Legal issues in the practice of critical care medicine: a practical approach

Critical care as a career for anaesthesiologists

Anaesthesiologists by virtue of their understanding of physiology, pharmacology and resuscitation skills are best suited to manage critical care units. Armed with this varied knowledge, the anaesthesiologist is 'physician to the surgeon and a surgeon to the physician'. Specialised training helps them to provide extended postoperative and critical care. During the past few months in the battle with coronavirus disease (COVID)-19, anaesthesiologists have stood up to the challenge of caring for critically ill patients, compromising on their operating room responsibilities. The fact from a growing body of literature suggests that an anaesthesiologist as a critical care specialist provides efficient care and better outcomes. With an increasing awareness and need for critical care, government support is going to increase with an increase in avenues for training and research leading to better professional development and earning potential.

Lumbar Punctures at an Academic Level 4 NICU: Indications for a New Curriculum

ISSUE

Pediatric residents commonly perform lumbar punctures during their clinical training. The objective of this study was to assess residents' rate of nontraumatic lumbar punctures, examine the adequacy of samples, and implement proper documentation of the procedure in an academic Level 4 Neonatal Intensive Care Unit. We hypothesize that traumatic taps are common and that documentation of the procedure is poor.

EVIDENCE

A retrospective chart review was done of infants admitted to the neonatal intensive care unit from January 2011 to November 2011 who underwent a lumbar puncture. Procedure notes were evaluated for completion of proper documentation, the lab specimen was assessed for red blood cell count less than 1,000 cells/mm(3), and individuals were assessed for their ability to obtain a cerebrospinal fluid sample to send to the lab for analysis (i.e., sample of adequate volume and not clotted) and the total number of attempts to obtain a sample. A total of 184 charts were reviewed. Procedure notes were incomplete (58%) and lacked pertinent details. Eight percent of samples obtained had no record of the procedure being preformed. There was inadequate sample acquisition in 23% of the lumbar punctures. More than three attempts were noted in 14% of lumbar punctures performed. Many specimens contained very high red blood cell counts. Seventy-five percent of lumbar punctures with full documentation (n = 60), resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm(3) and 55% of underdocumented lumbar punctures resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm(3) (n = 71).

IMPLICATIONS

We found that poorly documented lumbar punctures are common and the ability of residents to obtain satisfactory cerebrospinal fluid is low. The inability of residents to consistently perform nontraumatic lumbar punctures is likely a common phenomenon. New educational methods and evaluation criteria must be developed to address this gap in resident education.

Disaster Documentation for the Clinician

Documentation of the patient encounter is a traditional component of health care practice, a requirement of various regulatory agencies and hospital oversight committees, and a necessity for reimbursement. A disaster may create unexpected challenges to documentation. If patient volume and acuity overwhelm health care providers, what is the acceptable appropriate documentation? If alterations in scope of practice and environmental or resource limitations occur, to what degree should this be documented? The conflicts arising from allocation of limited resources create unfamiliar situations in which patient competition becomes a component of the medical decision making; should that be documented, and, if so, how?

In addition to these challenges, ever-present liability worries are compounded by controversies over the standards to which health care providers will be held. Little guidance is available on how or what to document. We conducted a search of the literature and found no appropriate references for disaster documentation, and no guidelines from professional organizations. We review here the challenges affecting documentation during disasters and provide a rationale for specific patient care documentation that avoids regulatory and legal pitfalls. (Disaster Med Public Health Preparedness. 2013;0:1–7)

Family Centred Care--a way to connect patients, families and nurses in critical care: a qualitative study using telephone interviews

OBJECTIVES

This study sought to describe families' experiences of providing physical care to their critically ill relatives with bed-side nurses' support.

METHODS

A qualitative research design was used and telephone interviews were conducted with 10 family members. The interviews were analysed using content analysis where data were grouped around central, recurrent ideas. A purposeful sample of family members who had performed care for their sick relative were drawn from a critical care unit in a large tertiary hospital in Australia.

FINDINGS

The data revealed three main themes in relation to the family members' perceptions of providing some fundamental care to their sick relative. The three themes included: (1) 'Enacting Care'; (2) 'Connecting with Sick Relatives' and (3) 'Partnering with Nurses'.

CONCLUSIONS

This study demonstrates that family members of critically ill patients enjoyed participating in their relatives' care and critical care nurses supported them in individualizing the care. They felt useful and it improved communication and facilitated close physical and emotional contact with their relative. This partnership approach successfully incorporated family members into the daily care for their sick relative and connects patients, families and nurses in critical care within this Family Centred Care model of care.

Medical malpractice and the chest physician

The US malpractice system is based on tort law, which holds physicians responsible for not harming patients intentionally or through negligence. Malpractice claims are brought against physicians from most medical disciplines in proportion to their numbers in practice and to the frequency with which they perform procedures. Claims against chest physicians most commonly allege injuries caused by the following: (1) errors in diagnosis, (2) improper performance of procedures, (3) failure to supervise or monitor care, (4) medication errors, and (5) failure to recognize the complications of treatment. Most of these injuries occur in hospitals, and many of the injured patients die. The social goals of the medical malpractice system include the following: (1) compensating patients injured through negligence, (2) exacting corrective justice, and (3) deterring unsafe practices by creating an economic incentive to take greater precautions. Some patients injured through negligence are compensated, but most are not. Claims are brought against some negligent physicians but also some who are not negligent, and being negligent does not guarantee that a claim will be brought. The deterrent effect of medical malpractice is unproven, and the malpractice system may prompt defensive medicine and increase health-care costs. And by stressing individual accountability, it conflicts with a systems-oriented approach to reducing medical errors.