When a hospital's policies contradict clinical guidelines

Q:I'm a cardiologist. My small urban hospital wants to eliminate open-heart surgery. The cardiology chief believes that angioplasty can still be performed on an emergency basis because of its low risk and because a hospital with an open-heart program is only five minutes away. I basically agree, but I'm concerned because the American College of Cardiology guidelines state that an absolute contraindication to angioplasty is absence of a formal cardiac surgical program within the institution. Does performing angioplasty at my hospital pose a legal risk to me and the institution?

A: Some states have regulations that specifically prohibit angioplasty without surgical backup within the hospital. If you practice in one of those states, you obviously cannot perform this procedure there. The plaintiff wouldn't be required to prove clinical negligence, only that you and your hospital deviated from the rules.

Plaintiffs' attorneys will argue that specialty society guidelines create a legal standard of care. Guidelines from a well-respected organization such as the ACC will carry a great deal of weight. However, if you can document that you considered the guidelines, had good reason to depart from them, and informed the patient of your thinking, you can often win the argument in court.(See "Clinical guidelines: A malpractice safety net?" April 12, 1999 (also available at www.memag.com).

The college's guidelines are several years old, and current research can be introduced as evidence regarding the standard of care. Many studies show that the incidence of occlusion has dropped dramatically as a result of stents and new platelet antagonist medications. The incidence of patients being sent to surgery following angioplasty has decreased significantly.

That has led to some controversy over whether the practice of angioplasty without backup surgical availability is safe. The college is currently formulating new guidelines.

The cardiologist's experience is the key to safety. "I wouldn't recommend allowing a doctor to do angioplasty without backup surgery unless he does several hundred a year," one leading cardiologist told me. "It's the inexperienced cardiologists who may run into trouble."