Dr Nick Kendall. Dr Peter Jansen. 7:00-7:55 ACC Breakfast Session Treatment Injury

Transcription

1 Dr Nick Kendall Clinical Psychologist Pain Management and Musculoskeletal Medicine ACC Dr Peter Jansen Clinical Lead Treatment Injury Accident Compensation Corporation New Zealand 7:00-7:55 ACC Breakfast Session Treatment Injury

2 Treatment Safety Chair: Peter Robinson, Chief Clinical Advisor, ACC Presenters: Peter Jansen, Clinical Lead Treatment Injury Nick Kendall, Manager Treatment Safety Date: 8 th June 2018

3 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

4 Surgical Mesh Peter Robinson

5 When What Why Surgical mesh-related claim insights Let s start at the beginning 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

6 Analysis of surgical mesh-related claim data (1 July 2005 to 30 June 2017) We found that over % $13m years claims were assessed were accepted for cover has been paid out by ACC POP: Pelvic Organ Prolapse SUI: Stress Urinary Incontinence Other mesh surgery (6%) 50 Other mesh surgery Hernia repair POP and/or SUI repair 170 Ventral hernia repair (36%) Groin hernia repair Other hernia repair Total POP repair (58%) 113 SUI repair 163 POP & SUI repair

7 Background to TI and Criteria Peter Jansen

8 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

9 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

10 Treatment: What s included and what s excluded? Includes... Seeking treatment and receiving treatment Excludes... 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 Ethics approved clinical trials not performed for benefit of the manufacturer / distributor Wear and tear of prosthesis or supervening act Desired results not achieved

11 Claims process

12 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

13 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.

14 Risk of harm notifications

15 Reporting belief of risk of harm to the public Section 284: Belief of risk of harm to the public What do we consider? 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

16 Examples

17 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?

18 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.

19 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?

20 Preventing Injury: Treatment Safety Nick Kendall

21 A key role for ACC is to provide information to support treatment safety National data Aggregate data for: 20 DHBs 38 NZPSHA facilities General Practice in

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24 Treatment Safety Initiatives NetworkZ surgical simulation training (formerly known as MORSim) Infection prevention Medication safety Pressure injuries Neonatal encephalopathy

25 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.

26 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

27 Multiple aspects to infection prevention

28 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.

29 Surgical site infection (SSI) Infections are the most frequent treatment injury claim.

30 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

31 Foetal Anti-Convulsant Syndrome (FACS) We have developed FACS prevention documents with a team of 15 clinicians and consumers one to inform health care professionals and one to inform patients about the risks and benefits of anti-epileptic medicines

32 Foetal Anti-Convulsant Syndrome (FACS) FACS is a cluster of various birth defects and developmental problems in infants exposed to antiepileptic medicines in utero. Taken for epilepsy, mood, and pain. Sodium valproate has the greatest absolute risk.

33 Pressure injury prevention & management 40% of serious injury clients with spinal cord injuries had a Stage 3 or 4 pressure injury within the last 3 years, cost ~ $42m. 6 auditable principles

34 Size of the problem 223 ACC Claims $27m moderate serious injury $48m severe serious injury $3.9b OCL 1.2/100 0 NE case 12.3 Claims per year 55-66% are potentially preventable Human Impact

35 How we are addressing it 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

36 Questions He Patai