Preventable complications that arise after surgery and discharge can come very close to being malpractice. Here, “preventable” is the operative word.
Complications will happen whenever interventions that impact the human organ systems intrude on the anatomical and physiological processes of the dynamic human physiology. That is the nature of surgery.
Thankfully, with the establishment of a minimum set of safeguards and the right tools, the deck is stacked in favor of our human physiology in most of today’s surgical procedures. From surgical aseptic technique to adherence to the standard of care, the innate human immune system and regulatory processes are very forgiving to the human body’s external manipulation, including surgery.
To Do or To Not Do Surgery
Although surgery is a significant disruption of one’s intact anatomy, its necessity is deemed by the risks-vs-benefits of not doing it. Every physician and surgeon must always ask the question of “is the patient better off having a particular surgery or by not having it?”
There is a dividing line between beneficial or damaging, which is objective and absolute for some conditions, such as cancer, life-threatening conditions (cardiovascular disease), or maintaining a quality of life (anatomical repair).
But that line isn’t always so clear with other conditions or surgical objectives. When personal considerations enter the fray, that line blurs and becomes subjective, such as with elective and cosmetic procedures that will improve self-esteem or feelings of well-being.
Regardless of objective and subjective considerations, however, patient health’s continuity remains the standard of care for all surgical teams and healthcare providers.
This continuity of patient health has many approaches. But the primary focus must be on a continuity of care that ensures the same level of quality throughout the entire process, from pre-surgical patient discussions and pre-op preparations to in-patient, out-patient, and post-op care. That continuity of care encompasses both the surgery itself and the entire perioperative environment that supports each surgical procedure.
Traditionally, this has been challenging, if not difficult. In the past, job descriptions of those in one setting do not always extend into or consider the responsibilities of other members of the team— for example, in-patient monitoring of vital signs versus postoperative surveillance of complications.
For example, a nurse anesthetist is finished with his or her ambulatory surgery patient at the end of the day’s shift and is not responsible for managing that patient’s intestinal obstruction symptoms days later. But that anesthetist’s work does impact how other care management team members look after post-op patients.
When Unpreventable Complications Become Preventable – and Potentially Malpractice
Within the surgical center or facility, monitoring and maintaining that continuity of patient care is relatively straightforward. Immediately following surgery, less-than-ideal outcomes can be easily identified by telltale alterations in the patient’s vital signs, so continuity of care continues seamlessly from the surgical suite to the post-anesthesia care unit (PACU).
However, after the patient recovers in this acute setting, home is often the best place for him or her to be. The challenge is monitoring and managing the patient’s post-discharge at-home recovery – and taking precautions against preventable complications.
Following discharge, outcomes other than ideal include fever, pain, bleeding, or complications from inadvertent damage to structures other than the site of surgery. These can occur days or even weeks after a surgical procedure.
For example, if a laparoscopic procedure injures a ureter, the damaged ureter and leakage of urine through the wound are complications. But ignoring its report or ignorance of that complication altogether on post-op day #3 is a preventable complication.
When unpreventable complications suffer from the disconnect between in-house care and at-home care, continuity of care ceases, and undesirable outcomes disastrous.
This breakdown in post-discharge care management is an important example of when an unpreventable but understandable complication can be accurately labeled as preventable.
The other label may also apply to malpractice, which has medical, legal, and financial implications on a facility’s viability in providing care.
Which Party Has the Final Responsibility for the Patient?
Who has a “holistic” responsibility for a patient? The facility? The physician/surgeon? The patient himself or herself?
The answer is all of them.
While that sounds intuitive, it is also dismissive, diluting each person’s responsibility: accountability isn’t divided by three but is owned 100% by each.
Because there is a technical skill in maintaining that continuity of care, however, the facility has the best ability to follow the patient’s course, supplemented by the physician’s prudent follow-up. Of course, the physician should be prepared to step in and intervene when complications happen, but this is an interim approach conducted along with interval assessments since he or she is juggling many patients at the same time.
The facility can use protocols to make sure the continuity is smooth and patient improvement is progressive. Protocols have the advantage of being initiated from the pre-op evaluation and continued past the surgery and through complete healing. They can be implemented in universal protocols as intrinsic to the entire facility process as collecting billing information.
Continuity of Care Follows the Path of the Patient, Not the Job Description of the Care Provider
Following above, when it is said that all have the responsibility for continuity of care, it’s important to remember that the following apply:
- Patient responsibility. The patient should follow the post-op instructions, written clearly, and given to him or her at discharge. This necessitates facility documentation that the patient thoroughly understands the instructions and caveats.
- Provider responsibility. The physician, surgeon, and support team should continuously follow-up with the patient to warn of signs of trouble brewing before a complication becomes critical or unsalvageable. This follow-up should include timely engagement with the patient based on the procedure’s possible consequences. It also assumes timely communication between physicians and facilities to exclude overlooking problems.
- Facility responsibility. The facility should enact protocols that supersede the patient and physician’s responsibilities, such as using flowsheets, follow-up procedures, and, increasingly, post-discharge remote patient monitoring (RPM) that are an on-going partnership with the patient over his or her well-being.
Perioperative Care Technology Adds the Glue, Bridges the Gaps
Where one player’s responsibility ends, and the other’s begins can cause redundancy or worse—such as omissions—in the continuity of care. The good news is that technological evolution, with the ability to parse volumes of data and automate them into meaningful relationships, means patients are no longer at the mercy of information bottlenecks or the lack of awareness of helpful associations among the numbers.
These meaningful relationships can come with simplified algorithms for software to populate a personalized “to-do” list for assuring smooth continuity from pre-op to post-op full recuperation.
Digital applications have transformed medical care, from electronic health records to real-time imaging being diagnosed worldwide. Moore’s Law, which states that the number of transistors feasible on a chip has doubled every two years while halving the manufacturing price, has allowed more and more data to be accrued into searchable collections and instantaneous retrieval by anyone authorized to have access.
Encrypted collaboration via private invitation can easily include patients and their loved ones, accessible by ubiquitous devices such as smartphones, pads, or laptop computers. These communication activities have been streamlined by media applications (“apps”) that are tailor-made to monitor the status of those who no longer have a medical facility wrapped around them for direct observation.
In today’s world of reimbursement based on benchmarks and budgeting based on key performance indicators, the same computing power can be used to monitor the continuity of care.
Preventing Unnecessary Readmission for Discharged Surgical Patients
A patient who leaves the site of surgery for their home will either get better or worse. Of course, the majority get better, but these are invisible victories compared to the repercussions that follow when a patient gets worse.
Such repercussions include an altered reimbursement schedule as a disincentive to readmission, a devaluation of facility reputation, or even exclusion from insurance panels. Unpreventable complications can be defended, but preventable complications cannot, adding legal and punitive costs to them.
Thus, remote patient management and perioperative care management apps designed to ensure continuity of care for discharged patients are designed to do primarily one thing—assure that a patient is getting better. This is a win for every interested party—facility, physician, and, most importantly, patient.
Specific Parameters for Assurance of a Continuity of Care Toward Improvement
What components make sense in assuring that a patient is improving?
That depends on the surgery performed, but essentially such a checklist would be an extension of what the PACU does—certify that the patient’s vital signs remain stable and that his or her general condition is improving:
- Pain. If there is any pain, is it slowly improving from day to day, or remaining without improvement or even worsening?
- Mental acuity. Dizziness, changes in mental status, or racy pulse might indicate blood pressure fluctuations or anemia from internal blood loss or uncompensated blood loss from the actual surgery itself.
- Medical reaction. Any adverse events from medication given or prescribed, including side effects and allergic reactions.
- Neurological issues. Any motor or sensory deficits that could indicate nerve damage, compression, or other neurological compromise.
- Obstruction. Specific abdominal pain could be an indicator of a bowel obstruction or damage.
And Then There is Fever
In the postoperative period, the onset of fever’s timing follows the 5-W paradigm (wind, water, walk, wound, wonder). In other words, the occurrence of which site of infection or source of fever typically follows a progressive time of onset, namely.
- Wind. A patient can suffer a low-grade fever with inconsistent expansion of the lungs, as occurs after general anesthesia or with the abdominal pain from diaphragmatic movement after abdominal surgery. However, another cause is pneumonia, which goes beyond compromised respiratory effort and is an actual infection of the lungs.
- Water. Urinary tract infections are the next earliest infection type to consider and monitor.
- Walk. This refers to the pain of leg movement, likely from deep vein calf thrombophlebitis or another deep vein thromboembolism (VTE).
- Wound. Post-surgery wound infections can come next, typically up to and after a week after the surgery itself.
- Wonder (drugs). This is admittedly a stretch to make the mnemonic work, but when lung, urinary tract, wound, and thrombophlebitis have been ruled out, one should suspect the drug fever that can come from drugs used to treat them empirically.
Because these occur at—typically—3-4, 5-7, 6-8, 8-11, and 8-11 days, respectively, it would make sense to time serial communications with the patient the day after discharge, and then at least twice in the first week post–op and twice in the second–week post-op. A post-op or perioperative care app specifically designed for checking for these items can be tweaked as needed to pursue any positive complaints corresponding to the warning signs.
What Could Go Wrong?
Conceivably, anything could, of course. But due diligence is served by next day contact, followed by at least twice weekly remote assessment for two full weeks after surgery.
But suppose there is no fever, undue pain, abdominal distension, nausea or vomiting, shortness of breath, loss of appetite, palpitations or racing pulse, dizziness, or sensorium change on post-op day #1 and twice weekly for two weeks. In that case, there can’t be much that can go wrong for a smooth continuity of care for any patient from preop to post-op.
Everyone cannot do everything. But in the facility, physician, and patient triangle, the facility is uniquely qualified to use the digital advantages that perioperative care management apps can provide to oversee the continuity of care that should be seamless, from pre-op to full recovery.
Even better, these apps can be easily incorporated into the suite of healthcare provider dashboards and digital tools that facilities already use for other purposes, from demographics to billing. When preventable complications are prevented or nipped in the bud, adverse events are minimized at worst and eliminated at best. The patient profits the most, that benefit extending equally to the other players—the facility and physician.