Closed claims analysis: Emerging trends in pain management

Before 2005, there wasn’t a lot of data related to chronic pain medication management. However, with an increasing focus on ASA Closed Claims Analysis, anesthesiologists can see inherent risks and take steps to avoid liability.

During Saturday’s “Best Practices in Regional Anesthesia and Interventional Pain Medicine,” James Rathmell, MD, of Brigham and Women’s Hospital in Boston, explored studies arising from medication management in chronic pain malpractice cases and presented three emerging trends: complications associated with chronic opioid prescribing, cervical procedures, and implantation.

The opioid epidemic and medication misuse are increasingly showing up in malpractice claims. Dr. Rathmell found medication misuse or addiction often occurred in patients with specific risk factors and aberrant behavior, including depression, suicide attempts, and other drug and alcohol problems. Often, multiple factors were present in the same patient.

James Rathmell, MD

James Rathmell, MD

“Most of the time, the opioids were being managed by the anesthesiologist when a claim was made against that anesthesiologist,” he said. Unfortunately, these patients were managing illicit drugs and alcohol as well.

Death was the outcome in 57% of those cases. A high proportion of deaths (45%) were attributed to both an uncooperative patient and inappropriate physician management.

“The next major finding was a really big increase in the proportion of claims related to procedures performed at the level of the cervical spine,” he said.

The first factor was these are predominantly young, healthy females, 50-year-olds on average, ASA Physical Status I or II with neck pain.

“Compared to other pain treatments, it was a much higher proportion of women.  That was puzzling to us. But when we looked at the demographic of neck pain, the actual epidemiology of neck pain, this is the group that is most affected by neck pain,” he said.

The second finding was that most damaging event procedures (67%) were cervical epidural injections, followed by 11% stellate ganglion blocks for reflex sympathetic dystrophy of the upper extremity.

“What were the damaging events? I went into this thinking the intra-arterial embolic phenomenon with spinal cord infarctions and posterior circulation cerebellar strokes would be the most common,” Dr. Rathmell said. “In fact, the most common damaging event was direct trauma – needle trauma to the cord. That represented 31% of injuries; 14% were intra-arterial embolic phenomena. Damaging events 80% of the time were related to the procedure. This group of claims is directly related to the conduct of the procedure.”

He said these injuries are typically catastrophic, resulting in “uniformly permanent debilitating injuries,” such as paraplegia and quadriplegia.

The final study he referenced involved injury and liability associated with implantable devices. He said the majority (66%) were temporary minor injuries, such as an incision wound infection.

“Permanent disabling injuries were much less common, only 25%. Death occurred in 9% of the cases and was associated with mishaps with intrathecal pump refills, pocket refills where all of the dose for a month goes into the pocket,” he said.

The conclusion here is half of IDDS maintenance claims were associated with death or permanent severe injury, most commonly from medication errors or failure to recognize progressive neurologic deterioration, he said.

“These are very severe injuries, and that is because you put the entire dose into the pocket and it slowly absorbs. The patient is usually out of the office by the time they start to get sedated, then become obtunded,and they end up with brain injury or death by the time they are resuscitated.”

“If you are implanting, you need to really understand these risks and have a very clear pathway back to reaching you after-hours should the patient have symptoms. Several of these claims, the story was that the patient was trying to reach someone. There was no after-call mechanism to reach the practitioner, and that led to a delay in diagnosis,” he said.

For all of the chronic pain-related claims he explored, Dr. Rathmell concluded that complications associated with interventions in pain medicine are still rare. He said the Closed Case Analysis represented 300 closed cases out of millions of procedures performed in the United States every year.

He said strategies for the effective prevention and early detection of infection and or neurologic deterioration can be easily adopted and should be added to every practice.

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