RISKY BUSINESSMurky 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 Medicine

Emory University Hospital Midtown

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”.

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 weakness

Impression 1. R Hemiparesis likely 2/2 L MCA ischemic infarct2. Hypertension3. Diabetes Mellitus

MRI-confirms stroke L Basal ganglia and R frontal

MRA, Carotid Studies, TT Echo- NL

Case #1

Neuro 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, 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

Cardiology Consult-Dr G.

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

Case #1

SummaryIssues 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 complaintPositive physical findingsPrincipal diagnosisMajor ancillary resultsOther important diagnosesPast history w allergiesProcedures

Consultants by type and nameDischarge conditionDischarge medicationsDischarge instructionsFollow-up planPlace 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

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 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”

Case #2

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 A1-2 A1-3 A1-4 A1-5 A1-6 A1-7B1-1 B1-2 B1-3 B1-4 B1-5 B1-6 B1-7C1-1 C1-2 C1-3 C1-4 C1-5 C1-6 C1-7D1-4 D1-5 D1-6 D1-7 D2-1 D2-2 D2-3E1-4 E1-5 E1-6 E1-7 E2-1 E2-2 E2-3F1-4 F1-5 F1-6 F1-7 F2-1 F2-2 F2-3G2-7 G1-1 G1-2 G1-3 G1-4 G1-5 G1-6

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 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 rotation

EUHM 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 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.

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 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