Clinical practices and standards of care are constantly evolving. It's important that you regularly update your written protocols to reflect the most recent standards of care and how things should be done in your facility. Any disconnect between everyday practice and what's written in the protocols opens the door to liability should a case end up in court. That's what happened with a Florida hospital when a seemingly innocuous act — a CRNA extubated a patient without having an anesthesiologist present — resulted in a wrongful death suit. Why? Because the CRNA violated the hospital's standard of care.

Cardiac arrest after extubation
A 54-year-old man with a history of hypertension, peripheral artery disease, diabetes and a recent myocardial infarction was admitted to the hospital after cardiac catheterization in order to undergo a coronary artery bypass graft for triple vessel disease. The patient was evaluated by anesthesia and underwent the procedure without incident.

Following the surgery, the patient was admitted into the cardiovascular critical care unit. About 12 hours after surgery, a nurse anesthetist consulted with the anesthesiologist on duty and then extubated the patient. Within minutes of having the tube removed, the patient went into cardiac arrest and had to be revived with a balloon pump.

After a series of electroencephalograms, physicians determined that the patient had suffered a severe anoxic brain injury and was in a vegetative state. On the tenth day after surgery, the family consented to removal of life support. The patient died shortly after life support was stopped.

The decedent's estate sued the hospital, the CRNA and the anesthesiologist. The family claimed that the patient was treated negligently, which resulted in his wrongful death. Specifically, plaintiff's counsel argued that the CRNA extubated the patient without having the anesthesiologist present. This alone was a violation of the standard of care, they argued. Additionally, they argued that the CRNA's premature removal of the tube caused the cardiac arrest that led to the patient's death.

Before the discovery phase of the lawsuit, the hospital elected to settle the case for an undisclosed amount. The hospital's decision to settle was influenced by the fact that the hospital's 10-year-old written policy said that an anesthesiologist should be present during extubation. Over the years, the hospital had abandoned the practice, but the written policy and the procedure manual hadn't been updated. Hospital leaders decided that settling was better than taking the chance that the jury would find the facility guilty of corporate negligence.

Jury: no medical malpractice had occurred

During a 4-day trial, the defense attorneys for the anesthesia providers argued that their client didn't violate any standards of care. Nurse anesthetists routinely remove breathing tubes without physician supervision. With this patient, they alleged, the CRNA removed the tube out of concern that the patient was attempting to remove the tube himself. The defense expert witness testified that it wasn't the extubation that prompted the cardiac arrest, but the patient's compromised cardiac functioning and arterial damage. After all, when the patient's condition deteriorated after extubation, the nurse anesthetist had to use the balloon pump to revive him, added the expert witness.

At the end of the trial, the jury returned a verdict in favor of the defendants, finding that no medical malpractice had occurred. If the hospital had remained in the case, it could have exposed all parties to increased liability. The hospital would have been exposed for not following its own policy and procedure and permitting the staff to routinely violate the policy. However, without the hospital in the case, there was essentially no policy or procedure on extubation and supervision, since the policy the hospital had was antiquated and never rewritten. This let the CRNA and anesthesiologist allege that their habit and custom was for the CRNA to extubate following a consult with the anesthesiologist.

Undeniably, nurse anesthetists are doing more today than a decade ago, often without supervision. And the issue has generated much debate.

Regardless of where your facility stands on the supervision issue, it's important that the duties and responsibilities of the CRNA and the anesthesiologist are spelled out in your written protocols and that your anesthesia providers follow the protocols. Otherwise, any gaps increase your vulnerability should you end up in court.