Was the ObGyn’s dexterity compromised?
A woman underwent a hysterectomy. During surgery, the patient’s bladder was injured; the ObGyn called in a urologist to make the repair. 

Patient’s claim The ObGyn failed to inform the patient about the possible complications from hysterectomy. The patient also claimed fraudulent concealment because the ObGyn had suffered a serious injury 3 years earlier that affected his dexterity. At the time of surgery, the ObGyn had a pending lawsuit against the owner of the premises where he fell in which he claimed that he was unable to continue his surgical practice because of the injury. The ObGyn never informed the patient of the extent of his injury or any associated risks related to his injury.

Defendants’ defense The patient was fully informed that bladder injury is a known risk of the procedure. The ObGyn maintained that his injury only affected his ability to stand for many hours while operating. The hospital settled during trial.

Verdict A $12,000 Louisiana settlement was reached with the hospital. Summary judgment was granted to the ObGyn on the informed consent claim. A $30,000 verdict was returned on the fraud count.

Placental abruption: Was child dead?
At 32 weeks’ gestation, a woman was found to have placental abruption. At the hospital, her ObGyn could not find a fetal heartbeat or detectable fetal movement on ultrasonography. A radiologist performed another ultrasound 30 minutes later and detected a fetal heart rate of 47 bpm. An emergency cesarean delivery was performed. Soon after birth, the child had seizures and was found to have hypoxic ischemic encephalopathy and diffuse brain injury. The child is profoundly disabled. 

Parents’ claim The ObGyn was negligent for failing to detect the fetal heart rate and in failing to respond properly to placental abruption. Cesarean delivery should have been performed immediately after placental abruption was identified.

Defendant’s defense The case was settled at trial.

Verdict A $13 million Illinois settlement was reached, including $5 million in cash and $8 million placed in trust for the child.

Large fetus, shoulder dystocia: Erb’s palsy
Labor was induced at 39 weeks’ gestation because the fetus was anticipated to be large. During vaginal delivery, shoulder dystocia was encountered. At birth, the baby weighed 9 lb 2 oz. She sustained a brachial plexus injury to the posterior shoulder with permanent nerve root damage and Erb’s palsy. The child continues to have limited use of her left arm and hand even after 3 corrective operations.  

Parents’ claim While performing maneuvers to relieve shoulder dystocia, the ObGyn exerted excessive traction on the baby’s head, causing a C-5 nerve root injury and complete avulsion at C-8. A cesarean delivery should have been performed.

Physician’s defense There was no negligence. The nerve injury was caused by the natural forces of labor and the mother’s pushing while the posterior shoulder was wedged behind the mother’s sa-
cral promontory.

Verdict A $1 million Illinois verdict was returned.  

Woman dies from toxemia
A 22-year-old woman was seen by her ObGyn 4 days after vaginal delivery. Early the next day, the patient had a seizure at home and was transported by ambulance to the hospital. She could not be resuscitated and died. At autopsy, the cause of death was determined to be toxemia from pregnancy. 

Estate’s claim The ObGyn failed to properly diagnose and treat the patient’s hypertension.

Defendant’s defense The case was settled during trial.

Verdict A $775,000 New York settlement was reached.

Blood transfusion delayed for hours: $14.75M net award
After emergency cesarean delivery, the baby was extremely anemic. The physicians determined that a fetal-maternal hemorrhage had started days before, causing the fetus to lose most of her blood.

An hour after birth, the attending neonatologist ordered blood from the hospital’s blood bank and arranged for emergency transport to a neonatal intensive care unit (NICU). Blood transfusion did not occur prior to transport. The child has severe cerebral palsy (CP) and cannot walk or talk at age 8 years.

Parents’ claim The neonatologist ordered cross-matched blood, which, because it is tested for compatibility, takes longer to supply. Universal donor blood could have been delivered in 20 minutes or less because it is readily available. The ambulance from the receiving hospital took an hour to drive 9 miles between the facilities, a trip that should have taken 12 minutes. The ambulance staff did not call ahead to the medical center to have blood ready for the baby. It took 4.5 hours before the newborn received a blood transfusion, a delay that caused severe injury to the child.

Defendants’ defense The matter went to trial against the neonatologist and his employer after the other defendants settled. 

Verdict Before trial, an ObGyn and the hospital settled for a combined $750,000, and the county agreed to a $12 million settlement. During trial, a $2 million Illinois settlement was reached.

Pregnant woman has a massive stroke: $10.9M
Pregnant with her third child and at 26 weeks’ gestation, a 35-year-old woman had a massive intracerebral hemorrhage at home.

The day before, she had contacted her ObGyn’s office to report severe headache and abdominal pain. The call was taken by an associate of her ObGyn, who told her there was no need to go to the hospital and suggested that she had a gastrointestinal virus.

The stroke caused severe cognitive impairment, loss of memory, partial vision loss, dysphasia, and partial paralysis on her right side. At trial, she was still undergoing therapy to regain mobility, speech, and memory. She uses a wheelchair. 

Patient’s claim The covering ObGyn was negligent for not sending the patient to the hospital when she reported severe headache.

Defendants’ defense The ObGyn and medical practice denied negligence, contending that the patient’s pregnancy was normal and that there was no indication that she was at risk for a stroke.

Verdict A $10,928,188 Ohio verdict was returned.

Was the fetus properly monitored?
One month before her due date, a woman was found to have premature rupture of membranes. She had gestational diabetes controlled by diet. She was admitted for induction of labor.

For more than 12 hours, external fetal monitor heart-rate tracings were reassuring. Then tracings began to show variable decelerations. For a period of 90 minutes, it was impossible to evaluate the fetal heart rate because the monitor was not working. An internal monitor was not placed. Just prior to birth, the tracings showed a 15-minute period of fetal tachycardia with the heart rate at 180 bpm. The physician’s notes indicated that the baby’s head had crowned for a prolonged period of time.

The baby was floppy at birth with Apgar scores of 2, 4, and 6 at 1, 5, and 10 minutes, respectively. The child was resuscitated and transferred to the NICU. She was found to have perinatal asphyxia, severe metabolic acidosis, multiorgan injury, hypoxic ischemic encephalopathy, and seizures. She stayed in the NICU for 1 month. At age 9 years, she has developmental delays and memory problems, but no motor injuries. 

Parents’ claim During the 90 minutes in which the fetal heart-rate monitor was not working properly, the fetus was in distress. An emergency cesarean delivery should have been performed when variable decelerations were seen on tracings.

Physician’s defense The lack of motor injury indicates that the injury was not related to birth.

Verdict A $2 million Michigan settlement was reached.

Rectal tear after vacuum extraction
Vacuum extraction was used to deliver a 47-year-old woman’s child. Later, the mother developed a rectovaginal fistula that became inflamed and involved vaginal passage of stool. The patient required 2 operations and still has residual complications.

Patient’s claim The ObGyn should have found and repaired the rectal tear at delivery. Vacuum extraction was used after only 2 pushes. The mother did not consent to the use of the vacuum extractor.

Physician’s defense The ObGyn admitted that he did not specifically remember this delivery. He claimed that there was informed consent and that the rectal injury was small and easy to overlook.

Verdict A $1.02 million New York verdict was returned.

 

Preeclamptic mother dies after giving birth
A 24-year-old woman developed preeclampsia when under prenatal care at a hospital clinic. At 36 weeks’ gestation, she presented to the clinic with a headache, “seeing spots,” and feeling ill; her blood pressure (BP) was 169/89 mm Hg. She was admitted for induction of labor and treated for preeclampsia with magnesium sulfate. A healthy baby was born 2 days later. The mother continued to have high BP and was prescribed nifedipine.

Her BP was 148/88 mm Hg at discharge. No antihypertensive medications were prescribed. She was given standard postpartum instructions and told to schedule a follow-up appointment in 6 to 8 weeks.

Five days after discharge, she experienced shortness of breath and swelling in her extremities, but did not seek medical attention until the next day, when breathing became labored. When emergency medical services arrived, she was in cardiac arrest. Prolonged resuscitation was required with intubation and artificial respiration. A computed tomo­g-raphy (CT) scan revealed cerebral edema from prolonged hypoxia. She was transferred to another hospital where a neurologist determined that she had suffered a profound anoxic brain injury. She died 3 days later.

Estate’s claim The hospital staff was negligent for failing to inform the patient of the signs and symptoms of continuing preeclampsia and for not prescribing antihypertensive medication at discharge. Her follow-up appointment should have been scheduled for 1 week.

Defendant’s defense The patient was given oral instructions regarding postpartum preeclampsia. The case was settled during trial.

Verdict A $50,000 North Carolina settlement was reached.

 

Was delivery properly managed?
When a 16-year-old woman was found to have preeclampsia, she was admitted and labor was induced using oxytocin. An external fetal heart-rate monitor was placed.

Three hours later, her ObGyn took over her care from the attending physician. He saw the patient once in the evening, then left to deliver a baby at another hospital. He maintained telephone contact with labor and delivery nurses, who told him that the mother’s labor was progressing as planned. Early the next morning, the nurse called the ObGyn to report that the mother was fully dilated and ready to deliver. The ObGyn was at the patient’s bedside within 30 minutes. After the mother pushed once, the ObGyn determined that a cesarean delivery was necessary.

After birth, the child suffered seizures in the NICU and was transferred to another facility. With CP and microcephaly, he cannot speak, is incontinent, has motor difficulties, and will require 24-hour care for life. 

Parent’s claim Labor was not properly monitored. Oxytocin doses were too large and continued for too long.

Defendants’ defense The mother’s treatment was appropriate and timely. There was no negligence.

Verdict A confidential Kansas settlement was reached with another defendant during the trial. A defense verdict was returned for the ObGyn.

Evidence of CMV on ultrasonography
During her pregnancy in 2012, a woman contracted congenital cytomegalovirus (CMV), although she did not have any symptoms. The child has CP, a hearing deficiency, and other complications caused by the virus.

Parents’ claim The ObGyn failed to identify CMV, despite ultrasound evidence that the virus was affecting the fetus. Studies available at the time of the pregnancy show considerable success in treating the condition in utero with hyperimmune globulin antiviral agents.

Defendant’s defense The case was settled during trial.

Verdict A confidential Idaho settlement was reached.  

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements, & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Was the ObGyn’s dexterity compromised?
A woman underwent a hysterectomy. During surgery, the patient’s bladder was injured; the ObGyn called in a urologist to make the repair. 

Patient’s claim The ObGyn failed to inform the patient about the possible complications from hysterectomy. The patient also claimed fraudulent concealment because the ObGyn had suffered a serious injury 3 years earlier that affected his dexterity. At the time of surgery, the ObGyn had a pending lawsuit against the owner of the premises where he fell in which he claimed that he was unable to continue his surgical practice because of the injury. The ObGyn never informed the patient of the extent of his injury or any associated risks related to his injury.

Defendants’ defense The patient was fully informed that bladder injury is a known risk of the procedure. The ObGyn maintained that his injury only affected his ability to stand for many hours while operating. The hospital settled during trial.

Verdict A $12,000 Louisiana settlement was reached with the hospital. Summary judgment was granted to the ObGyn on the informed consent claim. A $30,000 verdict was returned on the fraud count.

Placental abruption: Was child dead?
At 32 weeks’ gestation, a woman was found to have placental abruption. At the hospital, her ObGyn could not find a fetal heartbeat or detectable fetal movement on ultrasonography. A radiologist performed another ultrasound 30 minutes later and detected a fetal heart rate of 47 bpm. An emergency cesarean delivery was performed. Soon after birth, the child had seizures and was found to have hypoxic ischemic encephalopathy and diffuse brain injury. The child is profoundly disabled. 

Parents’ claim The ObGyn was negligent for failing to detect the fetal heart rate and in failing to respond properly to placental abruption. Cesarean delivery should have been performed immediately after placental abruption was identified.

Defendant’s defense The case was settled at trial.

Verdict A $13 million Illinois settlement was reached, including $5 million in cash and $8 million placed in trust for the child.

Large fetus, shoulder dystocia: Erb’s palsy
Labor was induced at 39 weeks’ gestation because the fetus was anticipated to be large. During vaginal delivery, shoulder dystocia was encountered. At birth, the baby weighed 9 lb 2 oz. She sustained a brachial plexus injury to the posterior shoulder with permanent nerve root damage and Erb’s palsy. The child continues to have limited use of her left arm and hand even after 3 corrective operations.  

Parents’ claim While performing maneuvers to relieve shoulder dystocia, the ObGyn exerted excessive traction on the baby’s head, causing a C-5 nerve root injury and complete avulsion at C-8. A cesarean delivery should have been performed.

Physician’s defense There was no negligence. The nerve injury was caused by the natural forces of labor and the mother’s pushing while the posterior shoulder was wedged behind the mother’s sa-
cral promontory.

Verdict A $1 million Illinois verdict was returned.  

Woman dies from toxemia
A 22-year-old woman was seen by her ObGyn 4 days after vaginal delivery. Early the next day, the patient had a seizure at home and was transported by ambulance to the hospital. She could not be resuscitated and died. At autopsy, the cause of death was determined to be toxemia from pregnancy. 

Estate’s claim The ObGyn failed to properly diagnose and treat the patient’s hypertension.

Defendant’s defense The case was settled during trial.

Verdict A $775,000 New York settlement was reached.

Blood transfusion delayed for hours: $14.75M net award
After emergency cesarean delivery, the baby was extremely anemic. The physicians determined that a fetal-maternal hemorrhage had started days before, causing the fetus to lose most of her blood.

An hour after birth, the attending neonatologist ordered blood from the hospital’s blood bank and arranged for emergency transport to a neonatal intensive care unit (NICU). Blood transfusion did not occur prior to transport. The child has severe cerebral palsy (CP) and cannot walk or talk at age 8 years.

Parents’ claim The neonatologist ordered cross-matched blood, which, because it is tested for compatibility, takes longer to supply. Universal donor blood could have been delivered in 20 minutes or less because it is readily available. The ambulance from the receiving hospital took an hour to drive 9 miles between the facilities, a trip that should have taken 12 minutes. The ambulance staff did not call ahead to the medical center to have blood ready for the baby. It took 4.5 hours before the newborn received a blood transfusion, a delay that caused severe injury to the child.

Defendants’ defense The matter went to trial against the neonatologist and his employer after the other defendants settled. 

Verdict Before trial, an ObGyn and the hospital settled for a combined $750,000, and the county agreed to a $12 million settlement. During trial, a $2 million Illinois settlement was reached.

Pregnant woman has a massive stroke: $10.9M
Pregnant with her third child and at 26 weeks’ gestation, a 35-year-old woman had a massive intracerebral hemorrhage at home.

The day before, she had contacted her ObGyn’s office to report severe headache and abdominal pain. The call was taken by an associate of her ObGyn, who told her there was no need to go to the hospital and suggested that she had a gastrointestinal virus.

The stroke caused severe cognitive impairment, loss of memory, partial vision loss, dysphasia, and partial paralysis on her right side. At trial, she was still undergoing therapy to regain mobility, speech, and memory. She uses a wheelchair. 

Patient’s claim The covering ObGyn was negligent for not sending the patient to the hospital when she reported severe headache.

Defendants’ defense The ObGyn and medical practice denied negligence, contending that the patient’s pregnancy was normal and that there was no indication that she was at risk for a stroke.

Verdict A $10,928,188 Ohio verdict was returned.

Was the fetus properly monitored?
One month before her due date, a woman was found to have premature rupture of membranes. She had gestational diabetes controlled by diet. She was admitted for induction of labor.

For more than 12 hours, external fetal monitor heart-rate tracings were reassuring. Then tracings began to show variable decelerations. For a period of 90 minutes, it was impossible to evaluate the fetal heart rate because the monitor was not working. An internal monitor was not placed. Just prior to birth, the tracings showed a 15-minute period of fetal tachycardia with the heart rate at 180 bpm. The physician’s notes indicated that the baby’s head had crowned for a prolonged period of time.

The baby was floppy at birth with Apgar scores of 2, 4, and 6 at 1, 5, and 10 minutes, respectively. The child was resuscitated and transferred to the NICU. She was found to have perinatal asphyxia, severe metabolic acidosis, multiorgan injury, hypoxic ischemic encephalopathy, and seizures. She stayed in the NICU for 1 month. At age 9 years, she has developmental delays and memory problems, but no motor injuries. 

Parents’ claim During the 90 minutes in which the fetal heart-rate monitor was not working properly, the fetus was in distress. An emergency cesarean delivery should have been performed when variable decelerations were seen on tracings.

Physician’s defense The lack of motor injury indicates that the injury was not related to birth.

Verdict A $2 million Michigan settlement was reached.

Rectal tear after vacuum extraction
Vacuum extraction was used to deliver a 47-year-old woman’s child. Later, the mother developed a rectovaginal fistula that became inflamed and involved vaginal passage of stool. The patient required 2 operations and still has residual complications.

Patient’s claim The ObGyn should have found and repaired the rectal tear at delivery. Vacuum extraction was used after only 2 pushes. The mother did not consent to the use of the vacuum extractor.

Physician’s defense The ObGyn admitted that he did not specifically remember this delivery. He claimed that there was informed consent and that the rectal injury was small and easy to overlook.

Verdict A $1.02 million New York verdict was returned.

 

Preeclamptic mother dies after giving birth
A 24-year-old woman developed preeclampsia when under prenatal care at a hospital clinic. At 36 weeks’ gestation, she presented to the clinic with a headache, “seeing spots,” and feeling ill; her blood pressure (BP) was 169/89 mm Hg. She was admitted for induction of labor and treated for preeclampsia with magnesium sulfate. A healthy baby was born 2 days later. The mother continued to have high BP and was prescribed nifedipine.

Her BP was 148/88 mm Hg at discharge. No antihypertensive medications were prescribed. She was given standard postpartum instructions and told to schedule a follow-up appointment in 6 to 8 weeks.

Five days after discharge, she experienced shortness of breath and swelling in her extremities, but did not seek medical attention until the next day, when breathing became labored. When emergency medical services arrived, she was in cardiac arrest. Prolonged resuscitation was required with intubation and artificial respiration. A computed tomo­g-raphy (CT) scan revealed cerebral edema from prolonged hypoxia. She was transferred to another hospital where a neurologist determined that she had suffered a profound anoxic brain injury. She died 3 days later.

Estate’s claim The hospital staff was negligent for failing to inform the patient of the signs and symptoms of continuing preeclampsia and for not prescribing antihypertensive medication at discharge. Her follow-up appointment should have been scheduled for 1 week.

Defendant’s defense The patient was given oral instructions regarding postpartum preeclampsia. The case was settled during trial.

Verdict A $50,000 North Carolina settlement was reached.

 

Was delivery properly managed?
When a 16-year-old woman was found to have preeclampsia, she was admitted and labor was induced using oxytocin. An external fetal heart-rate monitor was placed.

Three hours later, her ObGyn took over her care from the attending physician. He saw the patient once in the evening, then left to deliver a baby at another hospital. He maintained telephone contact with labor and delivery nurses, who told him that the mother’s labor was progressing as planned. Early the next morning, the nurse called the ObGyn to report that the mother was fully dilated and ready to deliver. The ObGyn was at the patient’s bedside within 30 minutes. After the mother pushed once, the ObGyn determined that a cesarean delivery was necessary.

After birth, the child suffered seizures in the NICU and was transferred to another facility. With CP and microcephaly, he cannot speak, is incontinent, has motor difficulties, and will require 24-hour care for life. 

Parent’s claim Labor was not properly monitored. Oxytocin doses were too large and continued for too long.

Defendants’ defense The mother’s treatment was appropriate and timely. There was no negligence.

Verdict A confidential Kansas settlement was reached with another defendant during the trial. A defense verdict was returned for the ObGyn.

Evidence of CMV on ultrasonography
During her pregnancy in 2012, a woman contracted congenital cytomegalovirus (CMV), although she did not have any symptoms. The child has CP, a hearing deficiency, and other complications caused by the virus.

Parents’ claim The ObGyn failed to identify CMV, despite ultrasound evidence that the virus was affecting the fetus. Studies available at the time of the pregnancy show considerable success in treating the condition in utero with hyperimmune globulin antiviral agents.

Defendant’s defense The case was settled during trial.

Verdict A confidential Idaho settlement was reached.  

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements, & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Was the ObGyn’s dexterity compromised?
A woman underwent a hysterectomy. During surgery, the patient’s bladder was injured; the ObGyn called in a urologist to make the repair. 

Patient’s claim The ObGyn failed to inform the patient about the possible complications from hysterectomy. The patient also claimed fraudulent concealment because the ObGyn had suffered a serious injury 3 years earlier that affected his dexterity. At the time of surgery, the ObGyn had a pending lawsuit against the owner of the premises where he fell in which he claimed that he was unable to continue his surgical practice because of the injury. The ObGyn never informed the patient of the extent of his injury or any associated risks related to his injury.

Defendants’ defense The patient was fully informed that bladder injury is a known risk of the procedure. The ObGyn maintained that his injury only affected his ability to stand for many hours while operating. The hospital settled during trial.

Verdict A $12,000 Louisiana settlement was reached with the hospital. Summary judgment was granted to the ObGyn on the informed consent claim. A $30,000 verdict was returned on the fraud count.

Placental abruption: Was child dead?
At 32 weeks’ gestation, a woman was found to have placental abruption. At the hospital, her ObGyn could not find a fetal heartbeat or detectable fetal movement on ultrasonography. A radiologist performed another ultrasound 30 minutes later and detected a fetal heart rate of 47 bpm. An emergency cesarean delivery was performed. Soon after birth, the child had seizures and was found to have hypoxic ischemic encephalopathy and diffuse brain injury. The child is profoundly disabled. 

Parents’ claim The ObGyn was negligent for failing to detect the fetal heart rate and in failing to respond properly to placental abruption. Cesarean delivery should have been performed immediately after placental abruption was identified.

Defendant’s defense The case was settled at trial.

Verdict A $13 million Illinois settlement was reached, including $5 million in cash and $8 million placed in trust for the child.

Large fetus, shoulder dystocia: Erb’s palsy
Labor was induced at 39 weeks’ gestation because the fetus was anticipated to be large. During vaginal delivery, shoulder dystocia was encountered. At birth, the baby weighed 9 lb 2 oz. She sustained a brachial plexus injury to the posterior shoulder with permanent nerve root damage and Erb’s palsy. The child continues to have limited use of her left arm and hand even after 3 corrective operations.  

Parents’ claim While performing maneuvers to relieve shoulder dystocia, the ObGyn exerted excessive traction on the baby’s head, causing a C-5 nerve root injury and complete avulsion at C-8. A cesarean delivery should have been performed.

Physician’s defense There was no negligence. The nerve injury was caused by the natural forces of labor and the mother’s pushing while the posterior shoulder was wedged behind the mother’s sa-
cral promontory.

Verdict A $1 million Illinois verdict was returned.  

Woman dies from toxemia
A 22-year-old woman was seen by her ObGyn 4 days after vaginal delivery. Early the next day, the patient had a seizure at home and was transported by ambulance to the hospital. She could not be resuscitated and died. At autopsy, the cause of death was determined to be toxemia from pregnancy. 

Estate’s claim The ObGyn failed to properly diagnose and treat the patient’s hypertension.

Defendant’s defense The case was settled during trial.

Verdict A $775,000 New York settlement was reached.

Blood transfusion delayed for hours: $14.75M net award
After emergency cesarean delivery, the baby was extremely anemic. The physicians determined that a fetal-maternal hemorrhage had started days before, causing the fetus to lose most of her blood.

An hour after birth, the attending neonatologist ordered blood from the hospital’s blood bank and arranged for emergency transport to a neonatal intensive care unit (NICU). Blood transfusion did not occur prior to transport. The child has severe cerebral palsy (CP) and cannot walk or talk at age 8 years.

Parents’ claim The neonatologist ordered cross-matched blood, which, because it is tested for compatibility, takes longer to supply. Universal donor blood could have been delivered in 20 minutes or less because it is readily available. The ambulance from the receiving hospital took an hour to drive 9 miles between the facilities, a trip that should have taken 12 minutes. The ambulance staff did not call ahead to the medical center to have blood ready for the baby. It took 4.5 hours before the newborn received a blood transfusion, a delay that caused severe injury to the child.

Defendants’ defense The matter went to trial against the neonatologist and his employer after the other defendants settled. 

Verdict Before trial, an ObGyn and the hospital settled for a combined $750,000, and the county agreed to a $12 million settlement. During trial, a $2 million Illinois settlement was reached.

Pregnant woman has a massive stroke: $10.9M
Pregnant with her third child and at 26 weeks’ gestation, a 35-year-old woman had a massive intracerebral hemorrhage at home.

The day before, she had contacted her ObGyn’s office to report severe headache and abdominal pain. The call was taken by an associate of her ObGyn, who told her there was no need to go to the hospital and suggested that she had a gastrointestinal virus.

The stroke caused severe cognitive impairment, loss of memory, partial vision loss, dysphasia, and partial paralysis on her right side. At trial, she was still undergoing therapy to regain mobility, speech, and memory. She uses a wheelchair. 

Patient’s claim The covering ObGyn was negligent for not sending the patient to the hospital when she reported severe headache.

Defendants’ defense The ObGyn and medical practice denied negligence, contending that the patient’s pregnancy was normal and that there was no indication that she was at risk for a stroke.

Verdict A $10,928,188 Ohio verdict was returned.

Was the fetus properly monitored?
One month before her due date, a woman was found to have premature rupture of membranes. She had gestational diabetes controlled by diet. She was admitted for induction of labor.

For more than 12 hours, external fetal monitor heart-rate tracings were reassuring. Then tracings began to show variable decelerations. For a period of 90 minutes, it was impossible to evaluate the fetal heart rate because the monitor was not working. An internal monitor was not placed. Just prior to birth, the tracings showed a 15-minute period of fetal tachycardia with the heart rate at 180 bpm. The physician’s notes indicated that the baby’s head had crowned for a prolonged period of time.

The baby was floppy at birth with Apgar scores of 2, 4, and 6 at 1, 5, and 10 minutes, respectively. The child was resuscitated and transferred to the NICU. She was found to have perinatal asphyxia, severe metabolic acidosis, multiorgan injury, hypoxic ischemic encephalopathy, and seizures. She stayed in the NICU for 1 month. At age 9 years, she has developmental delays and memory problems, but no motor injuries. 

Parents’ claim During the 90 minutes in which the fetal heart-rate monitor was not working properly, the fetus was in distress. An emergency cesarean delivery should have been performed when variable decelerations were seen on tracings.

Physician’s defense The lack of motor injury indicates that the injury was not related to birth.

Verdict A $2 million Michigan settlement was reached.

Rectal tear after vacuum extraction
Vacuum extraction was used to deliver a 47-year-old woman’s child. Later, the mother developed a rectovaginal fistula that became inflamed and involved vaginal passage of stool. The patient required 2 operations and still has residual complications.

Patient’s claim The ObGyn should have found and repaired the rectal tear at delivery. Vacuum extraction was used after only 2 pushes. The mother did not consent to the use of the vacuum extractor.

Physician’s defense The ObGyn admitted that he did not specifically remember this delivery. He claimed that there was informed consent and that the rectal injury was small and easy to overlook.

Verdict A $1.02 million New York verdict was returned.

 

Preeclamptic mother dies after giving birth
A 24-year-old woman developed preeclampsia when under prenatal care at a hospital clinic. At 36 weeks’ gestation, she presented to the clinic with a headache, “seeing spots,” and feeling ill; her blood pressure (BP) was 169/89 mm Hg. She was admitted for induction of labor and treated for preeclampsia with magnesium sulfate. A healthy baby was born 2 days later. The mother continued to have high BP and was prescribed nifedipine.

Her BP was 148/88 mm Hg at discharge. No antihypertensive medications were prescribed. She was given standard postpartum instructions and told to schedule a follow-up appointment in 6 to 8 weeks.

Five days after discharge, she experienced shortness of breath and swelling in her extremities, but did not seek medical attention until the next day, when breathing became labored. When emergency medical services arrived, she was in cardiac arrest. Prolonged resuscitation was required with intubation and artificial respiration. A computed tomo­g-raphy (CT) scan revealed cerebral edema from prolonged hypoxia. She was transferred to another hospital where a neurologist determined that she had suffered a profound anoxic brain injury. She died 3 days later.

Estate’s claim The hospital staff was negligent for failing to inform the patient of the signs and symptoms of continuing preeclampsia and for not prescribing antihypertensive medication at discharge. Her follow-up appointment should have been scheduled for 1 week.

Defendant’s defense The patient was given oral instructions regarding postpartum preeclampsia. The case was settled during trial.

Verdict A $50,000 North Carolina settlement was reached.

 

Was delivery properly managed?
When a 16-year-old woman was found to have preeclampsia, she was admitted and labor was induced using oxytocin. An external fetal heart-rate monitor was placed.

Three hours later, her ObGyn took over her care from the attending physician. He saw the patient once in the evening, then left to deliver a baby at another hospital. He maintained telephone contact with labor and delivery nurses, who told him that the mother’s labor was progressing as planned. Early the next morning, the nurse called the ObGyn to report that the mother was fully dilated and ready to deliver. The ObGyn was at the patient’s bedside within 30 minutes. After the mother pushed once, the ObGyn determined that a cesarean delivery was necessary.

After birth, the child suffered seizures in the NICU and was transferred to another facility. With CP and microcephaly, he cannot speak, is incontinent, has motor difficulties, and will require 24-hour care for life. 

Parent’s claim Labor was not properly monitored. Oxytocin doses were too large and continued for too long.

Defendants’ defense The mother’s treatment was appropriate and timely. There was no negligence.

Verdict A confidential Kansas settlement was reached with another defendant during the trial. A defense verdict was returned for the ObGyn.

Evidence of CMV on ultrasonography
During her pregnancy in 2012, a woman contracted congenital cytomegalovirus (CMV), although she did not have any symptoms. The child has CP, a hearing deficiency, and other complications caused by the virus.

Parents’ claim The ObGyn failed to identify CMV, despite ultrasound evidence that the virus was affecting the fetus. Studies available at the time of the pregnancy show considerable success in treating the condition in utero with hyperimmune globulin antiviral agents.

Defendant’s defense The case was settled during trial.

Verdict A confidential Idaho settlement was reached.  

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements, & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common allegationsby patients¹:

Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.¹

The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.¹ Susan Mann, MD,a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco (see “Frequent sources of malpractice claims” below).

Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims¹:  

“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”¹ See “Tips for reducing malpractice claims in obstetrics” below.

“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.¹

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common allegationsby patients¹:

Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.¹

The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.¹ Susan Mann, MD,a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco (see “Frequent sources of malpractice claims” below).

Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims¹:  

“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”¹ See “Tips for reducing malpractice claims in obstetrics” below.

“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.¹

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common allegationsby patients¹:

Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.¹

The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.¹ Susan Mann, MD,a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco (see “Frequent sources of malpractice claims” below).

Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims¹:  

“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”¹ See “Tips for reducing malpractice claims in obstetrics” below.

“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.¹

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Critique

Patients with mild pancreatitis can be treated with hydration alone. Initial feeding with a low-fat diet is safe and may reduce the duration of hospitalization, compared with a clear liquid diet in patients with mild pancreatitis. Multiple studies have demonstrated that enteral feeding is safe and tolerated in acute pancreatitis. Additionally, enteral feeding may preserve gut barrier function and prevent translocation of bacteria, which are implicated in pancreatic infections. A meta-analysis of the existing literature has demonstrated improved outcome with enteral feeding, compared with parenteral feeding, with less infectious complications, reduced cost, and better glycemic control.

References

1. McClave, S.A., Change, W.K., Dhaliwal, R., et al. Nutritional support in acute pancreatitis; a systemic review of the literature. J. Parenteral Enteral Nutr. 2006;30:143–56.

2. Vu M.K., van der Veek P.P., Frolich M., et al. Does jejunal feeding activate exocrine pancreatic secretions? Eur. J. Clin. Invest. 1999;29:1053–9.

3. Petrov M.S., van Santvoort H.C., Besselink M.S., et al. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch. Surg. 2008;143:1111–7.

Critique

Patients with mild pancreatitis can be treated with hydration alone. Initial feeding with a low-fat diet is safe and may reduce the duration of hospitalization, compared with a clear liquid diet in patients with mild pancreatitis. Multiple studies have demonstrated that enteral feeding is safe and tolerated in acute pancreatitis. Additionally, enteral feeding may preserve gut barrier function and prevent translocation of bacteria, which are implicated in pancreatic infections. A meta-analysis of the existing literature has demonstrated improved outcome with enteral feeding, compared with parenteral feeding, with less infectious complications, reduced cost, and better glycemic control.

References

1. McClave, S.A., Change, W.K., Dhaliwal, R., et al. Nutritional support in acute pancreatitis; a systemic review of the literature. J. Parenteral Enteral Nutr. 2006;30:143–56.

2. Vu M.K., van der Veek P.P., Frolich M., et al. Does jejunal feeding activate exocrine pancreatic secretions? Eur. J. Clin. Invest. 1999;29:1053–9.

3. Petrov M.S., van Santvoort H.C., Besselink M.S., et al. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch. Surg. 2008;143:1111–7.

Critique

Patients with mild pancreatitis can be treated with hydration alone. Initial feeding with a low-fat diet is safe and may reduce the duration of hospitalization, compared with a clear liquid diet in patients with mild pancreatitis. Multiple studies have demonstrated that enteral feeding is safe and tolerated in acute pancreatitis. Additionally, enteral feeding may preserve gut barrier function and prevent translocation of bacteria, which are implicated in pancreatic infections. A meta-analysis of the existing literature has demonstrated improved outcome with enteral feeding, compared with parenteral feeding, with less infectious complications, reduced cost, and better glycemic control.

References

1. McClave, S.A., Change, W.K., Dhaliwal, R., et al. Nutritional support in acute pancreatitis; a systemic review of the literature. J. Parenteral Enteral Nutr. 2006;30:143–56.

2. Vu M.K., van der Veek P.P., Frolich M., et al. Does jejunal feeding activate exocrine pancreatic secretions? Eur. J. Clin. Invest. 1999;29:1053–9.

3. Petrov M.S., van Santvoort H.C., Besselink M.S., et al. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch. Surg. 2008;143:1111–7.

Q1: ANSWER: B

Critique

This patient has developed an ulcer because of chronic NSAID use. She is older than 60 years old and is also on antiplatelet therapy. Therefore, her risk of peptic ulcer rebleeding is high and warrants lifelong secondary prophylaxis with a proton pump inhibitor (Choice B). Therefore, stopping all prophylactic measures would be inappropriate (Choice A). Repeat endoscopy to assess for gastric ulcer healing may be warranted, especially in the setting of risk factors for malignancy, but duodenal ulcers do not require endoscopic follow-up (Choice C). There is no role to empirically treat H. pylori in the context of having negative test results (Choice E).

References

1. Bhatt, D.L., et al. ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. Am. J. Gastroenterol. 2008;103:2890-907.

2. Abraham, N., et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. J. Am. Coll. Cardiol. 2010;56:2051-66.

Q1: ANSWER: B

Critique

This patient has developed an ulcer because of chronic NSAID use. She is older than 60 years old and is also on antiplatelet therapy. Therefore, her risk of peptic ulcer rebleeding is high and warrants lifelong secondary prophylaxis with a proton pump inhibitor (Choice B). Therefore, stopping all prophylactic measures would be inappropriate (Choice A). Repeat endoscopy to assess for gastric ulcer healing may be warranted, especially in the setting of risk factors for malignancy, but duodenal ulcers do not require endoscopic follow-up (Choice C). There is no role to empirically treat H. pylori in the context of having negative test results (Choice E).

References

1. Bhatt, D.L., et al. ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. Am. J. Gastroenterol. 2008;103:2890-907.

2. Abraham, N., et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. J. Am. Coll. Cardiol. 2010;56:2051-66.

Q1: ANSWER: B

Critique

This patient has developed an ulcer because of chronic NSAID use. She is older than 60 years old and is also on antiplatelet therapy. Therefore, her risk of peptic ulcer rebleeding is high and warrants lifelong secondary prophylaxis with a proton pump inhibitor (Choice B). Therefore, stopping all prophylactic measures would be inappropriate (Choice A). Repeat endoscopy to assess for gastric ulcer healing may be warranted, especially in the setting of risk factors for malignancy, but duodenal ulcers do not require endoscopic follow-up (Choice C). There is no role to empirically treat H. pylori in the context of having negative test results (Choice E).

References

1. Bhatt, D.L., et al. ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. Am. J. Gastroenterol. 2008;103:2890-907.

2. Abraham, N., et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. J. Am. Coll. Cardiol. 2010;56:2051-66.

Summary:

One of PHM15's first sessions was a workshop led by Dr. Rachna May focusing on the role of pediatric hospitalists in end-of-life conversations.

Medically complex pediatric patients are more likely to have end-of-life care in the hospital, placing the pediatric hospitalist in a unique position to address end-of-life issues. Medically complex patients may have waxing and waning courses, with frequent admissions for acute illness. Following these admissions, they may not fully return to their pre-illness baseline, leading to an overall gradual decline in health. An opportunity for discussing quality of life is available with each acute illness and hospitalization.

These conversations, however, can be difficult to initiate and present several barriers to overcome. These barriers include:

• Unknown parental expectations regarding outcome,
• Lack of an established relationship with the patient and family, and
• Lack of readiness of the patient and family to discuss end-of-life decisions.

To overcome these barriers, providers must develop tools for delivery. They must find the right setting for the conversation, limit distractions, and avoid medical jargon. Begin with asking the patient and family's perceptions of the clinical prognosis and be honest when discussing the predicted medical outcomes for the patient. Open discussion of the prognosis allows autonomy in decision making, helps families feel supported, and can help them manage distress surrounding end-of-life care.

Such terminology as "do not resuscitate" can be interpreted as “doing nothing,” and result in feelings of guilt for a family desiring care for their child. Using a phrase such as "allowing a natural death" can alleviate feelings of guilt over end-of-life decisions and help the family actively provide care while optimizing quality of life. TH

Dr. Player is a hospitalist and assistant professor in the Department of Pediatrics at Medical College of Wisconsin, Children’s Hospital of Wisconsin in Milwaukee.

Summary:

One of PHM15's first sessions was a workshop led by Dr. Rachna May focusing on the role of pediatric hospitalists in end-of-life conversations.

Medically complex pediatric patients are more likely to have end-of-life care in the hospital, placing the pediatric hospitalist in a unique position to address end-of-life issues. Medically complex patients may have waxing and waning courses, with frequent admissions for acute illness. Following these admissions, they may not fully return to their pre-illness baseline, leading to an overall gradual decline in health. An opportunity for discussing quality of life is available with each acute illness and hospitalization.

These conversations, however, can be difficult to initiate and present several barriers to overcome. These barriers include:

• Unknown parental expectations regarding outcome,
• Lack of an established relationship with the patient and family, and
• Lack of readiness of the patient and family to discuss end-of-life decisions.

To overcome these barriers, providers must develop tools for delivery. They must find the right setting for the conversation, limit distractions, and avoid medical jargon. Begin with asking the patient and family's perceptions of the clinical prognosis and be honest when discussing the predicted medical outcomes for the patient. Open discussion of the prognosis allows autonomy in decision making, helps families feel supported, and can help them manage distress surrounding end-of-life care.

Such terminology as "do not resuscitate" can be interpreted as “doing nothing,” and result in feelings of guilt for a family desiring care for their child. Using a phrase such as "allowing a natural death" can alleviate feelings of guilt over end-of-life decisions and help the family actively provide care while optimizing quality of life. TH

Dr. Player is a hospitalist and assistant professor in the Department of Pediatrics at Medical College of Wisconsin, Children’s Hospital of Wisconsin in Milwaukee.

Summary:

One of PHM15's first sessions was a workshop led by Dr. Rachna May focusing on the role of pediatric hospitalists in end-of-life conversations.

Medically complex pediatric patients are more likely to have end-of-life care in the hospital, placing the pediatric hospitalist in a unique position to address end-of-life issues. Medically complex patients may have waxing and waning courses, with frequent admissions for acute illness. Following these admissions, they may not fully return to their pre-illness baseline, leading to an overall gradual decline in health. An opportunity for discussing quality of life is available with each acute illness and hospitalization.

These conversations, however, can be difficult to initiate and present several barriers to overcome. These barriers include:

• Unknown parental expectations regarding outcome,
• Lack of an established relationship with the patient and family, and
• Lack of readiness of the patient and family to discuss end-of-life decisions.

To overcome these barriers, providers must develop tools for delivery. They must find the right setting for the conversation, limit distractions, and avoid medical jargon. Begin with asking the patient and family's perceptions of the clinical prognosis and be honest when discussing the predicted medical outcomes for the patient. Open discussion of the prognosis allows autonomy in decision making, helps families feel supported, and can help them manage distress surrounding end-of-life care.

Such terminology as "do not resuscitate" can be interpreted as “doing nothing,” and result in feelings of guilt for a family desiring care for their child. Using a phrase such as "allowing a natural death" can alleviate feelings of guilt over end-of-life decisions and help the family actively provide care while optimizing quality of life. TH

Dr. Player is a hospitalist and assistant professor in the Department of Pediatrics at Medical College of Wisconsin, Children’s Hospital of Wisconsin in Milwaukee.

Summary:

In an era where a majority of the pediatric hospital workforce is just starting to recognize fish bone diagrams, five why questions, root cause analysis, IHI, Lean, six sigma and pareto charts, hospitalists can be daunted as they try to serve as the home for quality improvement and patient safety in hospitals. Hospitalists are expected to know, understand, and practice these models for improvement with limited training and expertise. Beyond being looked at as experts, they are expected to teach residents and other learners when they are unsure of it ourselves. Governing education bodies (i.e., ACGME and CLER) have made it a requirement that residents have these concepts integrated into their curriculums and tracked.

Presented by an inter-professional team from Floating Hospital for Children at Tufts Medical Center in Boston, this PHM15 workshop focused on how to work in multidisciplinary teams to identify, analyze, and create patient-safety solutions, and, therefore, set the stage for systems- or department-based QI projects.

“It is OK to make mistakes, but it is not OK to not learn from them,” stated the presenters.

Starting with a near-miss event that led to a department/resident-led root cause analysis, the importance of system improvement became apparent. Presenters discussed the 12-week curriculum they created for pediatric residents and nursing students, which includes:

• Didactics,
• Online, self-directed learning, and
• An inter-professional, small-group project.

Trainees present their analysis and action items to their departments and, at times, even administration. This helps align hospital goals with resident teaching, while simultaneously providing an environment where discussing errors safely in order to prevent further harms.

Attendees of the workshop walked away with a generalizable, step-by-step toolkit to take home to their home institution.

Key Takeaways:

1. Convene a leadership team of nurses and physicians to develop the inter-professional program
2. Consider scheduling demands of nurses, physicians and residents.
3. Implement administrative support to assist with scheduling of meetings, maintenance of documents and email distribution.
4. Program participation must bring value to the staff such as CME credits
5. Make the educational experience program flexible in a blended learning environment.
6. Recognize staff’s completion of the program with a certificate.
7. Provide the opportunity, mentorship and support for staff willing to continue the project as a quality improvement initiative. TH

Dr. Hopkins is a pediatric hospitalist at All Children's Hospital Johns Hopkins Medicine, and an instructor at Johns Hopkins Medicine in St. Petersburg, Fla.

Summary:

In an era where a majority of the pediatric hospital workforce is just starting to recognize fish bone diagrams, five why questions, root cause analysis, IHI, Lean, six sigma and pareto charts, hospitalists can be daunted as they try to serve as the home for quality improvement and patient safety in hospitals. Hospitalists are expected to know, understand, and practice these models for improvement with limited training and expertise. Beyond being looked at as experts, they are expected to teach residents and other learners when they are unsure of it ourselves. Governing education bodies (i.e., ACGME and CLER) have made it a requirement that residents have these concepts integrated into their curriculums and tracked.

Presented by an inter-professional team from Floating Hospital for Children at Tufts Medical Center in Boston, this PHM15 workshop focused on how to work in multidisciplinary teams to identify, analyze, and create patient-safety solutions, and, therefore, set the stage for systems- or department-based QI projects.

“It is OK to make mistakes, but it is not OK to not learn from them,” stated the presenters.

Starting with a near-miss event that led to a department/resident-led root cause analysis, the importance of system improvement became apparent. Presenters discussed the 12-week curriculum they created for pediatric residents and nursing students, which includes:

• Didactics,
• Online, self-directed learning, and
• An inter-professional, small-group project.

Trainees present their analysis and action items to their departments and, at times, even administration. This helps align hospital goals with resident teaching, while simultaneously providing an environment where discussing errors safely in order to prevent further harms.

Attendees of the workshop walked away with a generalizable, step-by-step toolkit to take home to their home institution.

Key Takeaways:

1. Convene a leadership team of nurses and physicians to develop the inter-professional program
2. Consider scheduling demands of nurses, physicians and residents.
3. Implement administrative support to assist with scheduling of meetings, maintenance of documents and email distribution.
4. Program participation must bring value to the staff such as CME credits
5. Make the educational experience program flexible in a blended learning environment.
6. Recognize staff’s completion of the program with a certificate.
7. Provide the opportunity, mentorship and support for staff willing to continue the project as a quality improvement initiative. TH

Dr. Hopkins is a pediatric hospitalist at All Children's Hospital Johns Hopkins Medicine, and an instructor at Johns Hopkins Medicine in St. Petersburg, Fla.

Summary:

In an era where a majority of the pediatric hospital workforce is just starting to recognize fish bone diagrams, five why questions, root cause analysis, IHI, Lean, six sigma and pareto charts, hospitalists can be daunted as they try to serve as the home for quality improvement and patient safety in hospitals. Hospitalists are expected to know, understand, and practice these models for improvement with limited training and expertise. Beyond being looked at as experts, they are expected to teach residents and other learners when they are unsure of it ourselves. Governing education bodies (i.e., ACGME and CLER) have made it a requirement that residents have these concepts integrated into their curriculums and tracked.

Presented by an inter-professional team from Floating Hospital for Children at Tufts Medical Center in Boston, this PHM15 workshop focused on how to work in multidisciplinary teams to identify, analyze, and create patient-safety solutions, and, therefore, set the stage for systems- or department-based QI projects.

“It is OK to make mistakes, but it is not OK to not learn from them,” stated the presenters.

Starting with a near-miss event that led to a department/resident-led root cause analysis, the importance of system improvement became apparent. Presenters discussed the 12-week curriculum they created for pediatric residents and nursing students, which includes:

• Didactics,
• Online, self-directed learning, and
• An inter-professional, small-group project.

Trainees present their analysis and action items to their departments and, at times, even administration. This helps align hospital goals with resident teaching, while simultaneously providing an environment where discussing errors safely in order to prevent further harms.

Attendees of the workshop walked away with a generalizable, step-by-step toolkit to take home to their home institution.

Key Takeaways:

1. Convene a leadership team of nurses and physicians to develop the inter-professional program
2. Consider scheduling demands of nurses, physicians and residents.
3. Implement administrative support to assist with scheduling of meetings, maintenance of documents and email distribution.
4. Program participation must bring value to the staff such as CME credits
5. Make the educational experience program flexible in a blended learning environment.
6. Recognize staff’s completion of the program with a certificate.
7. Provide the opportunity, mentorship and support for staff willing to continue the project as a quality improvement initiative. TH

Dr. Hopkins is a pediatric hospitalist at All Children's Hospital Johns Hopkins Medicine, and an instructor at Johns Hopkins Medicine in St. Petersburg, Fla.

Presenters: Kelly Basaldua, MD; Daniel Sedillo, MD, MBA, and Jason Reynolds, MD

Summary:

In an environment where medicine is becoming ever more specialized and the scope of practice for many is ever narrowing into corridors of expertise, the hospitalist remains a bastion of generalism with an ever-diversifying skill set. One of the skills acquired by many hospitalists to aid in the overall efficiency of the hospital is intranasal (IN) sedation.

Intranasal sedation is becoming more popular given the rapid onset and offset and the relative safety of the sedation of patients without the need for intravenous catheters. This phenomenon is accomplished by avoiding the gut and thus avoiding first-pass metabolism. This allows for greatly increased bioavailability compared with oral administration. In addition, the nasal mucosa is in near direct contact with the CSF via the cribriform plate, allowing for rapid and effective action.

To maximize the effectiveness of intranasal sedation, low volumes with high concentrations, atomization, and minimal nasal occlusion are vital. The ideal volume per nostril is approximately 0.5 ml as using any greater volume results in oversaturation and minimal additional absorption. Thus, concentrating the medications into minimal volumes provides for more efficacious usage. Atomization aids in ensuring thorough surface area coverage and higher absorption. This is a far more efficacious method of delivery than liquid/drop administration.

Because intranasally administered agents have a delayed and widened serum peak compared to IV, IN sedation carries less of a chance to reach serum levels high enough to cause respiratory depression, though monitoring is still necessary. When compared to IV sedation, IN does have a delay in onset, but also provides for a more gentle recovery process, often resulting in a less disorienting recovery for the patient, while also providing for a wider safety profile.

The presenters covered three primary agents:

• midazolam,
• dexmedetomidine, and
• fentanyl

Midazolam is useful for non-painful, minimally invasive procedures. Fentanyl is more useful for painful or more invasive procedures. Dexmedetomidine is off-label use for intranasal sedation at this time, but has promising initial research given its safety profile and longer duration of action compared to most intranasal agents. Also, dexmedetomidine works extremely effectively in combination with other agents, particularly midazolam, to prolong sedations, making it very useful for longer procedures like combination MRIs.

The presenters then provided a practical workshop to practice the delivery of intranasal medication effectively. One of the pearls provided involved proper positioning of the patient in a reclined position as sitting to erect will cause the medication to drip out and having the patient lying flat will result in the medication dripping down the posterior pharynx. This position should be held for 30 seconds after delivery of the medication. Practicing with atomizers to achieve effective aerosolization was discussed. The target of medication should avoid the nasal septum given its poor absorption.

Key Takeaway:

With hospitalists being called to assist in ever-expanding roles within the hospital system while improving efficiency and throughput, intranasal sedation may provide reduced imaging wait times, bedside and ED procedure times in a safe and effective manner. TH

Dr. Crook is a hospitalist in the division of hospitalist medicine, assistant professor of pediatrics, and assistant pediatric clerkship director in the Department of Pediatrics at Vanderbilt University School of Medicine and Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville.

Presenters: Kelly Basaldua, MD; Daniel Sedillo, MD, MBA, and Jason Reynolds, MD

Summary:

In an environment where medicine is becoming ever more specialized and the scope of practice for many is ever narrowing into corridors of expertise, the hospitalist remains a bastion of generalism with an ever-diversifying skill set. One of the skills acquired by many hospitalists to aid in the overall efficiency of the hospital is intranasal (IN) sedation.

Intranasal sedation is becoming more popular given the rapid onset and offset and the relative safety of the sedation of patients without the need for intravenous catheters. This phenomenon is accomplished by avoiding the gut and thus avoiding first-pass metabolism. This allows for greatly increased bioavailability compared with oral administration. In addition, the nasal mucosa is in near direct contact with the CSF via the cribriform plate, allowing for rapid and effective action.

To maximize the effectiveness of intranasal sedation, low volumes with high concentrations, atomization, and minimal nasal occlusion are vital. The ideal volume per nostril is approximately 0.5 ml as using any greater volume results in oversaturation and minimal additional absorption. Thus, concentrating the medications into minimal volumes provides for more efficacious usage. Atomization aids in ensuring thorough surface area coverage and higher absorption. This is a far more efficacious method of delivery than liquid/drop administration.

Because intranasally administered agents have a delayed and widened serum peak compared to IV, IN sedation carries less of a chance to reach serum levels high enough to cause respiratory depression, though monitoring is still necessary. When compared to IV sedation, IN does have a delay in onset, but also provides for a more gentle recovery process, often resulting in a less disorienting recovery for the patient, while also providing for a wider safety profile.

The presenters covered three primary agents:

• midazolam,
• dexmedetomidine, and
• fentanyl

Midazolam is useful for non-painful, minimally invasive procedures. Fentanyl is more useful for painful or more invasive procedures. Dexmedetomidine is off-label use for intranasal sedation at this time, but has promising initial research given its safety profile and longer duration of action compared to most intranasal agents. Also, dexmedetomidine works extremely effectively in combination with other agents, particularly midazolam, to prolong sedations, making it very useful for longer procedures like combination MRIs.

The presenters then provided a practical workshop to practice the delivery of intranasal medication effectively. One of the pearls provided involved proper positioning of the patient in a reclined position as sitting to erect will cause the medication to drip out and having the patient lying flat will result in the medication dripping down the posterior pharynx. This position should be held for 30 seconds after delivery of the medication. Practicing with atomizers to achieve effective aerosolization was discussed. The target of medication should avoid the nasal septum given its poor absorption.

Key Takeaway:

With hospitalists being called to assist in ever-expanding roles within the hospital system while improving efficiency and throughput, intranasal sedation may provide reduced imaging wait times, bedside and ED procedure times in a safe and effective manner. TH

Dr. Crook is a hospitalist in the division of hospitalist medicine, assistant professor of pediatrics, and assistant pediatric clerkship director in the Department of Pediatrics at Vanderbilt University School of Medicine and Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville.

Presenters: Kelly Basaldua, MD; Daniel Sedillo, MD, MBA, and Jason Reynolds, MD

Summary:

In an environment where medicine is becoming ever more specialized and the scope of practice for many is ever narrowing into corridors of expertise, the hospitalist remains a bastion of generalism with an ever-diversifying skill set. One of the skills acquired by many hospitalists to aid in the overall efficiency of the hospital is intranasal (IN) sedation.

Intranasal sedation is becoming more popular given the rapid onset and offset and the relative safety of the sedation of patients without the need for intravenous catheters. This phenomenon is accomplished by avoiding the gut and thus avoiding first-pass metabolism. This allows for greatly increased bioavailability compared with oral administration. In addition, the nasal mucosa is in near direct contact with the CSF via the cribriform plate, allowing for rapid and effective action.

To maximize the effectiveness of intranasal sedation, low volumes with high concentrations, atomization, and minimal nasal occlusion are vital. The ideal volume per nostril is approximately 0.5 ml as using any greater volume results in oversaturation and minimal additional absorption. Thus, concentrating the medications into minimal volumes provides for more efficacious usage. Atomization aids in ensuring thorough surface area coverage and higher absorption. This is a far more efficacious method of delivery than liquid/drop administration.

Because intranasally administered agents have a delayed and widened serum peak compared to IV, IN sedation carries less of a chance to reach serum levels high enough to cause respiratory depression, though monitoring is still necessary. When compared to IV sedation, IN does have a delay in onset, but also provides for a more gentle recovery process, often resulting in a less disorienting recovery for the patient, while also providing for a wider safety profile.

The presenters covered three primary agents:

• midazolam,
• dexmedetomidine, and
• fentanyl

Midazolam is useful for non-painful, minimally invasive procedures. Fentanyl is more useful for painful or more invasive procedures. Dexmedetomidine is off-label use for intranasal sedation at this time, but has promising initial research given its safety profile and longer duration of action compared to most intranasal agents. Also, dexmedetomidine works extremely effectively in combination with other agents, particularly midazolam, to prolong sedations, making it very useful for longer procedures like combination MRIs.

The presenters then provided a practical workshop to practice the delivery of intranasal medication effectively. One of the pearls provided involved proper positioning of the patient in a reclined position as sitting to erect will cause the medication to drip out and having the patient lying flat will result in the medication dripping down the posterior pharynx. This position should be held for 30 seconds after delivery of the medication. Practicing with atomizers to achieve effective aerosolization was discussed. The target of medication should avoid the nasal septum given its poor absorption.

Key Takeaway:

With hospitalists being called to assist in ever-expanding roles within the hospital system while improving efficiency and throughput, intranasal sedation may provide reduced imaging wait times, bedside and ED procedure times in a safe and effective manner. TH

Dr. Crook is a hospitalist in the division of hospitalist medicine, assistant professor of pediatrics, and assistant pediatric clerkship director in the Department of Pediatrics at Vanderbilt University School of Medicine and Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville.

Presenters: Gitanjli Arora, Phuc Le, and Christiana Russ

Summary:

Overseas medical missions can be rewarding experiences for both trainees as part of a supervised program and attending physicians. There is substantial inequity in the global distribution of disease versus health care providers with most providers being located in developed countries and higher disease burdens in underdeveloped countries.  The goal of global healthcare training is mutual benefit, where the provider gains clinical experience and the host country gains enhanced medical care. Both provider and hosts gain increased cultural awareness.

The American Academy of Pediatrics guidelines for a meaningful international experience recommend 4 components:

• Pre-trip Training.  Don’t go without some idea of what to expect
• Pre-travel preparations.  Get your vaccines, travel plans, licensure, scope of practice taken care of.
• Preceptorship by host and US faculty
• Post-travel evaluation and feedback

Key Takeaways:

Providers in overseas medical missions will encounter challenging situations—culturally, ethically and medically. Get as much information beforehand. Be respectful of different cultural norms. Get a cultural ambassador. Keep in mind the Serenity Prayer. TH

Presenters: Gitanjli Arora, Phuc Le, and Christiana Russ

Summary:

Overseas medical missions can be rewarding experiences for both trainees as part of a supervised program and attending physicians. There is substantial inequity in the global distribution of disease versus health care providers with most providers being located in developed countries and higher disease burdens in underdeveloped countries.  The goal of global healthcare training is mutual benefit, where the provider gains clinical experience and the host country gains enhanced medical care. Both provider and hosts gain increased cultural awareness.

The American Academy of Pediatrics guidelines for a meaningful international experience recommend 4 components:

• Pre-trip Training.  Don’t go without some idea of what to expect
• Pre-travel preparations.  Get your vaccines, travel plans, licensure, scope of practice taken care of.
• Preceptorship by host and US faculty
• Post-travel evaluation and feedback

Key Takeaways:

Providers in overseas medical missions will encounter challenging situations—culturally, ethically and medically. Get as much information beforehand. Be respectful of different cultural norms. Get a cultural ambassador. Keep in mind the Serenity Prayer. TH

Presenters: Gitanjli Arora, Phuc Le, and Christiana Russ

Summary:

Overseas medical missions can be rewarding experiences for both trainees as part of a supervised program and attending physicians. There is substantial inequity in the global distribution of disease versus health care providers with most providers being located in developed countries and higher disease burdens in underdeveloped countries.  The goal of global healthcare training is mutual benefit, where the provider gains clinical experience and the host country gains enhanced medical care. Both provider and hosts gain increased cultural awareness.

The American Academy of Pediatrics guidelines for a meaningful international experience recommend 4 components:

• Pre-trip Training.  Don’t go without some idea of what to expect
• Pre-travel preparations.  Get your vaccines, travel plans, licensure, scope of practice taken care of.
• Preceptorship by host and US faculty
• Post-travel evaluation and feedback

Key Takeaways:

Providers in overseas medical missions will encounter challenging situations—culturally, ethically and medically. Get as much information beforehand. Be respectful of different cultural norms. Get a cultural ambassador. Keep in mind the Serenity Prayer. TH

Presenters: Sarah White MD, Mark Corden, MD, and Parminder Suchdev, MD, MPH

Summary:

This PHM15 workshop kicked off the Global Health pathway. The speakers explained that they had become interested in nutrition through the international experiences they had in the past with malnourished children around the world.

The learning objectives included reviewing:

• Criteria for admission of malnourished children to feeding centers or inpatient care for severe acute malnutrition (SAM);
• Micronutrient deficiencies in SAM;
• Specific things to look for when treating SAM using rehydration and refeeding protocols;
• Definitions and classification of malnutrition states; and
• The burden disease malnutrition represents in global children’s health, as well as its association with increased mortality.

The presenters used case studies to give specific examples of how malnutrition complicates children’s health. Mid-upper arm circumference (MUAC) was reviewed as a proxy measure to quickly identify children at risk for malnutrition as well as the need for length and weight to fully describe the nutritional/growth state of a child. “Appetite test” was introduced as a way to assess if children have capability to try to increase feeding at home (if access to food is assured) or if they are experiencing a malnutrition state that would benefit from inpatient management. Comorbidities, such as edema, shock, and infections, were considered as reasons to admit the patient for malnutrition rated illness. WHO guidelines for use of specific refeeding formulas [PDF] and therapeutic ready-to-use food (RUTF) to manage stabilization versus transition phases were also reviewed.

In caring for acutely malnourished children, providers also need to be prepared to manage refeeding syndrome. It can be confused with sepsis due to both conditions presenting with acute decompensation of the patient, so it is important to keep in mind. Dehydrated malnourished children have very specialized needs, are sodium sensitive and are at risk of heart failure and pulmonary edema with typical rehydration methods. ReSoMal rehydration solution was described as an oral rehydration solution and lactated ringers IV for use in the management of a dehydrated, malnourished child.

Other topics covered in the workshop included the implications of the presence of edema in a malnourished patient, the use of antibiotics in improving mortality, and need for replenishing micronutrient stores. Overall, the workshop had an effective use of cases to show specific complications that a health care provider may encounter when treating children with SAM. TH

Dr. Hodge is a pediatric hospitalist at Kosair Children’s Hospital in Louisville, Ky., an assistant professor in the department of pediatrics, and director of distinction in global health track at the University of Louisville School of Medicine.

Presenters: Sarah White MD, Mark Corden, MD, and Parminder Suchdev, MD, MPH

Summary:

This PHM15 workshop kicked off the Global Health pathway. The speakers explained that they had become interested in nutrition through the international experiences they had in the past with malnourished children around the world.

The learning objectives included reviewing:

• Criteria for admission of malnourished children to feeding centers or inpatient care for severe acute malnutrition (SAM);
• Micronutrient deficiencies in SAM;
• Specific things to look for when treating SAM using rehydration and refeeding protocols;
• Definitions and classification of malnutrition states; and
• The burden disease malnutrition represents in global children’s health, as well as its association with increased mortality.

The presenters used case studies to give specific examples of how malnutrition complicates children’s health. Mid-upper arm circumference (MUAC) was reviewed as a proxy measure to quickly identify children at risk for malnutrition as well as the need for length and weight to fully describe the nutritional/growth state of a child. “Appetite test” was introduced as a way to assess if children have capability to try to increase feeding at home (if access to food is assured) or if they are experiencing a malnutrition state that would benefit from inpatient management. Comorbidities, such as edema, shock, and infections, were considered as reasons to admit the patient for malnutrition rated illness. WHO guidelines for use of specific refeeding formulas [PDF] and therapeutic ready-to-use food (RUTF) to manage stabilization versus transition phases were also reviewed.

In caring for acutely malnourished children, providers also need to be prepared to manage refeeding syndrome. It can be confused with sepsis due to both conditions presenting with acute decompensation of the patient, so it is important to keep in mind. Dehydrated malnourished children have very specialized needs, are sodium sensitive and are at risk of heart failure and pulmonary edema with typical rehydration methods. ReSoMal rehydration solution was described as an oral rehydration solution and lactated ringers IV for use in the management of a dehydrated, malnourished child.

Other topics covered in the workshop included the implications of the presence of edema in a malnourished patient, the use of antibiotics in improving mortality, and need for replenishing micronutrient stores. Overall, the workshop had an effective use of cases to show specific complications that a health care provider may encounter when treating children with SAM. TH

Dr. Hodge is a pediatric hospitalist at Kosair Children’s Hospital in Louisville, Ky., an assistant professor in the department of pediatrics, and director of distinction in global health track at the University of Louisville School of Medicine.

Presenters: Sarah White MD, Mark Corden, MD, and Parminder Suchdev, MD, MPH

Summary:

This PHM15 workshop kicked off the Global Health pathway. The speakers explained that they had become interested in nutrition through the international experiences they had in the past with malnourished children around the world.

The learning objectives included reviewing:

• Criteria for admission of malnourished children to feeding centers or inpatient care for severe acute malnutrition (SAM);
• Micronutrient deficiencies in SAM;
• Specific things to look for when treating SAM using rehydration and refeeding protocols;
• Definitions and classification of malnutrition states; and
• The burden disease malnutrition represents in global children’s health, as well as its association with increased mortality.

The presenters used case studies to give specific examples of how malnutrition complicates children’s health. Mid-upper arm circumference (MUAC) was reviewed as a proxy measure to quickly identify children at risk for malnutrition as well as the need for length and weight to fully describe the nutritional/growth state of a child. “Appetite test” was introduced as a way to assess if children have capability to try to increase feeding at home (if access to food is assured) or if they are experiencing a malnutrition state that would benefit from inpatient management. Comorbidities, such as edema, shock, and infections, were considered as reasons to admit the patient for malnutrition rated illness. WHO guidelines for use of specific refeeding formulas [PDF] and therapeutic ready-to-use food (RUTF) to manage stabilization versus transition phases were also reviewed.

In caring for acutely malnourished children, providers also need to be prepared to manage refeeding syndrome. It can be confused with sepsis due to both conditions presenting with acute decompensation of the patient, so it is important to keep in mind. Dehydrated malnourished children have very specialized needs, are sodium sensitive and are at risk of heart failure and pulmonary edema with typical rehydration methods. ReSoMal rehydration solution was described as an oral rehydration solution and lactated ringers IV for use in the management of a dehydrated, malnourished child.

Other topics covered in the workshop included the implications of the presence of edema in a malnourished patient, the use of antibiotics in improving mortality, and need for replenishing micronutrient stores. Overall, the workshop had an effective use of cases to show specific complications that a health care provider may encounter when treating children with SAM. TH

Dr. Hodge is a pediatric hospitalist at Kosair Children’s Hospital in Louisville, Ky., an assistant professor in the department of pediatrics, and director of distinction in global health track at the University of Louisville School of Medicine.

Doctor and patient in hospital

Photo courtesy of the CDC

New research indicates that a higher institutional case volume is associated with lower in-hospital mortality in patients with lower extremity deep vein thrombosis (LE-DVT) who undergo catheter-directed thrombolysis (CDT).

However, a hospital’s CDT case volume did not have a significant impact on other outcomes, such as bleeding events, the incidence of pulmonary embolism, or the need for blood transfusion.

Researchers reported these findings in Circulation.

The team noted that patients who have LE-DVT are increasingly undergoing CDT rather than receiving anticoagulation alone. Recent studies have shown reductions in lifestyle-limiting complications, such as post-thrombotic syndrome, in patients who undergo CDT. However, data have also shown CDT to be associated with an increased risk of bleeding complications.

So Riyaz Bashir, MD, of Temple University Health System in Philadelphia, Pennsylvania, led a study aimed at determining whether the increase in bleeding complications was correlated with the volume of CDT procedures performed at a particular institution.

Dr Bashir and his colleagues used the Nationwide Inpatient Sample database to identify 90,618 patients admitted to US hospitals with an LE-DVT diagnosis from 2005 to 2010.

The researchers further narrowed that group down to 3649 patients treated with CDT. The team then divided the hospitals into 2 groups: high-volume centers, which performed 6 or more CDT procedures per year, and low-volume centers, which performed less than 6 CDT procedures per year.

In-hospital mortality in patients treated with CDT was significantly lower at high-volume centers than low-volume centers—0.6% and 1.5%, respectively (P=0.04).

The rate of intracranial hemorrhage for high-volume centers was less than half that of low-volume centers, but this difference was not statistically significant—0.4% and 1.0%, respectively (P=0.07).

Likewise, there was no significant difference between high-volume centers and low-volume centers with regard to the rate of blood transfusion (10.4% vs 10.8%, P=0.70), gastrointestinal bleeding (1.4% vs 1.8%, P=0.35), or pulmonary embolism (18.4% vs 17.9% P=0.72).

The median length of hospital stay was 6 days in both groups. But hospital charges were higher at high-volume centers than low-volume centers—$75,870 and $65,500, respectively.

“These findings have potentially major future implications for the treatment of deep vein thrombosis,” Dr Bashir said. “For the first time, we have shown a significant inverse relationship between the institutional CDT volumes and adverse outcomes like death . . . .”

“This does not mean that low-volume centers should not perform CDT for patients with LE-DVT. It means that we should focus on standardizing CDT protocols that include careful patient selection as well as peri-procedural patient monitoring. In addition, establishment of centers of excellence in treating venous thromboembolic disease may provide the necessary framework within which bleeding risk to the patient can be minimized.”

Dr Bashir added that patients with LE-DVT, especially young patients, should feel comfortable considering CDT, particularly at a high-volume center, as a viable option to prevent post-thrombotic syndrome.

“Our overall goal is to treat these DVT patients early on and prevent post-thrombotic syndrome and its adverse consequences on the quality of life,” he said. “We feel this research provides more clarity and direction in identifying the best strategies for how to achieve that goal.”

Doctor and patient in hospital

Photo courtesy of the CDC

New research indicates that a higher institutional case volume is associated with lower in-hospital mortality in patients with lower extremity deep vein thrombosis (LE-DVT) who undergo catheter-directed thrombolysis (CDT).

However, a hospital’s CDT case volume did not have a significant impact on other outcomes, such as bleeding events, the incidence of pulmonary embolism, or the need for blood transfusion.

Researchers reported these findings in Circulation.

The team noted that patients who have LE-DVT are increasingly undergoing CDT rather than receiving anticoagulation alone. Recent studies have shown reductions in lifestyle-limiting complications, such as post-thrombotic syndrome, in patients who undergo CDT. However, data have also shown CDT to be associated with an increased risk of bleeding complications.

So Riyaz Bashir, MD, of Temple University Health System in Philadelphia, Pennsylvania, led a study aimed at determining whether the increase in bleeding complications was correlated with the volume of CDT procedures performed at a particular institution.

Dr Bashir and his colleagues used the Nationwide Inpatient Sample database to identify 90,618 patients admitted to US hospitals with an LE-DVT diagnosis from 2005 to 2010.

The researchers further narrowed that group down to 3649 patients treated with CDT. The team then divided the hospitals into 2 groups: high-volume centers, which performed 6 or more CDT procedures per year, and low-volume centers, which performed less than 6 CDT procedures per year.

In-hospital mortality in patients treated with CDT was significantly lower at high-volume centers than low-volume centers—0.6% and 1.5%, respectively (P=0.04).

The rate of intracranial hemorrhage for high-volume centers was less than half that of low-volume centers, but this difference was not statistically significant—0.4% and 1.0%, respectively (P=0.07).

Likewise, there was no significant difference between high-volume centers and low-volume centers with regard to the rate of blood transfusion (10.4% vs 10.8%, P=0.70), gastrointestinal bleeding (1.4% vs 1.8%, P=0.35), or pulmonary embolism (18.4% vs 17.9% P=0.72).

The median length of hospital stay was 6 days in both groups. But hospital charges were higher at high-volume centers than low-volume centers—$75,870 and $65,500, respectively.

“These findings have potentially major future implications for the treatment of deep vein thrombosis,” Dr Bashir said. “For the first time, we have shown a significant inverse relationship between the institutional CDT volumes and adverse outcomes like death . . . .”

“This does not mean that low-volume centers should not perform CDT for patients with LE-DVT. It means that we should focus on standardizing CDT protocols that include careful patient selection as well as peri-procedural patient monitoring. In addition, establishment of centers of excellence in treating venous thromboembolic disease may provide the necessary framework within which bleeding risk to the patient can be minimized.”

Dr Bashir added that patients with LE-DVT, especially young patients, should feel comfortable considering CDT, particularly at a high-volume center, as a viable option to prevent post-thrombotic syndrome.

“Our overall goal is to treat these DVT patients early on and prevent post-thrombotic syndrome and its adverse consequences on the quality of life,” he said. “We feel this research provides more clarity and direction in identifying the best strategies for how to achieve that goal.”

Doctor and patient in hospital

Photo courtesy of the CDC

New research indicates that a higher institutional case volume is associated with lower in-hospital mortality in patients with lower extremity deep vein thrombosis (LE-DVT) who undergo catheter-directed thrombolysis (CDT).

However, a hospital’s CDT case volume did not have a significant impact on other outcomes, such as bleeding events, the incidence of pulmonary embolism, or the need for blood transfusion.

Researchers reported these findings in Circulation.

The team noted that patients who have LE-DVT are increasingly undergoing CDT rather than receiving anticoagulation alone. Recent studies have shown reductions in lifestyle-limiting complications, such as post-thrombotic syndrome, in patients who undergo CDT. However, data have also shown CDT to be associated with an increased risk of bleeding complications.

So Riyaz Bashir, MD, of Temple University Health System in Philadelphia, Pennsylvania, led a study aimed at determining whether the increase in bleeding complications was correlated with the volume of CDT procedures performed at a particular institution.

Dr Bashir and his colleagues used the Nationwide Inpatient Sample database to identify 90,618 patients admitted to US hospitals with an LE-DVT diagnosis from 2005 to 2010.

The researchers further narrowed that group down to 3649 patients treated with CDT. The team then divided the hospitals into 2 groups: high-volume centers, which performed 6 or more CDT procedures per year, and low-volume centers, which performed less than 6 CDT procedures per year.

In-hospital mortality in patients treated with CDT was significantly lower at high-volume centers than low-volume centers—0.6% and 1.5%, respectively (P=0.04).

The rate of intracranial hemorrhage for high-volume centers was less than half that of low-volume centers, but this difference was not statistically significant—0.4% and 1.0%, respectively (P=0.07).

Likewise, there was no significant difference between high-volume centers and low-volume centers with regard to the rate of blood transfusion (10.4% vs 10.8%, P=0.70), gastrointestinal bleeding (1.4% vs 1.8%, P=0.35), or pulmonary embolism (18.4% vs 17.9% P=0.72).

The median length of hospital stay was 6 days in both groups. But hospital charges were higher at high-volume centers than low-volume centers—$75,870 and $65,500, respectively.

“These findings have potentially major future implications for the treatment of deep vein thrombosis,” Dr Bashir said. “For the first time, we have shown a significant inverse relationship between the institutional CDT volumes and adverse outcomes like death . . . .”

“This does not mean that low-volume centers should not perform CDT for patients with LE-DVT. It means that we should focus on standardizing CDT protocols that include careful patient selection as well as peri-procedural patient monitoring. In addition, establishment of centers of excellence in treating venous thromboembolic disease may provide the necessary framework within which bleeding risk to the patient can be minimized.”

Dr Bashir added that patients with LE-DVT, especially young patients, should feel comfortable considering CDT, particularly at a high-volume center, as a viable option to prevent post-thrombotic syndrome.

“Our overall goal is to treat these DVT patients early on and prevent post-thrombotic syndrome and its adverse consequences on the quality of life,” he said. “We feel this research provides more clarity and direction in identifying the best strategies for how to achieve that goal.”