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In the recent Texas case of Denton Regional Medical Center v. LaCroix, a patient was admitted to deliver her first child. However, prior to the delivery, she experienced difficulty in breathing. The obstetrician decided to deliver by Caesarian section, and so a certified registered nurse-anesthetist was present. The nurse-anesthetist attempted to establish an airway, but was unsuccessful, and so an anesthesiologist was summoned. Before he arrived, however, the patient coded and had to be resuscitated. During the code, the nurse-anesthetist attempted tracheal intubation, but was initially unsuccessful. The patient suffered an irreversible brain injury.
The patient sued the nurse anesthetist, the anesthesiologist and the hospital. The nurse anesthetist and the physician settled their cases. But the plaintiff proceeded to trial against the hospital on the theory that the hospital was not following appropriate policies for the supervision and training of nurse-anesthetists. The jury found against the hospital.
The hospital appealed, asserting that its policies regarding nurse-anesthetists met the standard of care. The policy required that nurse anesthetist’s have direct supervision by physicians and that an anesthesiologist evaluate and prepare the patient.
But the plaintiff presented both expert testimony and documents that established that the supervision was not sufficient in this case. Interestingly, a suggestion was made by the hospital that the obstetrician was supervising the nurse-anesthetist. However, the obstetrician disagreed, asserting that he was not qualified to do so.
Finally, a memo from the hospital’s Chief of Anesthesiology, expressing concern about the lack of supervision for nurse anesthetists, was used to buttress the plaintiff’s case. The plaintiff presented standards promulgated by the American Society of Anesthesiologists which also required that the anesthesiologist direct the administration of anesthesia and participate in anesthesia induction and emergence.
The appeals court sided with the plaintiff. The court noted that the jury could reasonably find that the guidelines requiring physician supervision had not been complied with. Therefore, the standard of care would not have been met.
During the last 20 years, the way in which health care has been delivered has changed dramatically. One particular change involves the increased use of non-physician professionals for the provision of care, and therefore increased litigation of these professionals.
The use of non-physician professionals requires forethought and planning about their role in the provision of patient care. Guidelines promulgated by state licensing agencies, the Joint Commission, and professional groups need to be considered. A hospital’s failure to adopt policies consistent with these recommendations may be interpreted by juries as a cost saving approach to the detriment of patient care. In Massachusetts advanced practice nursing policies must be developed in compliance with regulations from the Board of Registration in Nursing.
The appeals court found that Denton Regional Medical Center had policies that were not followed in the LaCroix case. So establishing appropriate policies is just a first step; educating staff and developing a process by which compliance with the policies can be assured is then mandatory. In the end these policies will establish the standard by which the hospital will be judged in medical malpractice proceedings.
Physicians Supervising Non-Physician Professionals
by Attorney Frank E. Reardon
January 1998