by limiting his scope of responsibility. He essentially said this was a surgical complication, and it was therefore the surgical team’s responsibility to make the diagnosis. Defense experts were quick to affirm that Dr. Hospitalist was consulted for a specific issue – postoperative tachycardia – and that he performed a focused history and physical examination to address that issue. Plaintiff experts cited the Society of Hospital Medicine Hospitalist Orthopedic Co-Management Implementation Guide, which outlines that co-management is the “shared responsibility, authority, and accountability for the care of a hospitalized patient.” The Guide further states: “Inevitably, there will be circumstances where either of the co-managing services could manage a specific problem, or where it is unclear which service would be best equipped to manage a specific problem. These situations can be best managed by following two basic principles: 1) Do what is best for the patient in a timely fashion and do not assume that a problem is being handled by the other service; and 2) communicate frequently and directly with the other service.” Plaintiff experts argued that Dr. Hospitalist failed to follow both of these principles.

Conclusion:

Hospitalists are frequently co-managers of surgical patients, and thus they are in part responsible for evaluating diagnosing, and treating both medical and surgical complications. Once again, it is vital that hospitalists delineate responsibilities explicitly through direct communication and then memorialize such discussions in the medical record. In this case, the chart consultation deferred examination of the operative leg to a surgical team that claimed they were “unaware” of any issues. This case was settled on behalf of the patient for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at eHospitalist news.com/Lessons.

Deferring management of a postop complication to the surgery team resulted in treatment delay with a serious adverse outcome.

History:

RR is a 54 year-old man with a medical history of hypertension, hyperlipidemia, obesity, and chronic left knee pain from osteoarthritis. He was admitted to the hospital and underwent an elective left total knee replacement with monitored anesthesia care, combined with a left femoral nerve block. There were no intraoperative complications. When RR awoke in the recovery unit, he was in excruciating pain. He received another femoral nerve block and was sent to the regular nursing floor around 4 p.m. By early evening, the pain in his left leg remained poorly controlled and was consistently rated as 10/10. In addition, RR’s heart rates were elevated (130-140 bpm). The orthopedic surgeon was notified of the uncontrolled pain and elevated heart rates and he requested a hospitalist consult.

©Alliance/Fotolia.com

Dr. Hospitalist saw RR sometime before 9 p.m. that evening. RR was somewhat sedated by opiate analgesics, and his wife was at the bedside. During the interview, she related that her husband had been taking nightly benzodiazepines for sleep for several months leading up to the surgery. Dr. Hospitalist did not examine RR’s left foot and leg, and he documented in his consult that he was deferring left leg issues such as bleeding and swelling to the orthopedic surgery team. Dr. Hospitalist’s impression was that RR had sinus tachycardia, possibly because of the benzodiazepine withdrawal. Fluids were ordered along with low-dose benzodiazepines.

Throughout the night, RR awakened and complained of severe pain. The evening nurse charted that RR was having difficulty moving the toes on his left foot and that the pulses in his foot were barely palpable. By the early morning, RR’s pulses were no longer palpable but could still be detected by Doppler. Examination by the surgical team the following morning documented that RR had decreased sensation in his left lower extremity as well. An ultrasound of the left leg was ordered and revealed a large left popliteal pseudoaneurysm with complete occlusion of the left popliteal, tibial, and peroneal arteries below the knee. The patient went to the operating room three times over the next 4 days in an attempt to revascularize the leg. Unfortunately, RR ultimately had an above-the-knee amputation (AKA) performed 9 days after his elective total knee replacement.

Complaint:

RR sought a “quality of life”–enhancing procedure for his chronic left knee pain. What he ended up with was an AKA and a significant decrease in his overall quality of life. RR was angry that his postoperative pain, which was out of proportion to what should have been expected for this type of surgery, was essentially ignored until it was too late. He blamed the surgeon and the hospitalist for failing to diagnose his condition while his leg was still salvageable.

Scientific principles:

Complications during and after total knee replacement are generally uncommon and can often be prevented with meticulous surgical technique and with attentive postoperative management. Vascular injuries in total knee arthroplasty are exceedingly rare, but careful examination of the limbs is necessary to detect signs of acute limb ischemia. The six P’s of acute ischemia include paresthesia, pain, pallor, pulselessness, poikilothermia, and paralysis. A diagnosis of acute lower extremity ischemia can generally be made based upon the history and physical examination. Once the diagnosis of acute arterial occlusion has been made, anticoagulation should be initiated. Subsequent treatment varies depending upon the classification of acute ischemia. The initial options include catheter-directed thrombolytic therapy with or without percutaneous intervention or surgery.

Complaint rebuttal and discussion:

Dr. Hospitalist defended himself by limiting his scope of responsibility. He essentially said this was a surgical complication, and it was therefore the surgical team’s responsibility to make the diagnosis. Defense experts were quick to affirm that Dr. Hospitalist was consulted for a specific issue – postoperative tachycardia – and that he performed a focused history and physical examination to address that issue. Plaintiff experts cited the Society of Hospital Medicine Hospitalist Orthopedic Co-Management Implementation Guide, which outlines that co-management is the “shared responsibility, authority, and accountability for the care of a hospitalized patient.” The Guide further states: “Inevitably, there will be circumstances where either of the co-managing services could manage a specific problem, or where it is unclear which service would be best equipped to manage a specific problem. These situations can be best managed by following two basic principles: 1) Do what is best for the patient in a timely fashion and do not assume that a problem is being handled by the other service; and 2) communicate frequently and directly with the other service.” Plaintiff experts argued that Dr. Hospitalist failed to follow both of these principles.

Conclusion:

Hospitalists are frequently co-managers of surgical patients, and thus they are in part responsible for evaluating diagnosing, and treating both medical and surgical complications. Once again, it is vital that hospitalists delineate responsibilities explicitly through direct communication and then memorialize such discussions in the medical record. In this case, the chart consultation deferred examination of the operative leg to a surgical team that claimed they were “unaware” of any issues. This case was settled on behalf of the patient for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at eHospitalist news.com/Lessons.

Deferring management of a postop complication to the surgery team resulted in treatment delay with a serious adverse outcome.

History:

RR is a 54 year-old man with a medical history of hypertension, hyperlipidemia, obesity, and chronic left knee pain from osteoarthritis. He was admitted to the hospital and underwent an elective left total knee replacement with monitored anesthesia care, combined with a left femoral nerve block. There were no intraoperative complications. When RR awoke in the recovery unit, he was in excruciating pain. He received another femoral nerve block and was sent to the regular nursing floor around 4 p.m. By early evening, the pain in his left leg remained poorly controlled and was consistently rated as 10/10. In addition, RR’s heart rates were elevated (130-140 bpm). The orthopedic surgeon was notified of the uncontrolled pain and elevated heart rates and he requested a hospitalist consult.

©Alliance/Fotolia.com

Dr. Hospitalist saw RR sometime before 9 p.m. that evening. RR was somewhat sedated by opiate analgesics, and his wife was at the bedside. During the interview, she related that her husband had been taking nightly benzodiazepines for sleep for several months leading up to the surgery. Dr. Hospitalist did not examine RR’s left foot and leg, and he documented in his consult that he was deferring left leg issues such as bleeding and swelling to the orthopedic surgery team. Dr. Hospitalist’s impression was that RR had sinus tachycardia, possibly because of the benzodiazepine withdrawal. Fluids were ordered along with low-dose benzodiazepines.

Throughout the night, RR awakened and complained of severe pain. The evening nurse charted that RR was having difficulty moving the toes on his left foot and that the pulses in his foot were barely palpable. By the early morning, RR’s pulses were no longer palpable but could still be detected by Doppler. Examination by the surgical team the following morning documented that RR had decreased sensation in his left lower extremity as well. An ultrasound of the left leg was ordered and revealed a large left popliteal pseudoaneurysm with complete occlusion of the left popliteal, tibial, and peroneal arteries below the knee. The patient went to the operating room three times over the next 4 days in an attempt to revascularize the leg. Unfortunately, RR ultimately had an above-the-knee amputation (AKA) performed 9 days after his elective total knee replacement.

Complaint:

RR sought a “quality of life”–enhancing procedure for his chronic left knee pain. What he ended up with was an AKA and a significant decrease in his overall quality of life. RR was angry that his postoperative pain, which was out of proportion to what should have been expected for this type of surgery, was essentially ignored until it was too late. He blamed the surgeon and the hospitalist for failing to diagnose his condition while his leg was still salvageable.

Scientific principles:

Complications during and after total knee replacement are generally uncommon and can often be prevented with meticulous surgical technique and with attentive postoperative management. Vascular injuries in total knee arthroplasty are exceedingly rare, but careful examination of the limbs is necessary to detect signs of acute limb ischemia. The six P’s of acute ischemia include paresthesia, pain, pallor, pulselessness, poikilothermia, and paralysis. A diagnosis of acute lower extremity ischemia can generally be made based upon the history and physical examination. Once the diagnosis of acute arterial occlusion has been made, anticoagulation should be initiated. Subsequent treatment varies depending upon the classification of acute ischemia. The initial options include catheter-directed thrombolytic therapy with or without percutaneous intervention or surgery.

Complaint rebuttal and discussion:

Dr. Hospitalist defended himself by limiting his scope of responsibility. He essentially said this was a surgical complication, and it was therefore the surgical team’s responsibility to make the diagnosis. Defense experts were quick to affirm that Dr. Hospitalist was consulted for a specific issue – postoperative tachycardia – and that he performed a focused history and physical examination to address that issue. Plaintiff experts cited the Society of Hospital Medicine Hospitalist Orthopedic Co-Management Implementation Guide, which outlines that co-management is the “shared responsibility, authority, and accountability for the care of a hospitalized patient.” The Guide further states: “Inevitably, there will be circumstances where either of the co-managing services could manage a specific problem, or where it is unclear which service would be best equipped to manage a specific problem. These situations can be best managed by following two basic principles: 1) Do what is best for the patient in a timely fashion and do not assume that a problem is being handled by the other service; and 2) communicate frequently and directly with the other service.” Plaintiff experts argued that Dr. Hospitalist failed to follow both of these principles.

Conclusion:

Hospitalists are frequently co-managers of surgical patients, and thus they are in part responsible for evaluating diagnosing, and treating both medical and surgical complications. Once again, it is vital that hospitalists delineate responsibilities explicitly through direct communication and then memorialize such discussions in the medical record. In this case, the chart consultation deferred examination of the operative leg to a surgical team that claimed they were “unaware” of any issues. This case was settled on behalf of the patient for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at eHospitalist news.com/Lessons.

A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?

A. 1% lidocaine.

B. 1% lidocaine with epinephrine.

C. Bupivacaine.

Myth: You should not use lidocaine with epinephrine on a digit.

Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).

Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.

Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.

A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.

There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.

In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).

Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.

There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).

In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.

The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.

Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at [email protected].

A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?

A. 1% lidocaine.

B. 1% lidocaine with epinephrine.

C. Bupivacaine.

Myth: You should not use lidocaine with epinephrine on a digit.

Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).

Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.

Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.

A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.

There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.

In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).

Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.

There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).

In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.

The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.

Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at [email protected].

A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?

A. 1% lidocaine.

B. 1% lidocaine with epinephrine.

C. Bupivacaine.

Myth: You should not use lidocaine with epinephrine on a digit.

Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).

Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.

Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.

A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.

There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.

In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).

Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.

There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).

In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.

The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.

Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at [email protected].