pgy-iii m&m responding to falls on the floors

PGY-III M&MResponding to Falls on the Floors

Noon Conference

Eric W. Leland, DO

November 6, 2019

This information is protected as peer review activities under Ohio Revised Code 2305.24, 2305.25, and 2305.251 to 2305.253.

1. Case Presentation

2. What Went Wrong

3. How Can We Fix This (with Audience Participation)

4. Next Steps Moving Forward

Outline


Case Presentation


History of Present Illness

• 68 yo M PMHx EtOH abuse, COPD, BPH, HTN presented on 10/11/19 for respiratory distress. Found to have HAGMA (gap of 38) in the ED and glucose in the 40’s. pH normalized to 7.324 after IVF and dextrose, patient denied ingestion of non-EtOH alcohols, volatile panel negative.

• Patient is baseline A/O x 2, so history was limited. Per family and patient, he had been vomiting for the previous 2 days (possible coffee grounds) and was only drinking wine without having any food or other beverages.

• Last drink was the day prior to presentation. Patient denies any history of withdrawal seizures or DTs.

• He was admitted to the ICU for sepsis workup, aggressive fluid resuscitation, 2 units pRBC, bicarb drip, and respiratory support.


Past Medical and Surgical History

• Medical history

o COPD

o EtOH abuse

o Peptic ulcer disease

o HTN

o BPH

• Surgical History

o Upper endoscopy and colonoscopy 5/2019

o Prostate surgery (unknown what specifically) 2007


Family and Social History

• Family history

o HTN in mother and father

o No family history of cancer

• Social history

o Current everyday drinker, family states about 1 bottle of wine per day

o Former smoker

o Smokes marijuana


Review of Systems

• Pertinent positives

o Fever

o SOB

o Nausea and vomiting

• Negatives

o No speech difficulty

o No memory changes

o No visual disturbances

o No focal neurological defects


Physical exam

• Vitals: Temp 97.2 F, HR 124, RR 28, SpO2 100% RA, BP 107/76

• HEENT: PERRLA, non-icteric, poor dentition

• Neck: no JVD, no thyromegaly

• CV: sinus tachycardia, no murmurs, rubs or gallops

• Thorax: expiratory wheeze noted, increased WOB

• Abdomen: soft, non-tender, non-distended, hepatomegaly noted

• Extremities: moves all extremities, no cyanosis

• Neuro: A/O x 2, anxious, no focal deficit

• Integument: no bruises or rash


Labs

144

3.4

98 5

1.21

AG 36

11311

10.8

33.7

15.7 81

MCV: 89.3RDW: 18.0ANC: 12.6

Troponin: < 0.015

hCG: negative

HIV: negative

S. Pneumo Ag: Positive

Legionella Ag: negative

Influenza: negative

Blood Cx: 1/2 GPC+, likely contaminant


Albumin: 2.6Tbili: 3.5Alk Phos: 65ALT: 23AST: 103

Lactate: 26.4INR: 1.5

Hospital Course

• Patient was stabilized in the ICU

o Gap closed

o Lactic acidosis resolved

o Had EGD 10/14 due to coffee ground emesis and anemiasevere erosive gastritis, no varices, + portal hypertensive gastropathy

o Blood cultures ended up growing CoNS (Staph Caprae), treated with vancomycin for 10 days scheduled to end 10/24/19

o EtOH withdrawal symptoms improved, did require precedex for agitation but was weaned by 10/15


Hospital Course

• Transferred out of ICU on 10/15

o Patient continued to improve, EtOH withdrawal almost completely resolved by 10/16

o His memory and cognition remained at his baseline A/Ox2 with some confusion

• On 10/19 at 0237, patient had a fall

o Per nursing note: “Called to see patient for fall. Staff heard patient fall into hallway. Upon arrival, patient is lying on the floor in the hallway outside his room, laying on his left side. Patient is awake and alert, cooperative and communicating appropriately. He states his legs gave out and he landed on the left side of his head. He denies any loss of consciousness or hitting any other part of his body.”

o AI 2 evaluated patient at 0245: “Patient evaluated at bedside…pt was seen laying on the floor on his left side. Pt was alert and oriented to person and place (usual baseline). Pt understood commands and was able to properly communicate what happened. Pt had C collar placed prior to being lifted back into bed. On exam, pt has some swelling to L side of face but no bleeding or erythema. Pt not currently on anticoagulation therapy. Given absence of symptoms, no acute intervention necessary at this time. Nursing instructed to notify floor intern if neuro changes/other symptoms manifest.”

11

Hospital Course

• 0530 on 10/19:

o Nursing found patient to have mental status change during neuro check. He was not able to answer questions and had weak grasps. He also had a L gaze preference.

o CT head ordered:

• SDH with 1 cm L to R shift

12

Hospital Course

• Patient transferred to surgical ICU

o Trauma consulted, GCS 13 upon their evaluation

o Neurosurgery took patient to the OR emergently at approximately 0600 on 10/19

o Had L craniotomy for evacuation of SDH

o Platelets and pRBC transfused intraoperatively due to preop thrombocytopenia and anemia

o Patient tolerated the procedure well and was transferred out of the SICU on 10/21

o Patient returned to baseline mental status prior to transfer to the floor, but was started on seroquel at night due to ICU delirium

o He was medically and surgically stable and transferred to SNF on 10/25/19

13

Systems Issue


Gap in Quality

• This case is a good example of previous knowledge of a patient’s condition affecting our care of that patient

o With a standardized treatment approach, this type of miss would not occur again

• Why is there a gap in quality?

o Patient was known to be baseline A/Ox2 with some confusion, so an appropriate neurological assessment was challenging to obtain

o He was not on a neuro floor, and nurses may have not noticed early signs of cerebral hemorrhage

o Because there is not a standardized method for dealing with falls on the floor, the decision making was left to the discretion of the residents, and I believe any one of us could have (and maybe even has) made this mistake


Potential Solutions

• Make a dot phrase to standardize the treatment or response to a fall on the floor

• Unless the fall was witnessed by a nurse or other healthcare provider, assume that the patient hit their head and pursue further imaging

• If possible, there could be an order set to expedite the response to these potentially catastrophic events

• For example:

o Stat non-contrast CT head, CT c-spine

o Repeat non-contrast CT head in 4 hours

o q15 minute neuro checks for 1 hour followed by q1 hour neuro checks for 3 hours

o Consider transfer to neuro floor, however this may be cumbersome and challenging to deal with

o Follow ICH order set and note template if a bleed is found

• Follow-up: perform retrospective chart review for falls in the hospital and determine the percent with any type of complication and compare that to a sample after intervention

• What does the audience think?


References

• Uptodate.com: “Subdural Hematoma in Adults: Etiology, clinical features, and diagnosis”

• EPIC medical charts, Summa Health Akron City Hospital.


Acknowledgements

• Dr. Mike Simonson, Dr. Abhay Patel, Dr. Nathan Yu, Dr. David Szilagy


Questions?


Thank you


Why Can’t We Be Friends?

M+M/Quality Improvement

Rahul Dasgupta, MD

11//2019


1. Discuss Case

2. Discuss Systems Issue

3. Potential Solutions

• With audience participation

Outline


Case Presentation



• 91 year old gentleman with PMH inclusive of HTN, HPL, AF (CHADS2VASC of 3, no OAC), aortic stenosis s/p AVR, and renal insufficiency

• FMH: Stroke in Mother, Heart Disease and Cancer in Father

• Social: Former Tobacco Abuse

• Presented to OSH on 12/16/2018 with chief complaint of a one day history of epigastric pain

• Pain was associated with nausea, but not alleviated or worsened by any factors

• OSH ED documentation stated that the patient had noted decreased PO intake, and intermittent abdominal pain for one week in duration

• Diagnostics obtained at outside hospital included CMP, CBC, Lipase, and CT Scan of the Abdomen W Contrast



• CMP: Direct Hyperbilirubinemia of 3.8 (direct bilirubin of 1.84), AST of 58

• CBC: WBC of 1.1, Hb of 16.6, Plt of 81

• Lipase: 243

• CT Abdomen Pelvis: Interval abdominal and pelvic ascites, pneumatosis intestinalis, bilateral pleural effusions, pancreatic cysts, anasarca, cirrhotic liver, renal atrophy, sigmoid diverticulosis, and minimal cholelithiasis.


Review of Systems

• 10 point review of systems negative


Physical exam

• Vitals: Temp 98.2 F, HR 97, RR 17, SpO2 96% RA, BP 109/73 (85)

• HEENT: PERRLA. Pink/moist mucosa. No ETT present.

• Neck: Trachea midline. No thyromegaly. No crepitus. No JVD.

• CV: Irregularly irregular rhythm. Non-tachycardic. Murmur auscultated.

• Thorax: Clear, non-labored respirations. Diminished left laterally, but with good aeration.

• Abdomen: Soft. Mild guarding without rebound tenderness. Bowel sounds present.

• Extremities: Cyanosis absent. Moves all extremities. Peripheral edema present.

• Neuro: AA0x3. Not Hard of Hearing. Follows Commands. Withdraws to Tactile

• Integument: Warm, no rashes, no tattoos.


Hospital course

• Admitted to T2 ICU, with subsequent initiation of broad spectrum antibiotics and General Surgery consultation

• Consult placed at 0600

• General Surgery notified of patient’s case at 0950

• Upon exam, patient was noted to have increased guarding, but blood pressure on objective measure remained stable

• Patient taken to the OR emergently for exploratory laparotomy

• Ex-lap significant for 8 mm ruptured duodenal ulcer (s/p repair), liver hemangioma, and 4.5 L of ascitic fluid

• Patient intubated, sedated, and on vasopressor support upon return to T2 ICU

• Patient was quickly weaned off of ETT and vasopressor support on 12/18/2018

• Body fluid culture obtained intraoperatively significant for Klebsiella Oxytoca and Escherichia Coli• ID consulted: Recommended continuation of Zosyn

• Patient developed thrombocytopenia of 30,000• Hematology consulted: Transfuse if platelets less than 30,000, like secondary to sepsis and cirrhosis


Hospital course

• JP drain noted to have increased serous output 12/21/2018• Bilirubin increased to 5.2

• Thought to be secondary to bile leak

• Determined to not be a surgical candidate

• Palliative Care consulted on 12/22/2019• Transferred to 3E

• Discharged to Wooster Acute Inpatient Hospice on 12/27/2019


Systems Issue


Gap in Quality

• The gap in quality in this case is the delay of life saving treatment!

• Why is there a gap in quality?• Lack of open looped communication between ICU and Surgery Teams

• What can we do about this?


Potential Solutions

• Placing consults that require urgent Surgery evaluation as STAT

• Calling the associated residents on said services to discuss cases

• Examples• Pneumatosis Intestinalis (regardless of stability of patient) • Acute Abdomen

• Ruptured Peptic Ulcer• Acute Mesenteric Ischemia • Incarcerated Hernias• Intestinal Obstruction secondary to adhesions, volvulus

• Ascending Aortic Dissection • Limb Ischemia • Pneumothoracies requiring chest tube placement


Potential Solutions

• There are 2 sides to every story! • Input of surgery residents

• “All consults should be called with the exception of simple I+D’s. Occasionally, the consult can be delayed for hours secondary to the consult being called out!”

• “We need to call all of our consults. I suppose that if I had to identify the most urgent issues, I would guess anything involving perforation or critical limb ischemia.”

• “If you expect the consult to be seen in less than 6 hours, calling is very appropriate.”


References

• McCord C, Ozgediz D, Beard JH, et al. General Surgical Emergencies. In: Debas HT, Donkor P, Gawande A, et al., editors. Essential Surgery: Disease Control Priorities, Third Edition (Volume 1). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2015 Apr 2. Chapter 4. Available from: https://www.ncbi.nlm.nih.gov/books/NBK333506/doi: 10.1596/978-1-4648-0346-8_ch4

• Perneger, Thomas V. “The Swiss Cheese Model of Safety Incidents: Are There Holes in the Metaphor?” BMC Health Services Research, vol. 5, no. 1, Sept. 2005, doi:10.1186/1472-6963-5-71.

• Reitman, Ivan, director. Ghostbusters. Columbia Pictures, 1984.


Acknowledgements

• Dr. Emily George, MD

• Dr. Michael Nguyen, MD

• Dr. Julia Lantry, MD


Questions?


Thank you


pgy-iii m&m responding to falls on the floors

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