Transcript What you Need to Know Ahead of Time

RISKY BUSINESS
Murky Encounters
for the
Hospitalist and the Hospital
Bruce L. Mitchell, MD
Director of Hospital Medicine
Emory University Hospital Midtown
Georgia Society of Healthcare Risk Management
St Simons, Ga, May 14, 2015
Objectives
 Identify 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”.
Case #1
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 nl
Neuro-normal exam
Lab data-nl Head CT-nl
A/P 1. Admit
2. TIA-Stroke pathway, ASA, MRI
3. DM2-Diabetic diet, accu-checks
Case #1
Neuro Consult - Dr P.
Next Day (11/14)
R facial weakness w obliterated nasolabial fold. Slurred speech. R U
and LE weakness
Impression
1. R Hemiparesis likely 2/2 L MCA ischemic infarct
2. Hypertension
3. Diabetes Mellitus
MRI-confirms stroke L Basal ganglia and R frontal
MRA, Carotid Studies, TT Echo- NL
Case #1
Cardiology Consult-Dr G.
 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, Remeron, heparin
 PE- R sided weakness
 Impressions- Bilat CVA, HTN, DM2, HLD
 Recommendations-Agree w TEE. Because of mx risk factors
and recent chest discomfort-eventual thallium stress test will
be needed
Case #1
Hospital Course
 Trans 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) 11/20/08
 Stays in rehab for 3 days and is discharged home
 Sees his PCP twice, Neurologist once.
 Doesn’t see a Cardiologist after discharge
Case #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 later
 Autopsy shows - severe CAD
 Wife files law suit against: DC Hospitalist, Cardiologist
and Neurologist
Summary
Issues of Pt Care
 Final Discharge Summary was not done
 Initial 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 complaint
Positive physical findings
Principal diagnosis
Major ancillary results
Other important diagnoses
Past history w allergies
Procedures
Consultants by type and name
Discharge condition
Discharge medications
Discharge instructions
Follow-up plan
Place to which discharged
American Journal of Medical Quality, November/ December 2005
Handoff Recommendations
 A formally recognized handoff plan should be instituted
at change of shift or change of service
 Time during shift dedicated to verbal exchange of
information
 Template OR Tech solution to used for accessing and
recording patient information
 Training for new users on handoff expectations
 Tracking system to document the correct hospitalist
caring for a specific pt after a service change
Hospitalist Handoffs: A Systematic Review and task Force Recommendations. Journal of Hospital Medicine 2009;4:433-440
Handoff Recommendations
Verbal Exchange
 Interactive process is used during verbal exchange
 Ill patients are given priority during verbal exchange
 Insight on what to anticipate or what to do is the focus of
the verbal exchange
Hospitalist Handoffs: A Systematic Review and task Force Recommendations. Journal of Hospital Medicine 2009;4:433-440
Handoff Recommendations
 All pts that are handed off are included
 Available in a centralized location
 All data kept up-to-date
 Anticipated events for incoming hospitalist are clearly
labeled
 Action 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
Who gets readmitted?
Circulation: Cardiovascular Quality & Outcomes. 8(1):109-111, January 2015.
Case #2
 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
 PE-
Allergies-none
VS – T-38.2 BP-100/70 P-110 R-20 Ox Sat-88%
 Exam- rales L chest
 CXR- 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 inc
Case #2
A/P
1. Community Acquired Pneumonia-continue IV antibiotics, contin
supplemental oxygen
2. Diabetes Mellitus II -diabetic diet and SSI
3. Hypertension-hold anti-hypertensive meds
Next day (Hosp day # 1) seen by Hospitalist # 2
Exam Unchanged
Contin Plan
Case #2
Hospital day # 2 (Hospitalist # 2)
Pt feels better and less hypoxic Exam-less rales…contin plan
Hospital Day # 3 (Switch day…..Hospitalist # 3 …..20 pts)
Pt feels better…exam unchanged less hypoxic
Hospital 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 LFTs
Case #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 LFTs
 Too many patients
 “Too many cooks in the kitchen”
Miscommunication
CICLE Model
 Hospitalists reduced admitting rotations to 4
days (down from 7)
 Patients received improved continuity of care, i.e.
saw fewer/same physicians during their stay
 Patients discharged faster, reduced length of stay
Chandra 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
Mon
Tue
Wed
Thu
Fri
Sat
Sun
A1-1
B1-1
C1-1
D1-4
E1-4
F1-4
G2-7
A1-2
B1-2
C1-2
D1-5
E1-5
F1-5
G1-1
A1-3
B1-3
C1-3
D1-6
E1-6
F1-6
G1-2
A1-4
B1-4
C1-4
D1-7
E1-7
F1-7
G1-3
A1-5
B1-5
C1-5
D2-1
E2-1
F2-1
G1-4
A1-6
B1-6
C1-6
D2-2
E2-2
F2-2
G1-5
A1-7
B1-7
C1-7
D2-3
E2-3
F2-3
G1-6
EUHM HMS New
Schedule Format
Rules/Assumptions
1. 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 shift
3. 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 pts
6. Consult Team and Renal Team switch days unchanged
7. Two Teaching Teams (Fischer and Davis) on 15 day rotation
Case #3
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 dies
Later rhythm analysis shows rhythm to have been V Tach.
Case #3
Risk Analysis
Issues of Pt Care
 Code Rhythm misread
 Are Hospitalist Qualified to run Codes?
 Family alleges not enough weekend staff and files
suit.
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 2007
• Analyzed 58,593 cases
• Primary 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.
Summary
 A good discharge summary should contain certain basic
elements
 There are Joint Commission mandated components of
the discharge summary
 Hospitalist scheduling models can affect the number of
different physician encounters during a pts
hospitalization
 Weekend staffing models appear to affect the outcomes of
patients experiencing cardio-pulmonary arrest