Transcript morbidity_mortality - Northeast Iowa Family Practice

Morbidity and Mortality
Conference
Anne Zbaracki, MD
Northeast Iowa Family Practice
Jan 20, 2016
Case:
HPI
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61 yr old male testicular pain from bilateral hydrocele,
right spermatocele continues to c/o pain due to testicular
swelling, drainage and open wound following right
hydrocelectomy , hx of CAD with occasional c/o CP
Case:
PMHCAD cath 6/2014 Dr.Dib, lmca 20% ostial stenosis, lad normal 1st, 2nd, and 3rd diagonal very small and
normal, Circ normal 1st marginal 70% stenosis, rca 40% diffuse disease, left main OM1 with promus stent, ef
65%, lexiscan stress test 10/1/15 no evidence for ischemia ef 71-77%, 11//3/15 saw Dr.Majood started
imdur 30mg daily and increase to 60mg if needed f/u 1 yr, echo 11/11/14 nml ef 56% no phtn, dchf I, tietze’s
HTN
borderline intellectual functioning
Mood disorder follows BHGMH
OSA with sleep titration done, noncompliant
hx of drug use, cocaine, meth, marijuana
Obese
hx rib fracture 7/3/14
hx hep c completed treatment, 2007 interferon
tobacco abuse
Depression with GAD, and insomnia
hyperlipidemia
Gerd
RBBB
Constipation
Cirrhosis- normal lft’s, stable weight
DJD
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PSH- 9/8/15 testicular surg Dr.richardson, cataract removal
Dr.Mauer, cervical spine fusion 2003, right olecranon bursitis
bursa removal 2000, Colonoscopy in 2009 (negative), Liver bx
(1990)
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FH- mother cad, father emphysema
SH- lives in apt, denies current etoh use, denies drug use, help thru cedar valley
community support services for transportation and medications,
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Marital Status: Single, divorced
Children: None
Occupation: SSI since Dec 2014, stopped working may 2014 was a Janitor, part
time.
Education: High school
Alcohol: abstains to occasional, hx of etoh abuse, more than 20 dui in CA
Smoking: down to 8 cig day now, 40 pack years
Illicit drugs: hx of Cannibis, heroin, meth, LSD, over 30 years ago, hx of prison for
selling meth 2004- 2014
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Medications
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Rx: CLONAZEPAM 1MG Tablet - days, , Ref: 0
Rx: OLANZAPINE 15MG 2 Tablet - days, , Ref: 0
Rx: VENLAFAXINE HCL 75MG 2 Tablet at bedtime - days, 60, Ref: 11
Rx: VENLAFAXINE HCL 100MG 2 Tablet daily - days, 60, Ref: 2
Rx: MULTI VITAMIN/MINERALS 1 Tablet daily - days, 30, Ref: 2
Rx: ZOLPIDEM TARTRATE 10MG 1 Tablet - days, 30, Ref: 0
Rx: ASPIRIN 325MG 1 Tablet daily - days, 30, Ref: 11
Rx: NAPROXEN 500MG 1-2 Tablet twice daily PRN - days, 60, Ref: 1
Rx: PANTOPRAZOLE SODIUM 20MG 1 Tablet DR daily - days, 30, Ref: 1
Rx: NITROSTAT 0.4MG Tab Sublingual - days, 30, Ref: 2
Instructions: Place 1 tab under tongue for chest pain
every 5 minutes. Maximum of 3 doses. Call
911 after first dose.
Rx: PRAVASTATIN SODIUM 40MG 1 Tablet DAILY - days, 30, Ref: 2
Rx: FUROSEMIDE 20MG 1 Tablet daily - days, 30, Ref: 1
Rx: LISINOPRIL 40MG 1 Tablet daily - days, 30, Ref: 1
Rx: HYDROCODONE-ACETAMINOPHEN 5-325MG 1 Tablet every 6 hours PRN - days, 60, Ref:
Imdur 30mg daily
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No allergies
Last PE
Vital Signs:
Bp: 119/85, Left Arm, Pulse: 104
Temperature: 96.70 F, Height: 5'4", Weight: 199 lbs
BMI: 34.24 kg/m2
Respirations: 16
Physical Exam
Eyes: EOM intact Conjunctiva clear. Sclera clear.
Ears: bilateral TM(s) clear. Landmarks visualized. EAC's clear bil.
Nose: No lesions visible.
Mouth: Mucosal membranes are moist. Mucosa normal.
Pharynx: Mucosa normal.
Neck: Supple. No lymphadenopathy.
Heart: Regular rate and rhythm. Normal S1, S2. No murmur. No gallop. No rub. No thrills.
Lungs: Clear to auscultation bilaterally. Nonlabored respirations.
Abdomen: soft non-tender Nondistended.
Genitourinary: No lesions visible. No hernias. Penis w/o lesions. has open
wound to testicles for drainage of hydrocele
Extremities: No edema. Peripheral pulses intact.
Neurologic: Alert and oriented.
Musculoskeletal: Normal gait and station. No atrophy appreciated.
Skin: No rash. No lesions visible. Good turgor.
Hair: Normal texture. Normal distribution.
Nails: Normal color. no deformities
Lymphatics: No lymphadenopathy in cervical, axillary, or inguinal areas.
Psychiatric: Normal mood and affect. Intact recent and remote memory. Good
judgement. Insight appropriate. Denies suicidal ideations.
Appt timeline
2/7/14 neifp 1st appt establish care
2/26/14 neifp right leg radicular pain, PT start gaba
3/20/14 neifp f/u neuropathy, abi nml, refused PT, lumbar xray DJD
3/31/14 neifp f/u neuropathy, cont gaba
4/5/14 cmc ed cp r/o admit, neg lexiscan ef 73%, ddimer neg
4/15/14 neifp f/u CP ro at CMC, neg lexiscan
4/29/14 neifp c/o sob, ordered pft
5/7/14 cmc ed right calf pain, soft tissue injury
6/2/14 neifp f/u sob pft nml, referred to Dr.Kabel
6/11/14 Dr.Kabel, sent to Dr.Dib for cath
6/23/14 neifp f/u doe, sent to dr dib cath 1 stent 1st circ marginal, minimal disease
7/3/14 cmc ed rib fx, 6&7th no etoh or drug screen done, no rx for pain was given morphine at ed
7/7/14 neifp f/u rib fx, fell over railing, c/o pain, trouble sleeping
7/22/14 neifp f/u rib pain
7/29/14 Dr.Kabel no changes, plavix until june, f/u 6mo
8/3/14 cmc ed abd pain, ct fatty liver, healed fx’s , left ama
8/18/14 neifp f/u rib pain, f/u cmc ed abd pain, mention of scrotal swelling, us shows hydrocele, spermatocele, elevated
psa, referred to urology
9/24/14 cmc ed testi pain, given vicodin rx
10/7/14 neifp f/u rib pain, testicle swelling saw Dr. Mong not doing anything at this time, sleep study ordered
10/13/14 neifp h&p for cataract
10/23/14 cmc ed testi pain, given bactrim , us shows bilateral hydrocele
10/28/14 Dr.Kabel, c/o sob repeat echo nml, pending sleep study, determines non cardiac
11/6/14 cmc ed testi pain, rx vicodin
11/11/14 Dr.Kabel no changes questioned copd, f/u june
11/14/14 cmc ed testi pain Dr.Mong refer to uihc
Appts continued
11/17/14 neifp f/u sleep study, + needs titration, refer to UIHC from Dr. Richardson
12/17/14 neifp testi pain
1/5/15 neifp h&p for uihc
1/12/15 uihc urology, voiding done, nml
2/4/15 uihc, cyctoscopy set up, no chnages
2/9/15 uihc cyctoscopy nmp
2/28/15 cmc ed, fell on ice no fx , rx tramadol
3/11/15 neifp c/o cough, no tusing cpap. Smoking 8 cigs
3/28/15 cmc ed testi pain, us worsening hydrocele, sent home wth cephalexin
6/9/15 Dr.Kabel sob better, can walk 2mi w/o cp, stop plavix cont asa
6/26/15 neifp hip pain, sent to PT off plavix now
8/5/15 uihc us renal l7r cyst, cxr neg, scheduled hydrocelectomy 9/14/15 which he canceled
9/4/15 neifp h&p for hydroelectomy , Dr,Richardson, decided didn’t want to go to uihc
9/8/15 Dr.Richarson hydrocelectomy, left wound open to drain, cultures negative
9/16/15 cmc ed teste pain, epididymitis, given levaquin, percocet
9/19/15 cmc ed testi pain, Dr.richardson ok lortabs
9/22/14 neifp testi pain, started morphine
9/29/15 Dr.Richardson c/o cp go to fpc, given keflex rx #20 hydrocodone
9/29/15 neifp c/o cp, refused admit
9/30/15 neifp cp and teste pain, agreed lexiscan, 10/1/15 was negative
10/6/15 Dr.Sarsfield, testi pain, f/u 2 weeks
10/7/15 neifp testi pain, f/u cp
10/20/15 neifp f/u testi pain, c/o cp ekg no st, t wave changes
11/3/15 Dr.Majood started imdur 30mg daily may increase to 60mg , f/u 1 yr
11/23/15 neifp h&p for cataract, no c/o cp, tried fentanyl patch not covered, morphine makes tired and stomach upset,
started methadone 5mg daily, drug screen sent this day was pos bz and marijuana
Uptodate
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Conversion from oral opioids to oral methadone: Discontinue all other around-the-clock opioids when
methadone therapy is initiated; fatalities have occurred in opioid-tolerant patients during conversion to
methadone. Substantial interpatient variability exists in relative potency. Therefore, it is safer to
underestimate a patient’s daily oral methadone requirement and provide breakthrough pain relief with
rescue medication (eg, immediate release opioid) than to overestimate requirements. Patient
response to methadone needs to be monitored closely throughout the process of the conversion. Sum
the current total daily dose of oral opioid, convert it to a morphine equivalent dose according to
conversion factor for that specific opioid, then multiply the morphine equivalent dose by the
corresponding percentage in the table to calculate the approximate oral methadone daily dose. Divide
total daily methadone dose by intended dosing schedule (ie, divide by 3 for administration every 8
hours). Round down, if necessary, to the nearest strength available. For patients on a regimen of
more than one opioid, calculate the approximate oral methadone dose for each opioid and sum the
totals to obtain the approximate total methadone daily dose, and divide the total daily methadone dose
by the intended dosing schedule (ie, divide by 3 for administration every 8 hours). For patients on a
regimen of fixed-ratio opioid/nonopioid analgesic medications, only the opioid component of these
medications should be used in the conversion.
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Note: Conversion factors in table are only for the conversion from another oral opioid
analgesic to methadone. Table cannot be used to convert from methadone to another
opioid (doing so may lead to fatal overdose due to overestimation of the new opioid).
This is not a table of equianalgesic doses.
Daily oral morphine dose <100 mg: Estimated daily oral methadone dose: 20% to 30%
of total daily morphine dose
Daily oral morphine dose 100 to 300 mg: Estimated daily oral methadone dose: 10% to
20% of total daily morphine dose
Daily oral morphine dose 300 to 600 mg: Estimated daily oral methadone dose: 8% to
12% of total daily morphine dose
Daily oral morphine dose 600 to 1000 mg: Estimated daily oral methadone dose: 5% to
10% of total daily morphine dose.
Daily oral morphine dose >1000 mg: Estimated daily oral methadone dose: <5% of
total daily morphine dose.
Conversion from parenteral methadone to oral methadone: Initial dose: Parenteral:
Oral ratio: 1:2 (eg, 5 mg parenteral methadone equals 10 mg oral methadone)
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Alternative recommendations: Opioid-tolerant:
Conversion from oral morphine to oral methadone: 1) There is not a linear relationship when
converting to methadone from oral morphine. The higher the daily morphine equivalent dose the
more potent methadone is, and 2) conversion to methadone is more of a process than a calculation.
In general, the starting methadone dose should not exceed 30 to 40 mg/day, even in patients on
high doses of other opioids. Patient response to methadone needs to be monitored closely
throughout the process of the conversion. There are several proposed ratios for converting from oral
morphine to oral methadone (Ayonrinde, 2000; Mercadente, 2001; Ripamonti, 1998). The estimated
total daily methadone dose should then be divided to reflect the intended dosing schedule (eg,
divide by 3 and administer every 8 hours). Patients who have not taken an opioid for 1 to 2 weeks
should be considered opioid naïve (Chou, 2014).
Titration and maintenance: Manufacturer's labeling: May adjust dosage every 3 to 5 days to a
dose providing adequate analgesia and minimal adverse reactions. However, because of high
interpatient variability, substantially longer periods between dose adjustments may be necessary in
some patients (up to 12 days). Breakthrough pain may require a dose increase or rescue
medication with an immediate-release analgesic. Some guidelines note that dose increases should
not be more than 10 mg per day every 5 to 7 days (Chou, 2014).
Medicaid Prior auth
Prior authorization is required for all non-preferred long-acting narcotics. Payment will be considered
under the following
conditions: 1) There is documentation of previous trials and therapy failures with two (2) chemically
distinct preferred longacting
narcotics (such as extended-release morphine sulfate and methadone) at therapeutic doses, and 2) A
trial and therapy
failure with fentanyl patch at maximum tolerated dose, and 3) A signed chronic opioid therapy
management plan between the
prescriber and patient must be included with the prior authorization, and 4) The prescriber must
review the patient’s use of
controlled substances on the Iowa Prescription Monitoring Program (PMP) website at
https://pmp.iowa.gov/IAPMPWebCenter/ prior to requesting prior authorization. 5) Requests for longacting narcotics will only
be considered for FDA approved dosing. The required trials may be overridden when documented
evidence is provided that
use of these agents would be medically contraindicated.
Iowa medicaid prior auth
Drug Name:___________________________________________
Strength:______________________________________
Dosage Instructions:______________________________________
Quantity:__________ Days Supply: _____________
Diagnosis:
Document 2 chemically distinct preferred long-acting narcotic treatment
failure(s) including drug names, strength,
exact date ranges and failure reasons:
Preferred Long-Acting Narcotic Trial #1: Name/Dose:
_______________________________ Trial Dates: _______________
Failure reason:
_____________________________________________________________________
__________________
Preferred Long-Acting Narcotic Trial #2: Name/Dose:
________________________________Trial Dates: _______________
Failure reason:
_____________________________________________________________________
__________________
*Please refer to the methadone dosing guidelines located at www.iadur.org under the
Report Archive tab.
Trial of fentanyl patch: Dose: ____________ Trial Dates:__________________
Failure Reason: ____________________
Medical or contraindication reason to override trial requirements:
_______________________________________________
Prescriber review of patient’s controlled substances use on the Iowa PMP
website: No Yes Date Reviewed:___
Attach signed chronic opioid therapy management plan between the prescriber
and patient.
Prescriber signature (Must match prescriber listed above.) Date of submission
IMPORTANT NOTE: In evaluating requests for prior authorization the consultant will
consider the treatment from the standpoint of medical
necessity only. If approval of this request is granted, this does not indicate that the
member continues to be eligible for Medicaid. It is the
responsibility of the provider who initiates the request for prior authorization to
establish by inspection of the member’s Medicaid eligibility
card and, if necessary by contact with the county Department of Human Services, that
the member continues to be eligible for Medicaid.
Conversion from hydrocodone to morphine is 1:1
20mg hydrocodone = 20mg of morphine
20-30% of this is 4-6mg methadone
Started 5mg 11/30/15
Wanted refill 12/18/15 was taking 4 tabs daily, gave rx for 10 mg bid, ua drug screen done that day
came back neg for methadone, was positive for BZ and marijuana
12/21/15 was found dead at home, reported 24 of 60 tabs left, no autopsy done, no drug or etoh
levels, was reportedly drunk day before, died natural causes according to coroner at scene
differentials
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??? PE, MI, intentional od, respiratory arrest from etoh
and BZ, hepatic encephalopathy, liver failure
Adverse events/outcomes
triggering case presentation
Case
Unexpected death
Medical or surgical complication
Delay in care
Delay in Diagnosis
Prolonged medical care in setting of poor prognosis
Other
Yes
x
No
x
x
x
x
Review of Pertinent
Literature:
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Title: Oral methadone for chronic noncancer pain: a
systematic literature review of reasons for administration,
prescribing patterns, effectiveness, and side effects
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Level of Evidence: 2a
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Type of Study: 21 studies doses ranging 20-930mg daily
Factors contributing to adverse outcome
Factor
Y N
Communication: e.g., inadequate handoffs; incomplete clinical information
Coordination of care: e.g., involving multiple services and/or care sites
Volume of activity/workload: e.g., increased clinical volume and /or perception of
workload
Escalation of care: e.g., delay or failure to involve more senior physician or nurse
Recognition of change in clinical status: e.g., delay or failure to recognize
changing clinical signs +/or symptoms
Other factors:
x
Root Cause Analysis
Fishbone Diagram
People
Causes:
_______multiple
caregivers
______________
_______
______________
______________
Procedure
Causes:
_____medications
______________
_________
______________
______________
Equipment
Causes:
______________
______________
______________
______________
Causes:
Causes:
Causes:
Environment
Policy
Other
Adverse
Outcome
Root Cause Analysis
Fishbone Diagram
People
Solutions:
__better
communication
coordination of
care___________
______________
______________
_
Solutions:
Environment
Procedure
Solutions:
____slower
titration________
______________
__
______________
______________
Solutions:
Policy
Equipment
Solutions:
______________
______________
______________
______________
Solutions:
Other
Outcome
Comments &
Discussion