north carolina society of eye physicians and …...profuse bleeding left eye along suture line,...

September 21-22, 2018 • Grandover Resort • Greensboro, NC

2018 ANNUAL MEETING FRIDAY PRESENTATIONS

NORTH CAROLINA SOCIETY OF EYE PHYSICIANS AND SURGEONS

This continuing medical education activity is jointly provided by the North Carolina Society of Eye Physicians and Surgeons and Southern Regional Area Health Education Center

ComanagementOMIC Risk Management

Hans K Bruhn, MHS OMIC Risk ManagerNCSEPS

September 21, 2018

Disclosures

• Hans Bruhn: I have no financial interests to disclose.

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Risks of poorly comanaged patients

• Delay in diagnosis or treatment• Difficulty in perceiving patterns• Inadaquate evaluations of credentials.• Failure to follow-up• Patient confusion regarding direction of

care.• Lawsuits

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Communication breakdown

• Communication top contributing factor of medical errors in Joint Commission study

• 70% of sentinel events – At least 50% of these during “hand-offs”

• - Transfer of care is a hand-off.

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Objectives

After participating in this presentation, ophthalmologists will be better able to:

• Develop guidelines for comanagement of patients

• Communicate needed information during patient hand-offs (providers)

• Manage patient expectations

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Question

• Do you have a written protocol and written guidelines?

• Comanagement consent?• Transfer of care agreement?

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Comanagement

• Federal Guidelines – No Safe Harbor for Cataract Surgery. Kickback concerns

• State Regulatory Requirements.• OIG Guidance • National Society Guidance.

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OMIC: Shared Care & Comanagement

• OD qualifications• Reason for comanagement• Role of the surgeon• Informed consent• Communication with the OD• Laws, regulations, rules

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Comanagement

• Federal Statutory Guidelines Regarding Comanagement Fee Structure

• Fee Guidelines Dictate Shared Care Responsibilities

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Comanagement

• STATE REGULATION- State board regulations of professional

behavior- Multiple state boards involved medical and

optometric - Specific surgeon requirements- Referral behavior and expectations

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Risk Management:Comanagement

• Obtain informed consent– Comanagement consent form – Written protocols with review of records– Credentialing process– Elements of protocol – “Comanagement of ophthalmic patients”

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Shared Care

• Communication is critical• Active dialogue and participation in

care• Define the roles of each individual• Assure competence and training• Review and inspect care

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Case

• Bleph procedure, 62 y/o female• Medical hx: depression, anxiety, smoker,

hypertension, high cholesterol, diabetes and sleep apnea.

• Significant surgical hx: gallbladder, knee replacement, acid reflux and hysterectomy.

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Case

• 12/15/15, eval for blepharoplasty. • Corrected vision 20/25OD, 20/25 OS.• Bilateral 3+dermachalasis, normal eyelids.

Dx: bilateral dermachalasis upper lids. • Discussion on etiology of condition, effect

on visual field, risks & benefits of sx.

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Case

• 1/27/16: consult with another ophthalmologist. Pt. c/o heavy eyelids and blocked vision.

• VF test indicates peripheral vision loss due to dermachalasis.

• 3/16/16 : Pre-op exam, pt on aspirin. Reviewed risks of anticoagulants. Sx set for 4/6/16.

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Case

• 3/16/16 risks and possible complications discussed with patient. Consent signed for blepharoplasty.

• 4/6/16: Pre-op note, no meds taken that day. Uneventful bilateral upper lid surgery.Post op, advised no aspirin until next day, no pain, discharged same day. Med: Erythromycin ophthalmic solution 2x day.

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Case

• 4/6: Patient contacted on call OD to note profuse bleeding left eye along suture line, nausea and vomiting. Pt. reported she could see, could open left eye, denied proptosis. No report of pain.

• Pictures from pt reviewed by OD and surgeon. OD calls back patient.

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Case

• OD advised care companion to contact if signs of increasing hemorrhage. Ice packs and phenergan for nausea/ vomiting. Call back if decreased vision, proptosis and swelling.

• 4/8/16: Seen by OD with bleeding but no pain. Eye swollen shut, unable to examine the eye. NLP. Sent home, surgeon will contact, if she needs to be seen.

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Case

• 4/8/16: Surgeon contacted by O.D.• Surgeon does canthotomy and cantholysis,

IOP 44 after these procedures.• Diamox. IOP drops to 26.• Left afferent papillary defect noted. • Some light and movement from OS. Eye

drops and Diamox.

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Case

• 4/9/16: Surgeon sees the pt. No pain or nausea. Minimal bleeding at canthotomy site. Mild discomfort looking up. Pt. able to open left eye 5mm on her own. IOP 24. continue drops, Diamox increased.

• 4/11/16: Pt. examined by OD, NLP OS. Dx: Ischemic optic neuropathy, discussed w/ surgeon.

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Case

• 4/12/16: pt examined by OD. No change, NLP OS.

• 4/13/16: Surgeon examines pt., no change, referred to another ophthalmologist for 2nd

opinion. Seen same day: subacute profound vision loss w/in hours of bleph with fat excision.

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Case

• 4/14-22/16, no change. Referral to 3rd

ophthalmologist. • 4/29/16: Brain MRI. Abnormal signal in

white matter, moderate small vessel ischemic change of uncertain age. Mild thickening of left sinus. No evidence of intracranial aneurysm or arteriovenous confirmation.

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Case

• Possible occlusion of distal left middle cerebral artery trifurcation branch vessel may indicate CVA of uncertain age.

• Patient advised on vision loss OS.• 5/7/16: Pt. presented to ER, concern about

infection OS.• Hospitalized for periorbital cellulites OS,

antibiotics given. Discharge on Keflex.23

Case

• 5/11-5/16: pt concerned about possible right eye involvement.

• 5/16/16: Pt lost to followup.• Damages: • Initial demand: 1.2M

50% chance of defense verdict

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Case

• Issues with care:– OD (group) failed to communicate properly

with the surgeon. Failure to notify the surgeon regarding extent of the bleeding.

– Poor follow up- no visit on day 1.– Relied on camera text imaging from pt. – Comanaging optometrist not trained to treat

blepharoplasty patients.– Poor communication with the patient.

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Case

• Verdict range: 700-900K, Settlement range 600-750K

• Surgeon non sued• Claim against group/entity

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Bilateral Blepharoplasty Question

• Claim outcome?• A B C D

DISMISS $700K $1.2M$450K

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Bilateral Blepharoplasty Question


$450K

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Comanaged LASIK

• 38 year old myopic female with astigmatism presented for LASIK evaluation.

• Optometrist noted dry eyes. • Punctal plugs declined by patient.

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Comanaged LASIK

• Two days later, bilateral LASIK performed without complications. No pre-operative evaluation by surgeon of dry eyes.

• Postoperative day 1. Seen by optometrist. C/o dry eyes and poor vision.

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Comanaged LASIK

• PO day 7, patient c/o dry eyes and poor vision – artificial tears, no driving.

• PO day 13, patient c/o dry eyes and poor vision – artificial tears every 30 minutes.

• 4 weeks postoperative, c/o dry eyes and poor vision- artificial tears.

• 3 months postoperative, c/o dry eyes and poor vision- lower eyelid punctal plugs.

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Comanaged LASIK

• 5 ½ months postoperative – c/o dry eyes and poor vision- artificial tears.

• 6 months postoperative – c/o dry eyes and double vision – upper eyelid collagen punctal plugs

• 6 ½ months postoperative-- Refuses to be seen by O.D. and demands to by seen by surgeon.

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Comanaged LASIK

• Seven months post op surgeon examines patient. Dry eyes with double vision. Reinserts collagen punctal plugs. Returns patient to comanaging optometrist without long-term plan.

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Comanaged LASIK

• Two weeks later, patient c/o dry eyes and poor vision – artificial tears.

• Two weeks later – c/o dry eyes and poor vision, sent to a new comanaging O.D.

• Three weeks later (8 ½ months postoperative)– c/o dry eyes and poor vision – planned visit with surgeon – but did not occur.

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Comanaged LASIK

• Patient sought care elsewhere.• Six weeks later, c/o dry eyes and poor

vision – no driving or work.• Three weeks later (10 ½ months after

surgery), c/o dry eyes and poor vision –declines further follow up (bad sign).

• Last visit BCVA OD 20/70 OS 20/80

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Comanaged LASIK

• Patient files suit

• Plaintiff expert felt needed better preoperative evaluation of tear film and detailed informed consent

• Expert witness: dry eye known complication

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Comanaged- LASIK

• Poor communication- Initially regarding the dry eyes- Post op regarding patient complaints and

response to treatment to surgeon.- Then - Post op by surgeon to the comanaging

optometrist- With the patient regarding plan and prognosis

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Comanaged- LASIK

• No initial surgeon evaluation• No inspection of care• Minimal active intervention post operatively

by surgeon.• Unqualified optometric care• Poor consent process regarding dry eye.• Poor Outcome

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Comanaged LASIK Question


DISMISS $50K $500K$250K

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Comanaged LASIK Question


$250K

Settled 1st day of

trial

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Comanaged LASIK

• Outcome • Settled for $250,000 on first day of trial

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Comanaged Cataract Surgery

• 80 year old male had cataract surgery and IOL OD

• PO day 1: No complications so care transferred to OD

• PO day 6: seen by comanaging OD. c/o pain. Increased steroids. RTC 2 weeks

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• Two days later (PO day 8), patient’s daughter asks surgeon to see her father. Surgeon diagnoses endophthalmitis and starts antibiotic treatment

• Next day, improved, so surgeon referred patient back to OD in 2 days– Recall same OD had missed diagnosis

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• Next day (PO day 10), patient called surgeon to report pain. Told to use Motrin and eye drops. Called back later same day to report improvement. Told to follow-up with OD, who saw him that day.

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• PO day 15, went to E.R. with c/o poor vision and pain – retained cortex, increase steroids. Seen that day by optometrist who noted improvement – no dilation.

• PO day 17, saw retina specialist, VA HM, pseudomonas endophthalmitis.

• Final outcome VA HM

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• Patient files suit• Alleges surgery contraindicated with

history of blepharitis • Delay in diagnosis endophthalmitis by OD• Negligent management of endophthalmitis

by ophthalmologist and optometrists.

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• DEFENSE EVALUATION• Poor communication between surgeon and

optometrist on multiple occasions.- Initial complaints misdiagnosed by OD – not

qualified.- F/U complaints and ER visit- misdiagnosis.• Surgeon should have reviewed f/u plan – dilation.• Surgeon should have followed patient with

endophthalmitis


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Plaintiff Attorney Allegations:• Poor communication• No active or continued dialogue• No comanaging protocol• Poor oversight

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Comanaged Cataract Surgery Question

• Claim outcome?A B C D


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Comanaged Cataract Surgery Question

• Claim outcome?A B C D

$75K

Oph.

$79K

OD50

Comanaged Glaucoma

• 60 year old female with DM is evaluated by optometrist in group.

• Diagnosis: Cataracts, diabetic macular edema, rubeosis iridis, and narrow angles.

• Refer to M.D. in group in 2 months.

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Comanaged Glaucoma

• Patient no show for 2 month follow-up. MD indicates f/u on next available date.

• Four months after initial visit, patient presents emergently with pain

• VA LP, IOP 76 OS. • MD notes neovascular glaucoma, angle

closure, PDR, hyphema.

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Comanaged Glaucoma

• Expert Analysis- MD and OD below SOC- Optometrist should have referred

immediately- Physician should have reviewed chart and

seen immediately after missed appointment

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Comanaged Glaucoma

• Poor communication• No examination of optometrist’s skills• Poor oversight by ophthalmologist

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Comanaged Glaucoma Question



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Comanaged Glaucoma Question


$250K

OD

Oph. dismissed

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Shared Care

• Communication is critical• Active dialogue and participation in

care• Define the roles of each individual• Assure competence and training• Review and inspect care

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Time CheckOne more case?

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Shared CareNot

Abrogated Care

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Glaucoma-Retina

• GLAUCOMA EVALUATION• 66-year-old female• 25-year history of advanced

uncontrolled chronic angle closure glaucoma

• 10 degree islands

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Glaucoma-Retina

• Trabeculectomy performed OS• PO day 4: IOP mid teens• A/C formed but diffusely shallow• Referred to retina with ? diagnosis of

aqueous misdirection (malignant glaucoma)

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Glaucoma-Retina

• RETINA EVALUATION• VA 20/30 OD, CF OS• IOP 14 OD, 16 OS• Filtered eye (OS) diffuse bleb• Anterior chamber moderately shallow• Ultrasound: Diagnosis ? choroidal

detachment

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Glaucoma-Retina

• RETINA• Lensectomy/vitrectomy to reverse

aqueous misdirection• Operative note: found choroidal

detachment• Surgery stopped due to

suprachoroidal hemorrhage• Final outcome: Enucleation

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Glaucoma-Retina

Plaintiff allegations• Glaucoma specialist (non-OMIC) and

retina specialist (OMIC) BOTH SUED for misdiagnosis and unnecessary surgery

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Glaucoma-Retina

• PLAINTIFF EXPERT CONTENTIONS• Glaucoma made wrong diagnosis: problem

was over-filtering• Retina should have known that choroidal

detachment common after filtration surgery. Performed unnecessary surgery

• Surgery complications led to enucleation

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Glaucoma-Retina

• RETINA DEFENSE EXPERT• Initially supportive, later felt wrong diagnosis

by glaucoma expert• Sympathetic on referral to glaucoma

expertise, and desire to save vision• If choroidal detachment, need to wait due to

bleeding risk• “…caught between a rock and a hard place”

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Glaucoma-Retina

• OTHER PROBLEMS• Missing operative report• Letters to glaucoma had information and

dates that differed from other records• When record found, stated preoperative

deep anterior chamber, mild choroidal detachment

• Felt would lead to credibility issues

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Glaucoma -Retina

• Claim Outcome?• A B C D

$200K

(Settlement)

Retina

Unknwn for Glaucoma

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Thank You!

OMIC insureds: Be sure to complete an attendance form to

receive your OMIC premium discount of 10%

69

Burnout & Resilience

From Surviving to Thriving

Jullia Rosdahl MD PhDDuke Ophthalmology

NCSEPS 2018 Annual Meeting1

I feel burned out from my work

2

I have become more callous towards people since I took this job

3

I feel burned out from my work

I have become more callous towards people since I took this job

1 time per week = BURNOUT

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National & State‐levelHealth CareEnvironment

Local Organization & Culture

(including EMR)

Ourselves

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https://performancemanagementcompanyblog.wordpress.com/tag/lego‐and‐square‐wheels‐illustrations/ 10

Skills for Well‐being

Karen Kingsolver PhD

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Paying attention in a particular way:

on purpose, in the present moment, and non‐judgmentally.

Jon Kabat‐Zinn

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Positive

Negative

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“No problem can be solved from the same level of

consciousness that created it.”

Albert Einstein

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Instructions1. Complete the self‐

assessment wheel(s).2. Where is your tire flat?

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example

S Simple, Specific I want to stop eating out as much this year, to help my family eat more healthy

M Measurable I will go the to Farmers Market 1 time per week and the kids will each pick out 1 vegetable to try.

A Achievable,Attainable

We can use the Farmers Market Food Truck that comes to the neighborhood.

R Realistic, Relevant The babysitter can help, if I can’t get home in time.

T Time‐related,Trackable, Tangible

I’ll try this for 3 weeks and see how we did.

Instructions1. Focus area? Something

you want to change?2. Make a SMART goal

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BreatheCreate Positivity

Activated?

Connect

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[email protected]@DrJulliaEyeMD

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north carolina society of eye physicians and …...profuse bleeding left eye along suture line,...

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