ROP protocol may prevent clinical complications and provide protection from malpractice lawsuits

An expert recommends coordinating care and establishing an office plan to treat patients with retinopathy of prematurity.

Establishing office protocols and coordinating care among hospitals, private practices and parents may prevent lawsuits stemming from patients with retinopathy of prematurity, according to Robert S. Gold, MD.

Robert S. Gold

Dr. Gold spoke about practice management for retinopathy of prematurity (ROP) during the Pediatric Ophthalmology Subspecialty Day at the American Academy of Ophthalmology meeting.

“A bit of risk management now and, hopefully, you will not see a letter of intent later,” he said.

Dr. Gold said his interest in streamlining the treatment of ROP patients began in 1998 when he received a letter of intent regarding a baby he was following in the neonatal intensive care unit. The baby was incorrectly scheduled by the NICU staff for an appointment 1 month late to a different doctor.

“By the time the new pediatric ophthalmologist examined the baby, she had stage 4 ROP,” he said. “Despite laser treatment, the baby detached bilaterally. I was dropped from the case, fortunately, and the hospital settled with the family, but it changed the way that I follow ROP babies.”

Dr. Gold described how he handles these cases in his office and offered recommendations on how to coordinate care from the hospital to the outpatient setting, which he said is often the most vulnerable point in managing ROP babies.

“All ophthalmologists who follow ROP babies must refer to the essential document ‘Creating a Safety Net,’ which offers concrete suggestions to establish practical approaches to the management of ROP babies,” he said.

The document can be found on Ophthalmic Mutual Insurance Co.’s Web site, www.omic.com, he said.

Establishing an ROP protocol is essential for a pediatric practice, he said.

“All pediatric ophthalmologists and your retina specialists that you work with need to be familiar with the most up-to-date follow-up and treatment recommendations,” he said. “Ask your hospital about contracting for your services to aid in the establishment of a team approach to ROP care.”

Streamlining care

Coordinating care among the hospital, the physician’s office and the baby’s parents is crucial for continuity of care, Dr. Gold said.

“All babies should be entered into a tracking system in order to assure proper follow-up,” he said. “Accurate parental demographic and contact information is essential.”

To implement an ROP care plan, it is important to educate the office staff on the significance of scheduling ROP babies at specific times and not simply scheduling them in the next available time slot, Dr. Gold explained.

“Consider having ROP slots on specific times and days for easier scheduling and tracking,” he said. “Inquire about name changes, and have your staff stress the necessity of keeping the follow-up appointments to the parents.”

Malpractice claims

ROP malpractice suits are often related to babies who are lost to follow-up, Dr. Gold said.

ROP claims are less than 1% of the claims serviced by Ophthalmic Mutual Insurance Co., Dr. Gold said, but they make up four times the indemnity payment, more than $400,000. When looking at a broader base of claims, the indemnity payment for ROP can be 10 times the average of indemnity payments, almost $1.5 million, he said.

“Set up a tracking system in your office and have an ROP coordinator to enter and update patient and exam data for each hospital and office visit,” Dr. Gold said. “We review our data every week to make sure babies are seen when scheduled.”

Tracking progress

Dr. Gold said his practice follows patients carefully until their ROP resolves.

The practice uses a database containing the baby’s name, demographic information, and the date and result of the initial examination. The database has both the private practice and hospital information. It also details every follow-up exam.

“Each time a baby is seen, whether in the hospital or in the office, my ROP coordinator enters the appropriate information into the database,” he said. “The ophthalmologist must be involved in this process.”

Dr. Gold said he personally reviews all no-shows or cancellations on a weekly basis.

“I have my ROP coordinator communicate with the family by phone and/or mail,” he said. “We track these babies until the ROP resolves or if we can document transfer of care to another ophthalmologist.”

Follow-up appointments

Dr. Gold stressed that it is important to inform the parents about follow-up visits, but the office cannot rely on them to schedule these appointments.

“Parents must be educated on the importance of follow-up and consequences of missing an appointment,” he said. “We send letters and other information to parents when we see their baby in the hospital to help us to attempt to help them understand why follow-up is so important.”

A letter for a new ROP patient that has been seen in the NICU should detail the stage of the baby’s condition and include a specific statement telling parents that missed appointments could lead to severe visual problems, including blindness.

“Each time we see a baby in the hospital we send a follow-up letter to the family again informing them of the ROP stage and follow-up recommendation,” Dr. Gold said. “We review the schedules on a daily basis and communicate with those that have missed appointments with phone contact, missed appointment letters by regular and certified mail, notification of the pediatrician and even contact with governmental agencies.”

For Your Information:

• Robert S. Gold, MD, is the OSN Pediatrics/Strabismus Section Editor. He can be reached at 225 W. State Road 434, Suite 111, Longwood, FL 32750; 407-767-6411; fax: 407- 767-8160; e-mail: rsgeye@aol.com.

• Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology.