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Wound Care RN Not Qualified to Testify on Care Standard for ICU, Generalist RNs; Bed Sores


A woman with a faulty mitral valve, coronary artery disease, and congestive heart failure was admitted to the hospital. She underwent open-heart surgery lasting over seven hours during which she lay supine. Shortly after the procedure and while in transit to her hospital bed, she suffered a cardiac arrest requiring CPR followed by the insertion of an intra-aortic balloon pump (IABP). The IABP was threaded through the femoral artery in her leg to her aorta, requiring that her leg be immobilized.

 

While connected to an external pacemaker, the balloon pump console, various intra-venous lines, and a ventilator, the woman was transported to the intensive care unit (ICU) where she was the sole patient of a registered nurse (RN).

 

The IABP was removed three days later. Generally, during the removal of an IABP, the patient’s catheterized leg must be clamped to the bed so tightly that for the first five minutes the patient’s foot turns blue, with the clamp slowly released over the course of an hour to allow the blood to clot. Thereafter, the patient must lie flat for eight hours so as not to dislodge the clot.

 

The following day, another ICU nurse noted a discoloration to the woman’s coccyx which she described as a suspected deep-tissue injury, a category of pressure ulcer, a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.

 

Five days after open-heart surgery the woman underwent a cardiac catheterization lasting over an hour and after which she was required to keep her leg straight for six hours. The following day the nursing staff requested a consult by the hospital’s wound-care department and a wound-care nurse provided the woman with a specialty mattress. Her pressure ulcer ultimately reached stage IV, eventually requiring thirty-one debridement procedures and resulting in pain and symptoms alleged to be permanent.

 

The woman and her husband sued the hospital for medical malpractice. The complaint alleged that during her hospitalization the hospital breached its professional duties proximately causing the development of a decubitus ulcer by failing to appropriately minimize the pressure on the woman and negligently failing to timely discover the ulcer.

 

In support of the complaint, the couple submitted the affidavit of a board-certified wound-care RN. The expert RN opined that the hospital failed to reposition the woman during her recovery, proximately causing the pressure ulcer to develop, and failed to order a wound-care consultation and specialty mattress after discovering the pressure ulcer, causing it to worsen.

 

The hospital filed a motion for summary judgment. The motion argued that the couple’s expert was not qualified to render standard of care or causation opinions because she specialized in wound care and was not an ICU nurse. Consequently, the couple was unable to establish that the hospital breached the applicable standard of care. The couple requested additional time to secure a new expert.

 

At his deposition, the treating RN testified, “[a]nything that deviates the patient’s position can theoretically cause ... the actual balloon on the end of the pump, to go out of place” and “you have to be just extremely careful when you move the patient that the lines don’t get kinked, that nothing gets pulled.”

 

The couple sought evidence of past occurrences of decubitus ulcer conditions, in part, to discover whether there had been other incidents indicating a failure of compliance by staff with known repositioning requirements or evidence of knowledge on the part of NWMC of the need to implement changes. The Superior Court in Pima County ordered the hospital to produce patient records of all ICU patients who had developed pressure ulcers in the four years preceding the woman’s admission.

 

The trial court denied the couple leave to secure additional experts. The trial court granted summary judgment in favor of the hospital.

 

The Court of Appeals of Arizona, Division 2, affirmed the trial court’s finding the couple’s expert witness unqualified to testify as to standard of care, reversed the trial court’s denial of the couple’s request for additional time to secure a new expert, and remanded. The court held that the couple’s expert witness was not qualified to testify as to standard of care and the trial court erred by failing to allow the couple to secure a new expert, and the trial court did not abuse its discretion in ordering the hospital to produce patient records of all ICU patients who had developed pressure ulcers in the four years preceding the woman’s admission.

 

The couple’s expert witness was not qualified to testify as to the standard of care. The couple’s expert witness was a certified wound-care nurse with specialized education in wound care and ostomy, and worked in that specialty the year before the woman’s injury. If the ICU nurses are considered specialists, the couple’s expert witness was not practicing as an ICU nurse for the year prior to the woman’s injury. If ICU nurses are instead viewed as generalists, the couple’s expert witness did not work as a generalist the year before the woman’s injury. Because the couple’s expert witness was neither an ICU nurse nor a practicing generalist in the year before the woman’s injury, she was not qualified to testify as a standard of care expert for ICU nurses.

 

The trial court erred by failing to allow the couple to secure a new expert. The hospital did not challenge the sufficiency of the couple’s expert’s affidavit until nearly a year after the couple filed it and, after the disclosure deadline had expired, deposed the expert and filed its motion for summary judgment. The trial court strongly indicated that the couple’s expert’s opinions would be admitted at trial and it would be left to the jury to assess the credibility and weight to give them.

 

The trial court did not abuse its discretion in ordering the hospital to produce patient records of all ICU patients who had developed pressure ulcers in the four years preceding the woman’s admission. Despite the fact medical records generally are confidential and receive statutory protections from discovery, redacted non-party medical records may be subject to discovery if the records are relevant and certain precautions are taken to protect patient identities. The trial court ensured sufficient privacy safeguards by ordering the hospital to redact any confidential patient information from the records produced. The non-party medical records at issue here were not specifically created for safety or quality control purposes; instead, they were created to diagnose, treat, and/or evaluate a medical condition. Thus, even if identifying the specific patients whose records were to be produced requires accessing patient safety work product through the patient safety organization, doing so would not violate the statute because the information sought is exempt from protection.

 

The Court of Appeals of Arizona, Division 2, affirmed the trial court’s finding the couple’s expert witness unqualified to testify as to standard of care, reversed the trial court’s denial of the couple’s request for additional time to secure a new expert, and remanded.

 

See: Rasor v. Northwest Hosp., LLC, 2016 WL 2893996 (Ariz.App. Div. 2, May 17, 2016) (not designated for publication).

 

See also Medical Law Perspectives, February 2015 Report: Mending a Broken Heart: Malpractice Risks in Diagnosing and Treating Heart Disease

 

See also Medical Law Perspectives, November 2013 Report: Diagnosis and Treatment of Heart Attacks: Liability Issues

 

See also Medical Law Perspectives, November 2012 Report: Liability for Electronic and Other Medical Record Information Disclosure

 

See the Medical Law Perspectives July 31, 2015, Blog: Hospital’s Policies, Procedures Not Discoverable in Vicarious Liability Suit

 

See the Medical Law Perspectives May 6, 2015, Blog: Hospital Incident Reports Under Scrutiny Again; In Camera Review Found Necessary To Determine Discoverability 

 

See the Medical Law Perspectives March 2, 2015, Blog: Discovery of Hospital Incident Reports: Prepare for In Camera Review; Discovery Likely 

 

 

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