Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Dr Nick KendallClinical Psychologist
Pain Management and
Musculoskeletal Medicine
ACC
7:00 - 7:55 ACC Breakfast Session – Treatment Injury
Dr Peter JansenClinical Lead Treatment Injury
Accident Compensation
Corporation
New Zealand
Presenters:
Date:
Treatment Safety
8th June 2018
Peter Jansen, Clinical Lead Treatment Injury
Nick Kendall, Manager Treatment Safety
Chair: Peter Robinson, Chief Clinical Advisor, ACC
Agenda
Introduction
Dr Peter Robinson, Chief Clinical Advisor
Overview of Treatment Injury: What is It?
Dr Peter Jansen, Clinical Lead Treatment Injury
Treatment Safety: Preventing Injury caused by Treatment
Dr Nick Kendall, Manager Treatment Safety
Information on mesh-related claims
Dr Peter Robinson, Chief Clinical Advisor
Questions
Surgical MeshPeter Robinson
Surgical mesh-related claim insights
Let’s start at the beginning
When
What
Why
In 2014 the Health
Select Committee
received a public
petition
The petition raised
concerns about the
safety of surgical
mesh
Some patients had
developed severe
complications
following mesh
surgery
Analysis of surgical mesh-related claim data
(1 July 2005 to 30 June 2017)
We found that over…
163
113
194
14
106
170
50
POP & SUI repair
SUI repair
POP repair
Other hernia repair
Groin hernia repair
Ventral hernia repair
Other mesh surgery
Other mesh surgery
Hernia repair
POP and/or SUI repair
(6%)
(36%)
(58%)
Total
810
12years
810claims were assessed
79%were accepted for cover
$13mhas been paid out by ACC
POP: Pelvic Organ Prolapse
SUI: Stress Urinary Incontinence
Background to TI and CriteriaPeter Jansen
Medical Misadventure to Treatment injury
Change in legislation in 2005, with different criteria
Faster decisions on more claims, but still some uncertainty
Under medical misadventure...
60% of all claims were DECLINED for cover
17,500 decisions (approx.) were issued between 1992 to 2002
On average, it took 5 MONTHS to issue a
decision
Under treatment injury...
60% of all claims are ACCEPTED for cover
98,500 decisions (approx.) were issued
from 2007 to 2017
On average, it takes 30 DAYS to issue a
decision
What is treatment injury?
• Legislation change in 2005 from medical misadventure to treatment injury
• Personal injury that is caused by treatment (sections 32 and 33) from a registered health professional (section 6)
• Exclusions apply
• Personal Injury = actual bodily damage, not minor symptoms alone
Treatment: What’s included and what’s excluded?
Includes... Excludes...
Seeking treatment and receiving treatment Necessary part of treatment
Failure to diagnose or treat / failure to treat in
a timely manner
Ordinary consequence of treatment
Obtaining informed consent Withholding / delaying consent
Application of support systems Resource allocation
Equipment, device, prosthesis or tool failure Wear and tear of prosthesis or
supervening act
Ethics approved clinical trials not performed
for benefit of the manufacturer / distributor
Desired results not achieved
Claims process
Lodgement and initial consideration
Providers submit the claim, with relevant clinical records
Step 1 – is there a personal injury?
Step 2 – did that injury occur while seeking or receiving treatment by or at the direction of a RHP / RHPs?
• treatment injury includes personal injury from clinical trials if
• no written consent was obtained, or
• approved ethics committee approved the trial which is not for the benefit of the manufacturer or distributor
Step 3 – was the personal injury caused by the treatment? Taking into consideration:
• whether the client's underlying health condition(s) wholly or substantially caused the injury
• the client unreasonably withholding or delaying their consent to undergo treatment.
Step 4 – exclusions
• the injury a necessary part or ordinary consequence of treatment
• the injury caused solely by a resource allocation decision
• the treatment did not achieve the desired result
• implant or prosthesis failure due to wear and tear or an intervening act
• etc
Advice for the decision
• Further advice
• Internal or external medical advice as needed
• Objective, specialist advice taking all factors into account
• External advisors are contracted to ACC.
• Failure or Omission
• Claim is based on ‘failure’ then external clinical advice from a peer of the treatment provider is likely to be sought.
• Exclusions don’t apply where failure causes injury
• Complex Claims Panel
• Meets weekly
• Consider most complex claims and accidental death claims.
• Team leaders and medical advisers from TICA, representatives from legal and communications.
Risk of harm notifications
Reporting belief of risk of harm to the public
Section 284: Belief of risk of harm to the public
Public safety
• Statutory obligation to consider all claims
• Must report if reasonable belief of risk of harm to the public
Cover assessment
information only
• Information used to make a cover decision
• Can not seek additional information
Accepted and declined
claims assessed
• E.g. Medication omission without injury (declined claim)
• Trends and clusters
What do we consider?
Examples
Example 1
Liver failure
2 month old baby taken to public ED with 1 week of weight loss, fever, diarrhoea and vomiting causing dehydration.
Admitted to hospital for IV rehydration and other therapy.
Given 280mg of paracetamol in ED due to incorrect dose being charted – a dose of 80mg/kg instead of 10mg/kg.
On the following day abnormal liver function was noted.
Disclosure to parents of this overdose causing “acute liver failure”.
An ultrasound of the liver on the same day was normal liver and LFTs back in the normal range within 2 days.
The physical injury of acute liver failure has resolved.
What entitlements are available after discharge?
Example 2
Pressure injury
Patient admitted to ICU with acute neurological illness.
Resolved over 5 days with good recovery, and transferred to rehabilitation unit for a further 5 days.
Claim lodged for ‘friction blister’ to the right heel by rehabilitation unit staff.
ACC2152 from GP says the pressure injury to the right heel was caused by a failure to provide the appropriate preventive care. Hospital records provided show no evidence of assessment of risk for pressure injury nor any pressure injury prevention or treatment in ICU.
Wound located on day of admission to rehabilitation facility.
Exclusions don’t apply – failure.
ACC2184 says the patient had a high risk of developing a pressure area secondary to her health condition, underlying conditions and immobilisation in ICU. The risk of developing a pressure injury was not assessed and patient not provided with the appropriate preventive care.
Claim accepted grade 3 pressure injury caused by a failure to provide treatment.
Subsequently a district nursing care package was approved.
New request for motorised wheelchair due to immobility – neuropathy affecting right > left feet.
The heel wound is well healed.
Example 3
Disease progression
50 year-old presented to ED with severe new onset headaches.
CT performed to exclude vascular causes and was reported as normal.
Presented again 6 months later with 2-week history of increasing stridor. On direct examination a large mass obstructing the posterior pharynx was identified.
Collapse in ED with resuscitation
Emergency surgery was needed to protect the airway and biopsy the mass. Found to be XXX tumour, which was treated by wide excision and radiotherapy.
Blinded review of CT by three radiologists all identified the pharyngeal mass.
Expert advice that 6 month delay led to tumour growth, but no difference in treatment for the underlying tumour – the treatment plan would be the same if diagnosed earlier. Prognosis remains the same also.
Cover accepted for disease progression of tumour due to a failure to diagnose tumour with resulting obstruction of pharynx causing respiratory and cardiac arrest.
What if the treatment path was altered because of disease progression?
E.g. additional chemotherapy required or much greater excision?
What about recurrence?
Preventing Injury: Treatment SafetyNick Kendall
• National data
• Aggregate data for:
• 20 DHBs
• 38 NZPSHA facilities
• General Practice in 2019
www.acc.co.nz/treatmentsafety
A key role for ACC is to provide information to support treatment safety
Treatment Safety Initiatives
• NetworkZ surgical simulation training (formerly known as MORSim)
• Infection prevention
• Medication safety
• Pressure injuries
• Neonatal encephalopathy
Surgical Simulation Training
Safe surgery is important to ACC because the volume and
complexity of surgery increasing, greater risk factors in the
patient population. ‘Never Events’ include wrong-site surgery,
leaving items in patients, and major postoperative
complications.
Simulation training is well established in other sectors (e.g.
aviation) and is increasingly used in clinical training. More
effective teamwork and and communication have been shown
to reduce paient harm in operating rooms.
www.networkz.ac.nz
• “Train-the-trainer” approach to four cohorts of five DHBs
• Each DHB will have a state-of-the-art simulation suite and trainers
• At least 4,840 operating room staff will be trained
Multiple aspects to infection prevention
Infections
• Infections are the most frequent treatment injury claim.
• Most infection claims are low-cost, but a small minority have much
greater impact with higher cost and duration.
• Surgical site infections tend to be more expensive.
Surgical site infection (SSI)
Infections are the most frequent treatment injury claim.
Surgical site infection
• ACC funding to HQSC to support Surgical Site Infection
Improvement Programme (SSIIP).
• Target is deep/organ space and superficial SSIs for
Orthopaedics (only hip and knee replacement), and
Cardiac (coronary artery bypass graft, CABG).
Initiative interlocking with ICNet survelliance platform
Foetal Anti-Convulsant Syndrome (FACS)
We have developed FACS prevention documents with a team of 15 clinicians and consumers– one to inform health care professionalsand one to inform patientsabout the risks and benefits of anti-epileptic medicines
Foetal Anti-Convulsant Syndrome (FACS)
FACS is a cluster of various birth defects and developmental problems in infants exposed to anti-epileptic medicines in utero.
Taken for epilepsy, mood, and pain.
Sodium valproate has the greatest absolute risk.
Pressure injury prevention & management
6 auditable principleswww.acc.co.nz/treatmentsafety
40% of serious injury clients
with spinal cord injuries had
a Stage 3 or 4 pressure injury
within the last 3 years, cost ~
$42m.
1.2/100
0
NE case
Size of the problem
12.3
Claims
per
year
$3.9b
OCL$27m
moderate
serious
injury
223
ACC
Claims
$48m
severe
serious
injury
55 - 66% are
potentially
preventable
Human
Impact
Next steps could be
• Simulation training
• Support via “Maternity App”
Effective treatment
Cooling within 6 hours
to prevent neurological
damage … but need to
identify a potential case
How we are addressing it
Questions
He Patai