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Pitfalls in critical care referrals, illustrated with case-studies : Dr. Sanjay Gupte

M3 India Newsdesk Sep 29, 2019

Dr. Sanjay Gupte, a noted obstetrician who also holds a degree in Law highlights medico-legal issues that can happen with referral cases.







Dr. Sanjay Gupte, a noted obstetrician who also holds a degree in Law highlights medico-legal issues that can happen with referral cases.

Decisions to refer a high-risk patient are often complicated by social & financial considerations as well as medical risks.

It was found that doctors base their referrals predominantly on medical factors, but that other consideration can affect close decisions. (eg. Medicolegal or social threats).

The prime reason usually is that the case is medically high risk eg. Severe hypertensive disease in pregnancy with pulmonary edema. Such cases may require additional expertise but more than that they require additional equipment, investigation facilities and round the clock vigilance by the expert help which is usually not available in ordinary hospitals.

The other major reason for shifting the patient to the ICU can be Medicolegal issues.

In a number of cases, the courts have held doctors negligent for not offering intensive care help on time.  

Finally, nowadays a new ailment has cropped up and this is that of violence in the hospital. In many cases even in unavoidable complications, the doctors are harmed and hospitals ransacked by the patients’ relatives. This has caused a big deterrent in the doctors’ minds and they do not want to take this additional burden of social threat, so the patients are referred to ICU early. 
A pilot survey with 600 fellows was conducted by ACOG as regards referral to the tertiary centers in case of pregnancy diabetes. 

The obstetricians identified six risk factors for study 
1. The class of diabetes 
2. The presence of PIH 
3. The distance to the referral centre 
4. The level of nursery(including both availability of anesthesia & pediatric support) 
5. Socioeconomic status 
6. The perceived loyalty of the patient 


Medical Indications for transfer to ICU
 System Indication
Cardiovascular Hypotension or raised serum lactate persisting despite fluid resuscitation, suggesting the need for  inotrope support 
Respiratory Pulmonary edema 
Mechanical ventilation 
Airway protection 
Renal Renal dialysis 
Neurological Significantly decreased conscious level 
Miscellaneous Multi-organ failure 
Uncorrected acidosis 

Proper communication 
When it comes to referring a patient in an emergency to ICU certain steps should be taken, 
• Stay calm 
• Invite the main next of kin and one other to join you in another quiet room 
• Invite them to sit down. This has the effect of calming the person 
• Break the news quietly and confidently 
• Explaining the nature of the problem and the patient’s general condition 
• Inform about the efforts made to tide over the crisis. 
• Inform about the possible course of further action 
• Give them time to assimilate their thoughts and ask questions 
• Answer all questions honestly 

Risk identification 
Points to be considered while accepting the case 
• Diagnosis and risk involved in the given treatment or surgery 
• Whether it should be accepted to start with 
• If accepted proper communication and consent is a must including mentioning about available facilities. 
• A possibility of tie-up with a tertiary center (especially NICU) 
• When an emergency referral is necessary proper communication with the relatives explaining the need for reference,  
• Explain the treatment being given,  
• Explain the possible course of further action needed.  
• Obtain consent,  
• Communicate with the place of referral ensuring acceptance,  
• Obtain consent from the patient’s relatives,  
• Write a referral chit,  
• Keep a duplicate of this with a patient’s relative’s signature. 
• To arrange proper transport and accompanying person (doctor if required) 

Checklist for a referral to the tertiary center 
• Name of the patient 
• Time & date of the referral 
• Reason for the referral 
• Detailed condition of the patient: When first seen, When referred 
• Details of the treatment given 
• Communication with the referral hospital 
• Actions expected 
• Transport arrangement 
• Patient’s & relative's informed consent and signature 


Pitfalls in referrals 

Case 1 

In one of the cases in Delhi, the patient had severe chest pain. Patient aged about 50yrs with diagnosis AUB came with severe epigastric pain. The doctor rightly suspected a cardiac event. The patient was sent to multispecialty hospital 2 km from the hospital. When she reached there the CMO immediately told the hospital was full and there was no place for admission of the patient and she was told to go further to another tertiary care hospital which was 10 km away. By the time she reached, her condition had worsened and she died as the treatment was just started. The doctor and the CMO were held liable 

  Case 2 

A 14 yr old boy had severe hepatitis and was referred for tertiary care. He subsequently went in hepatic coma. He was taken to the hospital where he died. The relatives alleged negligence by the doctor. Actually, they had not taken the patient promptly to the intensive care center but had in between visited a quack and wasted time. The doctor had not kept the records of the referrals hence could not prove that referral was on time 

 Case 3 

A Case of road traffic accident was brought to the doctor. The patient had open fracture in femur and was bleeding profusely. The relatives were told to take the patient to a trauma care center. Unfortunately, the patient died on the way. The Doctor was held responsible for not administering lifesaving measures. 

In a number of cases, the Honorable Supreme Court has decreed that life-saving measures should be immediately provided by the hospitals. The Medicolegal problems or expenses for the treatment should not have any considerations as the life of the person should come first. 


Supreme Court - Daily Orders 
Bijoy Sinha Roy (D) By Lr. vs Biswanath Das.  
on 30 August 2017 

CIVIL APPEAL NO(S).4761 OF 2009 

The patient consulted a Gynecologist on the advice of her family physician.  It was found that she had multiple fibroids of varying sizes in the uterus. She was advised to undergo Hysterectomy. After about five months, she had severe bleeding and was advised emergency Hysterectomy. She was also suffering from high blood pressure and her hemoglobin was around 7 gm% which indicated that she was anemic. The treatment was given for the said problems but without much success. Finally, an operation was conducted but she did not regain consciousness and since the Nursing Home did not have the ICU facility, she was shifted to another Nursing Home and thereafter to Hospital where she died. 
In the appeal in front of the Supreme Court, two arguments were put forward 
The surgery was not an emergency but a planned one and conducted six months after the disease first surfaced and secondly, having regard to the foreseeable complications, the decision to perform surgery at a nursing home which did not have the ICU for post-operative needs also amounted to medical negligence.

Patient’s Hb was 7gm% & patient had high BP. The first argument was not held valid by the courts as the surgeon is entitled to make a choice as per the courts. Regarding the second argument at the time of the admission doctor Mukherjee (the owner of the hospital) had categorically stated to the complainant that all the best medical facilities will be provided which in fact was not so. The patient was not told that ICU facilities are not available.

The doctor did not bother to take initiative to get himself involved in transferring the case to the next level of the hospital when the patients (i.e. the wife of the Complainant) condition was critical. He also had not kept any documented proof to know that surgery was really urgent. 

“We, however, find that neither the State Commission nor the National Commission have examined the plea of the appellant that the operation should not have been performed at a nursing home which did not have the ICU when it could be reasonably foreseen that without ICU there was post-operative risk to the life of the patient.” 

This article was originally published on 16.09.18

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

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