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PICC line for urgent antibiotic in rural setting (01HDC01820)

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01HDC01820, 23 October 2002

Right to services of an appropriate standard ~ Reasonable care and skill ~ Right to be fully informed ~ Sufficient information ~ General practitioner ~ Rural ~ PICC ~ Lack of experience ~ Gentamicin ~ Vicarious liability ~ Right 4(1) ~ Right 6(1)(b)

A consumer complained that a general practitioner in a rural hospital did not provide the appropriate standard of health care on the basis that the GP: (1) did not undertake any tests to determine the nature of the bacterium in the bursa; (2) inappropriately placed a peripherally inserted central catheter (PICC) line; (3) did not adequately inform the consumer of the risks of gentamicin; and (4) did not undertake appropriate blood tests after prescribing gentamicin.

The facts were that the consumer had a potentially serious cellulitis of a lymphoedematous arm. It was difficult to find suitable IV access sites with conventional cannulae. The GP advised transfer to a city public hospital, which the consumer refused. The consumer stated that she was reluctant to go to the city hospital only because there was no reason for her to think that it was dangerous to remain at the rural hospital. The GP told the consumer that there was a small risk that gentamicin could affect her hearing and kidneys but did not go into "great detail" about the risks.

The Commissioner reasoned, after receiving independent expert advice from a general practitioner in a semi-rural practice, that:

(1) it was acceptable practice not to test the bursa for organisms but to treat with antibiotics; and

(2) the decision to insert a PICC line was inappropriate because they are used mostly for chronic disorders requiring long-term access and for difficult venous access in emergencies, and the GP could have encountered technical difficulties with the insertion, which he might not have been able to address as this was his first use of a PICC line, and the GP had other treatment options available, such as persisting with a peripheral IV.

The Commissioner held that:

(1) the GP did not breach Right 4(1) because:

(a) the actions were at a low level of non-compliance with professional standards and did not place the consumer at substantial risk

(b) the consumer did not suffer any adverse consequences

(c) the GP initially attempted to use another type of IV line

(d) the PICC line was correctly placed even though this was not confirmed with an X-ray as required by the manufacturer's instructions

(e) the consumer required urgent treatment

(f) the consumer had poor venous access in both her arms

(g) the procedure was undertaken in sterile conditions

(h) the rural hospital was equipped to deal with emergencies, such as complications arising from the use of the PICC line, and

(i) the GP has enrolled in a post-graduate diploma in rural hospital medicine to increase his knowledge and skills;

(2) the GP breached Right 6(1)(b) by failing to give the consumer sufficient information about the risks and potential complications of the PICC line and gentamicin, some of which are serious, and therefore she was not able to make an informed choice, including whether she should be treated locally or at a city hospital; and

(3) the employer is not vicariously liable as the employer could not reasonably have prevented the GP's actions, and the relevant protocols were satisfactory.

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