When transferring emergency patient, Treating Doctors should ensure Referral Hospital is informed, Hand Over medical notes: NMC

New Delhi: Emphasising proper communication between the primary treating hospital and the referral hospital, the National Medical Commission (NMC) has advised the doctors to ensure that the referral hospital is informed about the transfer of a patient during an emergency.

Apart from this, the Commission has also pointed out that the patient chart and admission notes are important evidence and asked the doctors to hand over the appropriate medical notes to the referral hospital.

NMC opined that proper communication between the doctors of both hospitals can ensure that continuity of care is established and the patient does not suffer.

Further, the Commission reiterated that Medical Termination of Pregnancy (MTP) procedures should be conducted as per the rules and regulations, by a qualified specialist, and after obtaining the requisite consent forms. NMC also highlighted the need for a separate general anesthesia consent form for surgeries like Hysterectomy.

These observations were made by the Commission in its recently released E-Book "Professional Conduct Review- Lessons from Case Archives", which was released by the Ethics and Medical Registration Board (EMRB) of NMC on October 05, 2023.

After examining the patient, he recommended an emergency hysterectomy and termination of the pregnancy to save the life of the mother. Accordingly, consent was taken from the attendant of the patient, and Form 1 for Medical Termination of Pregnancy was signed by the Surgeon and the duty doctor. 

Consequently, medical termination of pregnancy was done through hysterotomy, and the dead fetus was extracted from the uterus. However, the placenta could not be completely removed as it was adherent. The uterus continued to bleed and the condition of the patient gradually worsened despite resuscitation and blood transfusion.

Finally, the patient was transferred to the Government Hospital for expert care. The Government Hospital recorded that the patient's condition was critical and in hypovolemic shock on arrival. The patient was put on a ventilator in the ICU. The duty team decided to operate in order to stop the internal bleeding. A Laparotomy, Hysterectomy, and Bilateral Iliac Artery Ligation were done after obtaining high-risk consent from the bystander.

After the surgery, the patient was shifted to the ICU. However, she did not recover and expired after 5 days. In the post-mortem report, it was mentioned that the patient had multi-organ failure due to Disseminated Intravascular Coagulation (DIC) and hypovolemic shock.

The patient's husband, who arrived later, filed a case against the doctors of the private hospital for medical negligence. Based on the information provided by the government hospital doctors a case of medical negligence was registered by the police against the doctors of the private hospital. The police referred the case to the SMC for expert opinion.

The State Medical Council, after considering the case, decided that the Surgeon's name should be removed from the State Medical Register for 6 months and he should not undertake any gynecological procedure in the future. Further, the Anaesthetist and the junior doctor were also issued a warning. 

Challenging the SMC order, the Surgeon, Anaesthetist, and junior doctor appealed to the Ethics Board of NMC. After hearing the matter and reviewing the evidence and opinions of experts, the NMC Ethics Board upheld the decision of the State Medical Council.

NMC Observations: 

Referring to the case, the National Medical Commission mentioned in the E-Book that the patient, who was almost 20 weeks pregnant and was suffering from abdominal pain and bleeding, should have been treated by a gynaecologist. 

The Commission noted that the general surgeon treated the patient as the two gynaecologists working at the hospital were not available. However, the Commission opined that the patient should have been referred to another facility in that case and observed, "Although the surgeon was experienced, and did the best he could under those circumstances, the patient should have been referred to another hospital, as specialist expertise was required in this case. There were other hospitals in the vicinity that could have provided appropriate specialist care."

Further referring to the stage of pregnancy of the patient, the Commission observed that another reason for referral was that under the Medical Termination of Pregnancy (MTP) Act, 1971, the opinions of two gynaecologists are required at that stage of pregnancy.

"The decision for medical termination of pregnancy was made by the duty doctor and the General surgeon, and Form l (MTP Act) was signed by them. The treating team had time to take informed consent for the MTP rather than referring to the nearest available specialist care. Since the pregnancy was in the 19th week, it should have been terminated in these circumstances, by a practitioner qualified in obstetrics and gynecology according to the MTP Act," opined the Commission.

NMC noted that "In this case the Medical Termination of Pregnancy Act 1971 applies and was amended in 2021. There should be compliance with the law even in emergency situations. Hospitals are required to be registered under the MTP Act, procedures to be done by a qualified specialist and requisite consent forms should be signed."

Taking note of the issue of informed consent, the Commission observed that the consent form was filled by a person who posed as the patient's husband. Further, NMC observed that there was no separate consent for anesthesia.

"Specific informed consent must be taken from the patient for termination of pregnancy, or from husband or next of kin in case the woman is unable to give consent," opined NMC.

"In a surgery like Hysterotomy, there should be a separate general anesthesia consent form that ensures the patient understands the risks and type of anesthesia planned and should carry the name and signature of the anesthetist, in addition to the name and signature of the patient," it further added.

Another issue that has been highlighted by the Commission is the matter of case records, admission notes, and surgical notes. NMC noted that these documents were brief and incomplete and the anesthesia chart and notes were also unavailable. 

During the disciplinary proceedings, the surgeon and the anesthetist explained themselves by saying that it was an emergency situation. However, NMC emphasised that patient charts and admission notes are important evidence that will be called for and used in medico-legal cases.

As per the Commission, even in emergency situations, notes can be prepared after the patient is stabilized. Further, the NMC clarified that the admission notes are vital for the subsequent proper management of the patient.

At this outset, the Commission referred to the case at hand and pointed out that the Government hospital had alleged that there were inadequate information and referral notes at the time of handover of the case. It was further alleged that the patient was just left in the emergency room along with the attendant without any adequate communication from the private hospital to the duty team.

Referring to this, the Commission opined that the doctors should inform the referral hospital and noted, "When transferring/referring the patient during the emergency, the doctor must ensure that the referral hospital is informed, the patient and attendants are informed, and appropriate medical notes need to accompany the patient."

"The referring doctor should also ensure that the patient is received at the referral hospital with documentation and communication maintained between doctors of both hospitals so that continuity of care is established and the patient does not suffer," further noted the Commission.

Also Read: NMC Advice: Doctors should Carefully Document Patient's Case History, Examination Findings