Is Your Surgical Office Team Prepared to Manage Post-Op Telephone Triage?

Guest author Lori Atkinson talks about the risk factors contributing to adverse events and claims, including relevant case example, as well as risk management strategies that help improve the post-op triage process.

It's summertime, and people are outdoors hiking, cycling, and skateboarding resulting in broken bones and other injuries that might require surgery. When a patient calls the surgeon's office postoperatively (post-op), does the office team know how to triage symptom-related phone calls to reduce the chance of an adverse event and resultant malpractice claim?

In my work with surgeons, surgical practice administrators, and hospital risk managers, the focus on reducing surgical adverse events and malpractice claims is usually on what happens in the operating room (OR). However, surgical medical office claims are preventable and worthy of risk management efforts.

Surgical claims in the medical office setting

An analysis of a subset of Curi malpractice claims shows that surgical allegations are the most common in occurrence and number one in cost. The study also reveals that only 13% of surgical claims arise from care provided in the medical office setting. The majority of these claims involved orthopedists, post-op care, and allegations of improper surgical patient management.

The top three contributing factors in surgical medical office claims identified were:

1. Problems with the technique of the surgery and a known procedural risk - such as infection, pain, hematoma, or nerve damage - 63% of claims
2. Inadequate patient assessment, including the failure to respond to patient repeated complaints, the failure to order diagnostic testing to rule out a serious condition, and the failure to appreciate symptoms of a known procedural risk - 53% of claims
3. Communication breakdowns with patients, including informed consent and follow-up care instructions - 41% of claims

Improper post-op management case example

A 45-year-old man was evaluated by an orthopedist for right knee pain that had been present for a month following a cycling vacation. An MRI showed a meniscal tear, and the orthopedist scheduled the man for outpatient arthroscopic surgery.

Two pre-op notes from ambulatory surgical staff identified a preexisting abrasion near the patient's operative knee. The orthopedic surgeon noted that he did not consider the healing wound a contraindication to surgery. The surgery was completed without problems, and the man was discharged home with post-op instructions and a scheduled follow-up appointment.

The man called his orthopedist's office four times over the first several post-op days, complaining of increasing pain and swelling of the knee and lower right leg. Only one of these phone calls was documented in the patient's medical record. However, cell phone records confirmed the calls to the orthopedist’s office. The patient testified he was told not to worry about the swelling, his requests for more pain medication were denied, and he was told to keep his already scheduled follow-up appointment.

Five days post-op, the man presented to the orthopedist's office without an appointment because of uncontrollable pain and swelling of the right knee and lower leg. The office staff told the man that the orthopedist was unavailable but that they would contact him with a message. The message to the orthopedist stated, "Scope last week, c/o of calf pain and swelling." The surgeon ordered an ultrasound, which was done two hours later. It was interpreted by radiology as negative for DVT but did identify right para-articular fluid collection. The orthopedist noted this as a common post-op finding and instructed his office staff to tell the patient to keep his follow-up appointment.

On the eighth post-op day, the man called the orthopedist's office complaining of pain and swelling. The office team worked the man into the schedule. The surgeon noted a history of pain and swelling in the operative leg, noted right leg swelling with full range of motion, and prescribed Keflex as a precaution for what he thought was a skin infection.

Ten days post-op, the man presented to his local emergency department (ED), complaining of persistent right leg swelling and pain. The ED physician's impression was a septic knee. The orthopedic surgeon was consulted, and he took the man back to the OR for irrigation and debridement of the knee. He also ordered an MRI, which showed diffuse edema and cellulitis of the right knee. An infectious disease expert was consulted and diagnosed osteomyelitis due to a staph infection.

After discharge from the hospital, the man continued to see the orthopedist for several months with complaints of right leg weakness and loss of range of motion. He self-referred to another orthopedic surgeon who recommended total knee replacement.

The man filed a malpractice claim against the orthopedist alleging improper post-op management. The experts who reviewed the care were critical of the orthopedic surgeon’s office team for mismanaging the patient complaint calls. They were also critical of the orthopedist for not ruling out a potentially serious post-op complication. The case was closed, and payment was made to the man on behalf of the orthopedic surgeon.

Surgical office risk management

Understanding the risk factors contributing to adverse events and claims helps clinicians, administrators, and risk managers develop targeted risk mitigation strategies to prevent these events from happening again.

More than two-thirds of surgical office claims involve errors in technical skill and performance, including known risks of the procedure. These errors, combined with patient assessment issues and communication breakdowns, represent an opportunity to improve the post-op triage process.

Recommended risk mitigation strategies include implementing a formal telephone triage process and protocols:

• Standardize and outline the process for managing all patient symptom-related phone calls.
• Identify the information that staff must obtain from the patient to make appropriate clinical decisions.
• Clarify staff triage roles and responsibilities.
• Utilize a screening system or decision grid to outline triage categories to ensure calls are prioritized and forwarded to the appropriate clinician for clinical decision-making.
• Implement written symptom-based protocols and standing orders for managing routine, uncomplicated symptom calls.
• Ensure that post-op patients who call multiple times with symptoms are examined by the physician or referred to the ED for evaluation.
• Outline documentation standards for all symptom calls.
• Periodically review the triage system process for effectiveness in reducing adverse events.

Curi members can access the Risk Management Guide: Physician-Patient Relationship - Curi, the Risk Management Guide: Unlicensed Healthcare Personnel - Curi and Risk Assessments - Curi

Curi members, if you have any questions about this topic, please call 800-662-7917 to speak with one of Curi Advisory's Risk Solutions experts.