The Accident Rehabilitation and Compensation Insurance Corporation (ACC) notified the Commissioner of a complaint about a consumer receiving second degree burns and scarring to her right hand following wart removal treatment by a practice nurse.
The complaint was received by the Commissioner on 14 November 1997 and an investigation was undertaken. Information was obtained from the following people:
- The Consumer's Mother
- Provider/General Practitioner
- Provider/Practice Nurse
- A Plastic Surgeon
- A New Zealand Nurses Organisation Legal Adviser
- A Pharmacist
The consumer's clinical records were obtained and viewed. The Commissioner received independent advice from a General Practitioner and a practice nurse.
Outcome of Investigation
"[The practice nurse] is very experienced and has developed skills in wart treatment under doctor's guidance. As her skills have grown she has been treating some patients without doctors' supervision over the last 5 years."
The practice nurse assessed the warts and applied trichloracetic acid (TCA) to them using a small stick. The practice nurse advised ACC that the medical centre employed various methods to treat warts, including carbon dioxide slush, liquid nitrogen, diathermy and TCA. TCA was first recommended to them by a dermatologist and was used mainly to treat periungial warts. She stated that TCA was chosen because it caused little or no pain and there had been no evidence of scarring over the past ten years.
The practice nurse advised ACC that it was important not to cause undue pain in children and that the use of liquid nitrogen in children had, in the past, proved to be painful and traumatising.
The procedure used was to apply the minimum TCA and wipe up any excess. No protective grease was applied to surrounding areas. The consumer's mother advised the Commissioner that her daughter's hand was sore for the next couple of days and that scabs gradually formed over the affected area. After seven days, the consumer's mother took her daughter back to the medical centre. She advised the Commissioner that she described cracking and sore scabs to the practice nurse. The practice nurse inspected the warts, repainted some of the individual ones and noted that the treated area looked fine. The consumer's mother advised the Commissioner she was given bactroban ointment to apply and was told the scabs would heal within a week or so.
The consumer's mother advised the Commissioner that she was concerned about keeping ointment on her daughter's hand without a dressing and, when the ointment was applied, covered it with an extra wide sticking plaster. She stated that this regimen continued for 11-12 weeks.
The practice nurse noticed the scarring on the consumer's hand in mid-May 1997 when the consumer's mother brought another child in for treatment. She told the consumer's mother this was not normal and referred the consumer to the general practitioner. The GP saw the consumer in late May 1997 and arranged for her to see a plastic surgeon. The medical centre paid for all the dressing costs the consumer's mother incurred and referred the case to the Medical Misadventure Unit of ACC.
The GP advised the Commissioner that they had started using TCA some ten years ago on the recommendation of a skin specialist and had found it to be useful and relatively painless. The GP wrote:
"The acid needs to be confined to the wart with careful application with a fine stick and any excess soaked up immediately. [The practice nurse] was well aware of this. For some reason in [the consumer's] case some acid must have overflowed and caused the resultant burns. This was no doubt contributed to by the small flat warts [the consumer] had. Perhaps vaseline protection of the surrounding skin may have protected it but our years of experience with a careful application has not shown a need."
The GP also noted:
"It is unfortunate that we were not involved in the prolonged treatment of the burns. I think the Bactroban ointment recommended was quite appropriate if infection was present and further supervision by a doctor may have prevented some of the resultant scarring".
The medical centre's pharmacist reported that the concentration used was 90% w/w with water. This is the concentration recommended in Martindale, The Extra Pharmacopoeia, 31st Edition, 1996:
"It is used as a quick escharotic for warts. It is applied as a strong solution, prepared by adding 10% by weight of water [e.g. TCA 10g plus water 1g]; the surrounding parts are usually protected."
The consumer saw the plastic surgeon in early August 1997, who reported that the scarring was visible, being quite red and very slightly raised. The plastic surgeon ruled out any treatment as she expected the scarring to fade gradually, soften, and settle down over a period of a year or more.
The consumer's mother took her seven-year-old daughter to a medical centre in mid-January 1997 to have plain warts removed from the back of her right hand. The general practitioner and the practice nurse practice at the centre. The practice nurse has worked for the GP for the past twenty years. The GP, in his response to the Commissioner dated early February 1998, wrote:
The Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and disability Services Consumers' Rights are applicable to this complaint:
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
3) Every consumer has the right to have services provided in a manner consistent with his or her needs.
4) Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer.
5) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.
"The way doctors and practice nurses work out the boundaries for their roles."
The consumer was assessed and treated without any input from a general practitioner. The GP did not review the scarring until two weeks after it was noted by the practice nurse. In my opinion, the consumer should have been assessed by a doctor before treatment, and referral should have been immediate once the scarring was noticed. I am particularly concerned there was no follow-up to the second treatment in late January 1997.
Some fourteen weeks passed until mid-May 1997 when the practice nurse happened to see the consumer and note the scarring when the consumer's mother brought another child to the surgery for treatment. Thereafter, there was a delay of two weeks before the consumer saw the GP. This is unsatisfactory and raises concerns as to the extent to which the practice nurse was working independently of, rather than under the supervision of a doctor - in effect working as a "nurse practitioner". I am advised the use of the nurse practitioner is generally accepted and it is not uncommon for nurses to treat warts without the doctor having assessed the condition.
The advisability of independent practice and the accountability issues it raises, are matters of concern which must be addressed. In particular, GPs are vicariously liable for employees and therefore have a legal obligation to ensure appropriate practice and supervision of that practice.
In my opinion, the practice nurse and the general practitioner breached Right 4(2), Right 4(3), Right 4(4) and Right 4(5) of the Code of Health and Disability Services Consumers' Rights as follows:
In my opinion the practice nurse breached Right 4(2) by failing to apply current treatment practices. The GP, as the practice nurse's employer, is vicariously liable for her actions and is also in breach of Right 4(2) of the Code.
My GP advisor reported that although it is not inappropriate to use TCA to remove warts, it is not in general use, and it would not be appropriate to use a 90% concentration as applied by the practice nurse. This advice was supported by my practice nurse advisor.
My GP advisor added that even in concentrations of 15%, use of TCA on thin skinned areas such as the back of the hand, carries significant risks of scarring. Its use in a 90% concentration would not comply with acceptable standards for general practice.
In proceeding as she did, the practice nurse was acting in good faith on information from a reputable source. The practice worked for her for many years and, as a result, the practice nurse had not sought to update the information on which she based her wart treatment practices. Her successful application of this treatment, until this consumer's case, meant that neither she nor her employer had sought to update the information on which they based their wart treatment practices, and validation of the treatment was not sought.
Right 4(3) and Right 4(4)
In my opinion, the practice nurse and the GP did not provide the consumer with services that were consistent with her needs, or that minimised potential harm to her.
The GP did not assess the consumer or discuss with the practice nurse the treatment proposed. The practice nurse did not schedule any follow-up to the treatment done at the second appointment, and only noticed by chance that the consumer's hand was scarred in mid-May 1997. The GP did not see the consumer until late May 1997.
The practice nurse relied solely on her ability to notice and mop up any excess TCA. The practice nurse failed to protect the surrounding areas on the consumer's hand. Although this was the standard practice used without event for some years, the GP did mention the possibility of using vaseline to protect the surrounding skin.
In my opinion, the practice nurse and the GP breached Right 4(5) of the Code of Health and Disability Services Consumers' Rights.
My advisor stated that this case highlighted a difficult area:
I recommend that:
- Both the practice nurse and the general practitioner apologise in writing to the consumer and her mother for breaching the Code.
- The GP update himself, and other staff, on the appropriate treatment for wart removal.
- The GP conduct a review of all treatments that have been delegated to nursing staff and ensure that the practices are consistent with current medical practice.
- The GP ensure appropriate mechanisms are in place to ensure general practitioner intervention, when necessary, during treatment delegated to nursing staff.
- The GP ensure that consumers are fully informed about all wart treatment options and are advised that treatment with TCA is carried out in very few practices.
- The GP ensure that when TCA is used as a wart treatment it is at an acceptable concentration, that barrier cream is applied beforehand, and that consumers are fully informed about the risk of scarring.
The GP is to report to the Commissioner the results of his review and the mechanisms in place to ensure timely general practitioner intervention during treatment delegated to nursing staff.
A copy of this opinion will be sent to the Medical Council of New Zealand, the Nursing Council of New Zealand and ACC.
An article based on this opinion will be prepared for publication in an appropriate periodical.
For further information, contact: HDC Communications Section (09) 373 1060.