Risky Business Murky Encounters - PowerPoint Presentation

Risky Business Murky Encounters for the Hospitalist and the Hospital Georgia Society of Healthcare Risk Management St Simons, Ga, May 14, 2015 Bruce L. Mitchell, MDDirector of Hospital MedicineEmory University Hospital Midtown

ObjectivesIdentify the characteristics of a good discharge summary.Discuss the Joint Commission and it’s mandates regarding Transitions of Care. Identify how too many clinician “hand-offs” affect patient care.Demonstrate the relationship between night and weekend staffing decisions and “Code Blues”.

HPI A 58 y/o male w DM2 presents to ED w c/o “feeling funny, slurred speech and word finding difficulty. Occasional dry cough. PE VS nlNeuro-normal examLab data-nl Head CT-nl A/P 1. Admit2. TIA-Stroke pathway, ASA, MRI3. DM2-Diabetic diet, accu-checks Case #1

Next Day (11/14 )R facial weakness w obliterated nasolabial fold. Slurred speech. R U and LE weaknessImpression R Hemiparesis likely 2/2 L MCA ischemic infarctHypertensionDiabetes MellitusMRI-confirms stroke L Basal ganglia and R frontal MRA, Carotid Studies, TT Echo- NLCase #1Neuro Consult - Dr P.

HPI- 58 y/o male w h/o DM2, HTN and HLD presented w expressive aphasia, and w/u revealed L basal ganglia and right frontal CVA on MRI. Does endorse some recent CP. Because of bilat CVAs, CV source of embolism considered and asked to see for TEE.Meds-Aggrenox, Zocor, Protonix, Amaryl, R emeron, heparin PE- R sided weaknessImpressions- Bilat CVA, HTN, DM2, HLDRecommendations-Agree w TEE. Because of mx risk factors and recent chest discomfort-eventual thallium stress test will be neededCardiology Consult-Dr G.Case #1

Hospital CourseTrans esophageal echo is negative DC Summary dictated on 11/16/08 (HD # 3 by Dr Bynes)-send copy to pts PCP - William Patel vs (John Patel)Pt discharged to Rehab (HD # 7) 11/20/08Stays in rehab for 3 days and is discharged homeSees his PCP twice, Neurologist once.Doesn’t see a Cardiologist after dischargeCase #1

3 months later…..EMS called for pt w severe abdominal pain that moved to chest and weakness. Pt found pale w thready pulse at home.Transported to ED PEA in ED. Coded, intubated – dies 90 mins laterAutopsy shows - severe CADWife files law suit against: DC Hospitalist, Cardiologist and NeurologistCase #1

SummaryIssues of Pt CareFinal Discharge Summary was not doneInitial DC Summary did not give Cardiologist Reccs Stress Test Initial DC Summary did not get to pts PCP

What is A Good Discharge Summary ? Presenting complaintPositive physical findingsPrincipal diagnosisMajor ancillary resultsOther important diagnosesPast history w allergiesProceduresConsultants by type and nameDischarge conditionDischarge medicationsDischarge instructionsFollow-up planPlace to which dischargedAmerican Journal of Medical Quality, November/ December 2005

Handoff RecommendationsA formally recognized handoff plan should be instituted at change of shift or change of service Time during shift dedicated to verbal exchange of informationTemplate OR Tech solution to used for accessing and recording patient informationTraining for new users on handoff expectationsTracking system to document the correct hospitalist caring for a specific pt after a service changeHospitalist Handoffs: A Systematic Review and task Force Recommendations. Journal of Hospital Medicine 2009;4:433-440

Handoff RecommendationsVerbal Exchange Interactive process is used during verbal exchangeIll patients are given priority during verbal exchangeInsight on what to anticipate or what to do is the focus of the verbal exchangeHospitalist Handoffs: A Systematic Review and task Force Recommendations. Journal of Hospital Medicine 2009;4:433-440

Handoff RecommendationsAll pts that are handed off are includedAvailable in a centralized location All data kept up-to-dateAnticipated events for incoming hospitalist are clearly labeledAction items for incoming hospitalist are highlighted “to do list”Hospitalist Handoffs: A Systematic Review and task Force Recommendations. Journal of Hospital Medicine 2009;4:433-440

Circulation : Cardiovascular Quality & Outcomes. 8(1):109-111, January 2015.Who gets readmitted?

A 65 y/o male comes to ED w c/o cough, chest pain, and fever. In the ED found to be febrile with CXR/Chest CT shows PNA. Admitted by the Hospitalist #1 (Admitter)PMHX-HTN, DM Meds-Tenormin, Metformin Allergies-none PE- VS – T-38.2 BP-100/70 P-110 R-20 Ox Sat-88%Exam- rales L chestCXR- L UL PNA CT Chest- PNA seen and o/w neg (Rad later calls ED doc w “nodules on liver” - WBC – 14,000 Glu-320 LFTs-sl incCase #2

A/PCommunity Acquired Pneumonia-continue IV antibiotics, contin supplemental oxygen Diabetes Mellitus II -diabetic diet and SSIHypertension-hold anti-hypertensive medsNext day (Hosp day # 1) seen by Hospitalist # 2Exam UnchangedContin PlanCase #2

Hospital day # 2 (Hospitalist # 2) Pt feels better and less hypoxic Exam-less rales…contin planHospital Day # 3 (Switch day…..Hospitalist # 3 …..20 pts) Pt feels better…exam unchanged less hypoxicHospital Day # 4 (Hospitalist # 3) Pt feels much better…..exam unchanged. Oxygen sats nl DC home with 1 more day of antibiotics.Discharge instructions-f/u w PCP in 2 Sees PCP in 2 weeks Seems back to baseline. DC summary received….no mention of abnormal CT scan or LFTsCase #2

Eight months later pt dx with HCC and dies 6 months later.Wife sues the Hospital/ED Doc, all the Hospitalist for failure to diagnose HCC earlier.Issues of Pt Care DC Summary did not mention abnormal CT scan or abnormal LFTsToo many patients“Too many cooks in the kitchen”Case #2

Miscommunication

CICLE ModelHospitalists reduced admitting rotations to 4 days (down from 7) Patients received improved continuity of care, i.e. saw fewer/same physicians during their stayPatients discharged faster, reduced length of stayChandra et al, Mayo Clinic Proc. April 2012;87 (4):364-371

CICLE Model Chandra et al, Mayo Clinic Proc. April 2012;87 (4):364-371

EUHM HMS New Schedule Format MonTueWedThuFriSatSunA1-1A1-2A1-3A1-4 A1-5A1-6 A1-7B1-1B1-2B1-3B1-4B1-5B1-6B1-7C1-1C1-2C1-3C1-4C1-5C1-6C1-7 D1-4D1-5D1-6D1-7D2-1D2-2 D2-3 E1-4 E1-5 E1-6 E1-7 E2-1 E2-2 E2-3 F1-4 F1-5 F1-6 F1-7 F2-1 F2-2 F2-3 G2-7 G1-1 G1-2 G1-3 G1-4 G1-5 G1-6

Rules/ Assumptions1. Teams in bold admit on days 1-4 until "capped" then ove1rflow pts go to the teams on their day #5 and t "overflow team" E.2. Current Admitter becomes a Swing shift3. New Team G 4. Rounding Teams admit the majority of their patients 5. Goal is average daily census of 15 with team caps of 18 pts6. Consult Team and Renal Team switch days unchanged7. Two Teaching Teams (Fischer and Davis) on 15 day rotationEUHM HMS New Schedule Format

Pt is 55 y/o male admitted for elective knee replacement. Surgery is uncomplicated. On post of day # 3 (Saturday) pt c/o SOB, CP and palpitations and has a cardiac arrest. Code Blue is called.Hospitalist responds and pt coded as PEA. Resuscitative attempts unsuccessful…pt diesLater rhythm analysis shows rhythm to have been V Tach. Case #3

Risk AnalysisIssues of Pt CareCode Rhythm misreadAre Hospitalist Qualified to run Codes?Family alleges not enough weekend staff and files suit.Case #3

Survival From In-Hospital Cardiac Arrest During Nights and Weekends Question:Do outcomes after in-hospital cardiac arrest differ during nights and weekends compared with days and weekdays?Methods:Analyzed consecutive in-hospital cardiac arrest events National registry of Cardiopulmonary Resuscitation 57 med/surg hospitals Jan 2000-Feb 2007Analyzed 58,593 casesPrimary outcome-survival to discharge JAMA.2008;299 (7):785-792

Survival From In-Hospital Cardiac Arrest During Nights and Weekends JAMA.2008;299 (7):785-792

Unadjusted Rates of Survival to Hospital Discharge by Calendar Year. Girotra S et al. N Engl J Med 2012;367:1912-1920.

SummaryA good discharge summary should contain certain basic elements There are Joint Commission mandated components of the discharge summaryHospitalist scheduling models can affect the number of different physician encounters during a pts hospitalizationWeekend staffing models appear to affect the outcomes of patients experiencing cardio-pulmonary arrest