Transcript Case Review Lecture - from 6/07 Newsletter

Case Review
David John MD FACEP
The ED Quality Course
Spring Congress, San Diego April 25, 2007
Case Review
Objectives

To identify quality deviations and to review them
appropriately and in a non-punitive fashion.

To review and analyze your data from case reviews and
identify trends and focus areas.

To focus on systems not individual failures.

To foster an environment of quality reporting through
education and teamwork.

To educate your staff to be proactive rather than reactive
to possible quality events.
Case Review
The Truth

Medical errors happen every day

Systems, not individuals result in harm to our patients

We need to redesign these systems to minimize
harm to patients
Case Review
To Err is Human

IOM report 44,000 - 98,000 deaths per year from
medical errors

Handguns

One jumbo jet crash a day

Is 6-7 deaths per acute care facility excluding
ambulatory surgery, nursing homes, and doctor’s
offices

Believable?
Case Review
In a Perfect World

Patients get admitted

Consultants see and admit patients

The Hospitalist system is “open”

The ED and Hospital are fully staffed

All tests are available
All of the above lead to appropriate admissions.
Case Review
Does this ever happen?

Overcrowding leads to errors and patients are harmed

Off hours and inability to get the appropriate test or
consult leads to adverse events
When and if a patient is discharged from the ED,
appropriate and timely follow up must be available.
Case Review
Do you find the cases or do they find you?

Complaints/referrals

Unanticipated return visits

Deaths

Bad outcomes (missed diagnoses, etc.)
These cases find you even if you are not looking, but only 1
out of 5 quality deviations ever come to our attention.
Surveillance!
Case Review
Proactive vs. Reactive

Regular reviews and audits
– Core measures
– High risk
(intubations, “door to thrombolytics/cath lab times,” etc.)
– High volume: abdominal pain, headache
(use of CT or LP?)
– Focus areas or areas you have identified that your ED has
a problem with (elderly discharges, medical clearance,
undifferentiated abdominal pain, etc.)
Case Review
Case #1:
Communication and Swiss Cheese

A 90 year old male was sent to the ED because his
G-Tube had fallen out

He was mentally disabled and was non-verbal

He required feeding, fluids, and medications through
the G-tube and was sent in at 10pm
Case Review
Case #1:
Radiology has left the building

There was some blood at the gastrostomy site

The appropriate sized tube could not be replaced, so a
foley catheter was placed

A gastrograffin study was ordered and read by the ED
physician

The tube flushed well
Case Review
Case #1:
Early Identified Problems

There were no Operative Reports in the computer

No one at the nursing home knew when it was placed

The patient was mentally challenged and non-verbal

Radiology was not available

The tube was not easily replaced
Case Review
Case #1:
The next day…

Tube feeds had been resumed that night based on the
ED physicians interpretation of the study

The Radiologist did not think the tube was in the
stomach the next morning

The patient arrived unstable as the Radiologist was
calling the day doctor
Case Review
Case #1:
What went wrong?

The G-tube had been endoscopically placed
24 hours earlier

No Op Note was in the system, it was not done

There was no communication of this recent placement
by the nursing home staff to the ED staff

A new graduate or even an experienced physician
should not be reading gastrograffin studies

State Investigation
Case Review
Case #1:
A system fix

An “official read” should be available prior to initiating
tube feeds

If you do not read these studies… start an IV and
wait for the Radiologist to come in

Radiology off hours?

The tract for a gastrostomy tube is not mature for
6 weeks. If you do not know… do not replace it

Only a clearly documented mature tube with easy
replacement is low risk. If it does not go in easily… see
above
Case Review
Case #1:
Trial and Error

Good or bad

No longer an option

Inexperienced physicians need to be mentored.

Education and real-time case review need to be part of
the system.

Go over each case review with your inexperienced
physicians and point out future miss-steps.
Case Review
Case #1:
Breakdown

Inexperienced provider

Off hours

Test (Radiologist) not available

Communication issues

Elderly patient

Bad outcome
Case Review
Inexperienced Providers

80% of our quality reviews came from individuals in their
first three years out of training (MD, RN, MLPs)

Recent graduates only represent 25% of our work force

The rest of us have already made all of these same
quality deviations and survived

Is trial and error the best way to learn?
– Not if you are a patient.
Case Review
Where do they go wrong?

Reliance on tests and technology
– Positive tests only are helpful

Getting talked out of an admission

Overcrowding and deviation from basic treatment
patterns

Poor or difficult follow up

Training and experience
Case Review
No names

Don’t identify the providers at your meetings and don’t let
the providers identify this as “my case,”
-- this stifles any meaningful discussion

Education only occurs if systems are analyzed and
individuals are not blamed

Mary

Focus on real cases that could happened to any one
Case Review
Education First but…

Identify a problem and fix it

When your staff begins to come to you with cases, you
have succeeded

Create a culture of quality and patient safety

Encourage a Team Approach

When they come to you to fix problems, you walk on
water
Case Review
Don’t waste people’s time

Make these reviews the highlight of your meetings

Make them fun and interactive

Pick on people

Let others weigh in

Generate controversy and group discussion

Use humor
Case Review
Do your homework

Review the case carefully

Talk to the providers involved

Review the literature and provide up to date information

Provide the bare minimum in the review, make them ask
questions

Review a great save or diagnosis
Case Review
Case #2:
After the patient has left

A 40 year old male with a cat bite on his arm was
given PO Augmentin and sent home

He called back an hour later with itchy skin, tongue
and throat swelling

Policy on medical information over the phone

He was told to return by ambulance, but drove himself
back
Does this look like a quality case?
Case Review
Case #2:
Create your own scenario

He drove himself:
– MVA with multiple fatalities
– Airway compromise and arrest
– Emergent cricothyrotomy
Case Review
Case #2:
Why didn’t the doctor know I was
allergic to Penicillin?

He did fine

He arrived itchy and a little swollen

The nursing note clearly stated that the patient was
allergic to penicillin

One of the less than sympathetic nurses tried to blame
the victim

Augmentin does not sound like Penicillin
This was a good doctor. How did this happen?
Case Review
Case #2:
Change of shift

Triage nurse wrote down the allergy

Primary nurse signed out to a second nurse

The physician did not have the chart because the
nurse was signing out

The physician was going home and trying to tie up
loose ends
The ED was overcrowded.
Case Review
Case #2:
Breakdown

Change of shift

Communication issues

Availability of information

Medication error

Overcrowding
Case Review
Root-Cause Analysis of Medical Errors

Communication 65%
(sign-out, change of shift, follow up)

Orientation/Training 57%
(lack of experience)

Patient Assessment 35%
(interpretation of tests and availability of tests)

Availability of Information 20%
*There is some overlap because most errors that involve
harm have multiple factors (Swiss Cheese effect)
Case Review
Sign out / change of shift

This is a very high-risk area in Emergency Medicine

Formalized guidelines and systems should be developed
for these high-risk times (overcrowding, etc.)

Communication errors result in 65% of all quality cases

JCAHO will mandate formal transfer of care guidelines
throughout your hospital system in 2007 (now)
Case Review
High Risk for Medication Errors


Insulin, Heparin, Morphine, Coumadin, Dilantin, and
Epinephrine are in the top 6 – US Pharmacopeia
Why?

Poor handwriting (print)

Verbal orders

Communicate

Read back orders

Read nursing and EMS notes

Stop and look up medications you are not familiar with
Case Review
Have you ever: made a mistake?

Written on the wrong chart

Forgot to write a prescription

Forgot to write a work note

Forgot to put a patient in for
admission

Written for a medication that
the patient was allergic to


Written the wrong dose or
route of a medication

Forgot to sign out a patient

Forgot to call the patient’s
doctor when you said you
would

Missed an X Ray

Forgot to read an X Ray
Forgot to check a test prior to
discharge
Case Review
Entropy wins

We work in a chaotic environment handling numerous
sound bytes of information and distractions

With overcrowding, a new focus area in quality
includes the admitted patient held in the ED

Develop a clear set of guidelines for “boarders”
held in the ED

Transfer of Care will now involve shifts and other
departments

You need to create a seamless transfer of care or
patients will be harmed
Case Review
Case #3:
The Frail Elderly

An 80 year old male presented to the ED with a
complex laceration from a fall

He was sutured and discharged

He presented 8 days later with a facial contusion
from a fall the night before

He got a CAT scan of his head and a C-Spine X Ray
and was discharged to home
Does this look like a quality case?
Case Review
Case #3:
They don’t just suddenly deteriorate

He presented 2 days later with a fall and a hip fracture

He died in the hospital 3 weeks later from
complications of pneumonia

His BUN was 80, Creatinine was 3

This was referred from the in-patient service to the
ED for a quality review
Is this an ED quality issue?
Case Review
Case #3:
When the elderly arrive in the ED

Because of overcrowding and the sheer number of elderly
patients, we may look for reasons to discharge them

Often when they end up in the ED something is wrong


“She tripped over the rug”
They do not present typically and you really have to look
before you send them home or to a nursing home
“Don’t look, its not why he’s here.” - Dave John circa 1998
Case Review
Case #3:
Do you screen your elderly falls?

Nobody ever did gait testing

Nobody documented a social history, he lived alone

His previous stroke was never documented

He had been started on Furosemide 1 week prior to his
first visit for leg edema

No blood work was done

His pneumonia was present pre-op
Case Review
Case #3:
If he had only said he had
“general weakness”

At a minimum the frail elderly with co-morbid illnesses
and new falls should get:
– Routine blood work
– A chest X Ray
–
–
–
–

An EKG
A urinalysis
Gait testing
Documentation of their social history
You should also consider a call to their primary care
doctor, their family, VNA, etc.
Case Review
Case #3:
Breakdown

Elderly discharge

Communication with PMD

Discharge instructions for new falls in the elderly

The problem was treated, not the patient

No gait testing on either visit

Inadequate work up for repeated falls
Case Review
When reviewing cases

Look for clinical issues:
– Medical management
– Interpretation of tests
– Training
If there are provider issues, discuss them in private.
Case reviews are for the group’s benefit, not to embarrass individuals.
Do be on the look out for physician impairment.
You are the only one who knows just how many cases have been
missed by a provider. Watch out for outliers.
Case Review
Identify Systems Failures

As the Quality Person, part of your job is education

More importantly, you should identify weakness in your
system, correct them, and improve patient outcomes

Your department is only as good as the quality system
you have in place

Your surveillance for quality issues is only as good as
tour team ( A Rod )
Case Review
80 % of errors are
systems problems,
not individual problems.
Case #4:
Medical Clearance

A 41 year old female was brought to the ED by her
husband and two small children because she “wasn’t
acting right”

She was sleepy but arousable

Her answers to questions were a little inappropriate

She had a history of depression and alcohol abuse,
but had been sober for two years
Case Review
Case #4:
Transfer to Psychiatry

Her work-up including labs, tox screen, and
alcohol level were normal

She was given a diagnosis of depression

She was held overnight to see the Psychiatrist and
signed out to the night physician

The nurses could not wake her and the night physician
re-assessed her ordering a head CT and repeat labs
Case Review
Case #4:
She was Medically Cleared?

She was intubated and a foley catheter and IV’s were placed

Her initial bicarbonate was 10, the second was 8


Was she really clear?
Fluorescent urine
Case Review
Case #4:
In the middle of the night

They woke the husband and asked about antifreeze

He had a bottle that was half full in the garage

Poison control was contacted

Only one place in our state will run the test

An old fashioned alcohol IV drip was started,
the pharmacist did not know that they had 4-methylpyrazole in stock
Case Review
Case #4:
If the shoe does not fit

If the patient does not fit in the diagnostic box you have
put them in, take them out and start again

She had a positive screen for ethylene glycol

She got dialysis and had a full recovery of her renal
function which had been progressively deteriorating

Depression rarely presents with somnolence and
confused speech
Case Review
Case #4:
Breakdown

Communication- somnolent patient
(language barrier, dementia, comatose patient, etc.)

Interpretation of tests, a negative test
(medically cleared, but somnolent with Bicarb of 10)

Signed out as cleared
(imagine if it was busy and nobody noticed)

Nursing and the TEAM

Change of shift / Transfer of Care

Behavioral Health

Off hours and availability of tests
Behavioral Health Medical Clearance

First of all, none of us want to spend any more time
than we have to with them

They are often disruptive

They contribute to overcrowding

They can be dangerous

We all tend to blame the victim (alcohol, drug abuse)

They are aging, have co-morbid illnesses, dangerous
lifestyle issues, and are often poor historians

They all smoke
Case Review
Psychiatric facilities are not hospitals

Medical clearance means that their behavior or condition
can be explained by their illness or ingestion

Medical clearance further means that
– they are stable
– not a danger to staff or themselves and
– any co-morbid illnesses are under control
(diabetes, HTN, COPD, etc.)
Who writes for their medications?
Case Review
Case #5:
Transfer of care

A 12 year old female presented with severe
left lower quadrant pain at 11pm

Demographic

She had pain out of proportion to her labs and
physical findings

In spite of the risk of ionizing radiation in a young woman,
a CAT scan of the abdomen was ordered

No ultrasound was available after 11pm
Case Review
Case #5:
The patient left in the ED

The initial physician was leaving and “signing out”
to the night physician

CAT scan in young people without much body fat
will not show inflammatory changes until late

Ultrasound would have been a better test

The Ob-Gyn physician on Labor and Delivery was
informally consulted prior to the transfer of care
Case Review
Case #5:
A clear plan

The departing physician was concerned,
but knowing that the CT and teleradiology reading
would take several hours, chose to sign out

“If there are any findings (free fluid, mass, or anything)
call Ob-Gyn and she will admit the patient.
She has a lot of pain and no real findings,
I’m concerned about ovarian torsion.”
Case Review
Case #5:
X Ray Discrepancy

The next day, after the patient was discharged with a
negative CAT scan, the “official reading” was called to the
ED

Both of the original physicians were now gone and the
day shift doctor got the report

Radiology was concerned that there was fluid in the
cul de sac and a question of a mass in the adnexa
Case Review
Case #5:
Your worst nightmare

When the mother was called, she chose to go to another
hospital instead of the one that missed the diagnosis

At the time of discharge the mother kept repeating that
the first doctor was concerned about ovarian torsion

The child’s left ovary was removed later that day
Case Review
Case #5:
Breakdown

Ovarian torsion is difficult to diagnose

If it was considered, OB-Gyn should have been formally
consulted

The patient was discharged with pain requiring narcotic
medication

A negative test is just that, it does not exclude a
potentially dangerous diagnosis ( wrong test )

Radiology/Ultrasound, a test, was not available

The mother was concerned at discharge

Off hours and change of shift.
Abdominal Pain
Case Review
Discharge

If the family, patient, or anyone questions discharge,
rethink your decision

TEAM

Chances are very good that this patient will be back,
especially in the elderly, and in the event of a bad
outcome you have no friends

If you think the patient needs to be admitted, DO NOT
GET TALKED OUT OF WHAT IS RIGHT FOR THE
PATIENT
Case Review
Why we don’t get it right.

“The man in 3 is seizing.”

“Dr. X is on the line, he is sending in another patient.”

“The family in 10 would like to speak to you.”

“ Mr. Smith’s K is 8.”

“ The Hospitalist refuses to admit the lady in 2.”

“The computer just went down.”
Case Review
But there’s more…

“CT won’t be up for another 3 hours.”

“There are no beds.”

“I would like to present this case to you.”

“Was that the 5th ambulance in a row?”

“The lady with Fibromylgia refuses to leave without
Demerol.”

“A code is coming in.”

“Can we go on diversion?”
Case Review
We get it right most of the time

Systems account for 80% of all errors

Pareto’s principle:
If you fix the correct 20 percent of systems problems,
you will do away with 80 percent of your quality issues
Look at the last 2-3 years of quality reviews and
determine where you need to focus on systems
fixes, education, and closer surveillance.
Focus Areas
Case Review
Where I practice

Undifferentiated abdominal pain 40%

Elderly discharges 20%

Medical clearance 20%

Discharged patients > 80%

Inexperienced providers (first 3 years) 80%

Quality deviations are multifactorial (Swiss cheese)
We admit ~ 20% of ED visits
Case Review
Find your Achilles’ Heel
“Worry about the what is, not the what if.”
- Cartoon Channel
All ED’s are different.
Each one has it’s own quality concerns.
One size does not fit all ED’s.
Case Review
Become proactive and retrospective

Know what you review and where your weaknesses are

Put systems in place to attenuate harm

Increase your surveillance on these focus areas
Case Review
Our Quality Program

An event is identified

The case is referred to the chair and briefly reviewed

If it merits a quality review, it is referred to the director of
quality for a formal review

An email goes out to the providers involved for their input
Case Review
After the case has been reviewed

Copies go to the chair and providers and are filed.
Peer Review

If the case has educational value it is presented at the
monthly meeting

If a systems problem is identified, corrections are made

If a provider issue is identified, it is reviewed in private,
not at a meeting
Case Review
Case Review Template

Date of visit, Medical Record #, Provider

Source of review

Type of complaint

Extenuating circumstances

Brief description of case

Case Review

Conclusions

Actions taken

Remediation
Case Review
High Risk for a Quality Review

The extremes of age

Inexperienced provider

Discharges


Off hours
Appropriate tests not
available

Disagreement about
discharge

Overcrowded conditions

Sign out/change of shift

Negative tests

Unanticipated return visits
Case Review
Create a case

Age, demographic

Chief complaint

Extenuating circumstances (language barrier, etc.)

Time of day, time of shift

Disposition

Variables contributing to quality issues
Case Review
The Ten Commandments of Quality
1.
Do not force a diagnosis on a patient.
Tell them you don’t know and give them permission
to come back.
2.
Do the same thing when it is crowded as when it is not.
3.
If anybody disagrees with discharging the patient, rethink
your plan.
Case Review
The Ten Commandments of Quality
4.
Don’t rely on tests unless they are positive.
Trust your instincts.
5.
Sign out and change of shift need formal guidelines
and standards.
6.
Either look up or discuss with pharmacy any medications
with which you are unfamiliar.
7.
Make error reporting simple to complete and non-punitive.
These will identify your system failures and
create a culture of safety.
Case Review
The Ten Commandments of Quality
8.
Quality reviews should be educational and accurate.
Leave out the names and meet individually with
all new grads.
9. Beware of off hours.
10. It is all about the discharged patients.
Make sure the follow up plan makes sense and
that the patient/family can accomplish it.
Case Review
“You seldom improve quality
by cutting costs,
but you can often cut costs
by improving quality.”
- Karl Albrecht