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CASE SUMMARIES For Better Handovers

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CASE SUMMARIES For Better Handovers & Consult Requests David Lee Gordon, M.D., FAAN, FAHA Professor & Chair OUHSC Department of Neurology CASE SUMMARY: EXAMPLE 3 (96 ... – PowerPoint PPT presentation

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Title: CASE SUMMARIES For Better Handovers


1
CASE SUMMARIESFor Better Handovers Consult
Requests
  • David Lee Gordon, M.D., FAAN, FAHA
  • Professor Chair
  • OUHSC Department of Neurology

2
THE 6 COMPONENTS OF DOCTORINGThe Best Physicians
Excel in All Six
  • OUCOM Educational Program Objectives
  • Medical knowledge
  • Patient care
  • Communication
  • Professionalism
  • Practice-based learning improvement
  • Systems-based practice
  • Based on the 6 competencies of ACGME Outcome
    Project
  • Comprise the categories (major outline headings)
    of learning objectives in medical education

While communication is a category unto itself, 5
of the 6 categories depend on effective
communication skills.
PBLI evidence-based medicine quality
improvement SBP cost-effectiveness, team
skills, patient safety, handovers
3
COMMUNICATION IN HEALTHCAREBACKGROUND
  • Patient compliance depends on patient or
    caregiver comprehension of disease management
    plan
  • Healthcare is a team-based activity thus
    heavily depends on effective intra-
    interdisciplinary communication
  • ? duty-hour restrictions of trainees ?
    handovers
  • Effective communication depends on
  • Content knowledge
  • Interpersonal communication skills
  • Time effort

4
COMMUNICATION IN HEALTHCARETHE PROBLEM
  • Poor written documentation increases the risk of
  • Poor outcome for the patient
  • Liability for the physician
  • Poor communication in general is
  • Common among even experienced practitioners
  • A leading cause of medical errors
  • Medical errors are 8th leading cause of death in
    the U.S.
  • Measures to prevent medical errors (patient
    safety initiatives) are currently a high
    priority in healthcare

5
COMMUNICATION IN HEALTHCARETIPS
  • Use a systematic approach
  • Keep your audience in mind
  • Physiciansin your specialty and not in your
    specialty
  • Medical students
  • Nurses
  • Other health professionals (therapists, social
    workers, dietitians, pharmacists, etc.)
  • Patients, caregivers
  • Insurance companies, lawyers
  • Yourself (now in the future)
  • Define medical terms avoid inappropriate
    abbreviations
  • Explain your reasoning for diagnosis, evaluation,
    treatment

6
COMMUNICATION IN HEALTHCAREDOCUMENT BOTH WHAT
WHY
Written record of patient encounter should
include history, exam, diagnostic testing and
  • WHAT
  • Youre thinking
  • You did
  • If it isnt written it didnt happen!
  • WHY
  • You think it
  • You did it
  • If you dont explain your decisions, you are at
    greater risk for liability!

Explain all your actions and impressions!
7
COMMUNICATION IN HEALTHCAREPRESENTATION VS.
CASE SUMMARY
  • PRESENTATION
  • CASE SUMMARY
  • Venue during training
  • Duration 3-7 min
  • Audience
  • Ward team
  • Trainees instructors
  • Purpose / Tone
  • Lets try to figure this out
  • Method
  • Story first
  • Impression last
  • Supporting data not linked
  • Venue throughout life
  • Duration 30 sec - 2 min
  • Audience
  • Partner (handover)
  • Consultant
  • Purpose / Tone
  • Heres what pt has why
  • Method
  • Impression first
  • Supporting data linked
  • No story

8
CASE SUMMARIESPURPOSE
  • Used throughout career (beyond training years)
    for
  • Handovers (at shift changes)
  • Consult requests (from physicians other health
    professionals)
  • Clearly summarize pertinent information about
    patients diagnosis, management, discharge plan
    in a concise effective manner
  • Provide listener with jumpstart based on the time
    you have already spent with patient

9
CASE SUMMARIESTHINK BEFORE YOU TALK
  • Realize you know patient better than listener
  • You have actually seen the patient
  • You know the results of diagnostic testing
  • You have spent time thinking about the patient
    interpreting the data
  • Provide interpreted data for the listener
  • Include important data, not unimportant data
  • Never make listener think during case summary

The present letter is a very long one, simply
because I had no time to make it shorter Blaise
Pascal 1657
10
CASE SUMMARIESSTYLE MATTERS
  • Miscommunication is usually the fault of the
    speaker, not the listener
  • Both what you say and where you say it during the
    communication are important
  • An effective communicator
  • Grabs the attention of the listener at the
    beginning
  • Never allows the listeners mind to wander
  • States conclusions first, followed by
    explanations

11
CASE SUMMARIESSTRATEGIES
  • Dont play guessing gamesstate impression in 1st
    line
  • Resist temptation to tell story in chronologic
    order
  • Give your interpretation with supporting data
  • Patients diagnosis
  • Cause of patients diagnosis
  • Data to support diagnosis cause
  • Lump history exam into a summarized clinical
    presentation
  • Lumped HP listener must solve 1 set of data,
    remains attentive
  • Separate HP listener must solve 2 sets of
    data, then correlate them, becomes distracted
  • Be succinct, yet comprehensiveinclude both
    current projected plan of care

12
CASE SUMMARIESSBAR APPROACH FROM U.S. NAVY
  • Situation identifying data / context
  • What kind of patient is this?
  • Background diagnosis / impression
  • What is the patients current illness?
  • Assessments data to support impression
  • Why does the patient have current illness?
  • Recommendations plan of care
  • What are we doing for the patient?

S ? B ? A ? R Some assessments may fit better
in either B or R Put assessment in B if
intimately linked to diagnosis Put assessment in
R if not yet performed
13
CASE SUMMARIESDETAILED SBAR OUTLINE
  • Situationpatient identification data / context
  • Demographics
  • Pertinent medical history risk factors
  • Location of patient, reason for visit consult
  • Backgrounddiagnosis with rationale clinical
    issues
  • Diagnosissyndrome, cause, rationale (with
    pertinent tests)
  • Clinical presentationcombined history exam
  • Other clinical issuespertinent or concerning
  • Assessmentstest results planned tests
  • Tests pertinent to the diagnosis
  • Other testscritical or concerning
  • Recommendationscurrent planned therapies
    follow-up
  • Medicationsdoses, therapeutic targets,
    explanations
  • Non-medical therapiestherapeutic procedures
    rehabilitation
  • Discharge planboth immediately post-discharge
    and long-term
  • Follow-up appointmentsspecific physicians,
    tests, dates

14
CASE SUMMARY SBARSITUATION
  • Demographic data (age, handedness, sex)
  • 54-year-old, right-handed woman
  • 75-year-old, left-handed man
  • 4-year-old, right-handed boy
  • 9-year-old left-handed girl

Only neurologists require handedness. Do NOT
include race usually misleading, never
helpful. Use man/woman, boy/girl male/female
too impersonal, gentleman/lady too judgmental.
15
CASE SUMMARY SBARSITUATION
  • Pertinent medical history risk factors
    (including pertinent family history or social
    history)
  • with hypertension, hyperlipidemia, cigarette
    smoking...
  • with known migraine and otherwise healthy...
  • ...previously healthy
  • with idiopathic generalized tonic-clonic
    seizures since age 28...
  • with atrial fibrillation, status-post pacemaker
    placement
  • with family history of epilepsy
  • with a mother who has factor V Leiden mutation
  • with hypertension, coronary artery disease,
    alcoholism

Use alcoholism recreational drug use
alcohol abuse drug abuse are pejorative
terms reflecting moral judgments bias
16
CASE SUMMARY SBARSITUATION
  • Location of patient reason for admission,
    visit, consult
  • ...admitted to Neurology for...
  • ...admitted to Medicine for acute-on-chronic
    renal failure. Neurology was consulted for...
  • ...admitted to Pediatrics for fever of unknown
    origin. Neurology was consulted for...
  • ...in Neurology clinic for follow-up visit...

17
CASE SUMMARY SBARBACKGROUND
  • Diagnosis, including syndrome, cause, rationale
    for diagnosis
  • ...acute left frontal ischemic stroke seen on
    diffusion-weighted MRI due to atrial
    fibrillation...
  • ...acute right internal capsule ischemic stroke
    seen on diffusion-weighted MRI of as-yet
    undetermined etiology due to incomplete
    evaluation...
  • ...subacute left perinsular infarction seen on
    diffusion-weighted MRI, last time known normal 3
    days prior to admission, due to 90 right
    internal carotid artery stenosis per catheter
    angiography...
  • ...status migrainosus due to medication overuse
    phenomenon admitted for intravenous therapy...
  • ...generalized tonic-clonic seizure of
    undetermined cause with prolonged postictal
    state...
  • ...transient ischemic attack lasting 45 minutes
    with normal diffusion-weighted MRI...
  • ...Guillain-Barre syndrome with cerebrospinal
    fluid protein 210 and cells 0...

18
CASE SUMMARY SBARBACKGROUND
  • Clinical presentation with combined history
    physical exam pertinent negatives
  • Broca aphasia, right homonymous hemianopsia,
    left gaze deviation, right hemiplegia, and right
    hemisensory deficit
  • severe left hemiparesis involving face, arm, and
    leg without neglect, visual field deficit, or
    sensory deficit
  • spastic paraparesis with hyperreflexia,
    bilateral Babinski signs, sensory level at T3,
    constipation, bladder incontinence, and sexual
    dysfunction
  • moderate quadriparesis, diffuse areflexia, and
    low-back pain with no sensory deficits on exam
  • migratory right hemibody tingling for 1 hour,
    now with normal examination
  • right hemibody shaking for 1 minute followed by
    baseline mild right hemiparesis

19
CASE SUMMARY SBARBACKGROUND
  • Other clinical issuespertinent or concerning
  • last time known normal 2 hours prior to
    emergency department presentation
  • presenting outside the acute-therapy time
    window
  • ...with marked lethargy consistent with
    subfalcine herniation...
  • ...with urinary tract infection on admission...
  • ...with forced vital capacity 1.2 liters and
    negative inspiratory force -25
  • with rapid ventricular response that responded
    to intravenous metoprolol

20
CASE SUMMARY SBARASSESSMENT
  • 7a. Test results (positive negative) necessary
    to support the diagnosis
  • ...with normal carotid duplex, intracranial
    magnetic resonance angiography, transthoracic
    echocardiography, and transesophageal
    echocardiography...
  • ...with spikes in the left temporal lobe on
    EEG...
  • ...dehydration with BUN 75 and creatinine
    2.2...
  • ...with left lower lobe pneumonia seen on chest X
    ray...

Toxic-metabolic derangements can cause
encephalopathy or bring out focal deficits in
patients with old brain lesions, so conditions
such as dehydration pneumonia may be directly
pertinent to the cause of a neurologic
presentation
21
CASE SUMMARY SBARASSESSMENT
  • 7b. Planned or scheduled tests necessary to
    support the diagnosis
  • ...to undergo transesophageal echocardiogram
    before discharge...
  • ...to obtain hypercoagulable profile with
    follow-up of results as an outpatient...
  • ...to receive follow-up CT brain in two days to
    evaluate for worsening hydrocephalus...
  • Other test resultscritical or concerning
  • ...hypokalemia with potassium 2.2...
  • ...serum white blood cell count 15.4...

22
CASE SUMMARY SBARRECOMMENDATIONS
  • Medications with doses, therapeutic targets, if
    pertinent, explanations of specific therapies
    when necessary
  • ...taking warfarin with target INR 2.0-3.0...
  • ...taking pravastatin 80 mg daily with target LDL
    cholesterol less than 70...
  • ...taking losartan 50 mg daily with target blood
    pressure less than 120/80...
  • ...taking aspirin 81 mg and Plavix 75 mg daily
    due to coronary stent placement 3 months ago...
  • taking levetiracetam 1000 mg twice daily
  • taking Copaxone 20 mg subcutaneously daily
  • taking topiramate 25 mg twice daily for migraine
    prevention

23
CASE SUMMARY SBARRECOMMENDATIONS
  • Non-medical therapiestherapeutic procedures
    rehabilitation
  • status-post aneurysmal coiling and angioplasty
    for vasospasm
  • ...receiving physical therapy, occupational
    therapy, and speech pathology...
  • ...receiving counseling regarding diabetic diet
    from the dietitian...
  • Discharge planBOTH immediately post-discharge
    and long-term also include BOTH where with
    whom
  • He was discharged to inpatient rehabilitation
    hospital before going home with his wife.
  • After completion of intravenous therapy, will
    discharge to home with her parents.

24
CASE SUMMARY SBARRECOMMENDATIONS
  • Follow-up appointmentsspecific physicians,
    tests, dates
  • Appointment with Dr. Gordon of OU Neurology in 3
    months and follow-up of hypercoagulable results
    at that time.
  • Appointment with Dr. Williams in OU Neurology
    Residents clinic in 3 months.
  • Appointment for INR value in one week with
    primary-care physician, Dr. Joe Smith, of Ada,
    OK. No neurology follow-up necessary.

25
COMMUNICATION IN HEALTHCAREABBREVIATIONS
  • Often vary among specialties institutions
  • Avoid them as much as possible
  • Hinder more often than help communication
  • Acceptable to use those understood by most
    laypersons, for example CT, MRI, EEG, EMG, ECG,
    mg, mm, cm
  • Always acceptable to use if you first define them
    in the document, for example emergency
    department (ED)

26
COMMUNICATION IN HEALTHCARECAPITALIZATION OF
DRUG NAMES
  • Brand names of medicationscapitalize
  • For example, these are correct
  • Depakote
  • Keppra
  • Coumadin
  • Generic names of medicationsdo NOT capitalize
  • For example, these are correct
  • divalproex
  • levetiracetam
  • warfarin

27
ENGLISH 101HYPHENS
  • Hyphenate compound adjectives when they precede
    the noun they modify, for example
  • 25-year-old, right-handed man
  • Diffusion-weighted MRI
  • High-grade stenosis
  • CT-scan findings
  • Do NOT connect an adjective to a noun with a
    hyphen, for example, it is incorrect to write
    CT-scan showed....
  • Hyphens are not dashesdashes are longer and are
    commas with emphasis

28
ENGLISH 101E.G. ? I.E.
  • Please note that e.g. and i.e. are NOT
    equivalent
  • e.g. for example
  • i.e. that is to say

29
ENGLISH 101LATIN GREEK PLURAL ENDINGS
Language Singular Plural Examples
Latin -us -i alumnus, colliculus, embolus, focus, fundus, fungus, nucleus, syllabus
Latin -a -ae alumna, cisterna, fistula, macula
Latin -um -a datum, curriculum, memorandum
Greek -oma -omata atheroma, scotoma
Greek -on -a criterion, ganglion, phenomenon
30
CASE SUMMARY EXAMPLES
31
CASE SUMMARY EXAMPLE SHOWING SBAR OUTLINE
  • S 55-year-old, right-handed man with
    hypertension, newly diagnosed hypercholesterolemia
    , cigarette smoking,
  • B with subacute left frontal cerebral infarction,
    seen on diffusion-weighted MRI, presenting
    outside acute-treatment window, manifested by
    expressive aphasia and severe right hemiparesis,
    face, arm greater than leg, due to 80
    extracranial left internal-carotid-artery
    stenosis by catheter angiography.
  • A Transthoracic echocardiography normal.
    Admission LDL 148, hemoglobin A1C 5.8.
  • R Underwent left carotid angioplasty and
    stenting. Discharge to inpatient rehabilitation,
    then home with wife, taking aspirin 325 mg,
    Plavix 75 mg, losartan 50 mg (target blood
    pressure 120/80), atorvastatin 40 mg daily
    (target LDL 70). Two-month follow-up with Dr.
    Gordon to discontinue Plavix.

This example is 99 words
32
CASE SUMMARYEXAMPLE 1 (100 WORDS)
  • 44-year-old left-handed man with uncontrolled
    hypertension transferred to VA rehabilitation
    service after repair of large spontaneous aortic
    dissection with resultant multiple embolic
    infarcts to brain manifested by quadriparesis,
    left worse than right, heart failure, and renal
    failure requiring dialysis. Currently ambulating
    without assistance. Plan to discharge to home
    when physical and occupational therapy objectives
    are met. Arrange move from second story to
    ground-level residence with social work. Continue
    Plavix 75 mg and aspirin 81 mg daily for six
    months per cardiothoracic surgery metoprolol and
    furosemide for heart failure hemodialysis.
    Follow-up with cardiothoracic surgery in one
    month. Neurology follow-up unnecessary.

33
CASE SUMMARYEXAMPLE 2 (100 WORDS)
  • 69-year-old right-handed man with hyperlipidemia,
    hypertension, diabetes mellitus, coronary artery
    disease, status-post coronary bypass, admitted to
    Neurology for two transient ischemic attacks in
    past two days manifested by left hemiparesis and
    dysarthria lasting less than one hour. Neurologic
    exam normal except findings of peripheral
    neuropathy. Carotid Doppler, transthoracic
    echocardiogram, brain MRI, and brain MR
    angiography pending. LDL 135. Diabetes education
    due to poor control (hemoglobin A1C 15.7).
    Continue rosuvastatin 20 mg (target LDL 70) and
    start Aggrenox twice daily (allergic to Plavix)
    for stroke prevention metoprolol and furosemide
    for heart failure. After stroke work-up,
    discharge to home with wife.

34
CASE SUMMARYEXAMPLE 3 (96 WORDS)
  • 5-year-old, right-handed girl with relapsing
    acute lymphoblastic leukemia status-post
    chemotherapy and bone marrow transplant May 2011
    admitted to Pediatrics after presenting with
    complex-partial seizures manifested by staring
    spells. MRI brain showed focal hyperintensities
    in frontal subcortex and periventricular areas
    bilaterally, most likely due to adverse reaction
    of leukemia treatment and possible etiology of
    seizures. We will make our recommendation for
    anticonvulsant medication when we receive pending
    EEG results. Will discharge to Bethany Childrens
    Center for inpatient rehabilitation when
    medically able before going home with parents.
    Follow-up with heme-onc in 1 month. No neurology
    follow-up necessary.

35
CASE SUMMARYEXAMPLE 4 (86 WORDS)
  • 6-year-old, right-handed boy with febrile seizure
    at age 2, generalized tonic-clonic seizure at age
    4, and a grandmother with juvenile myoclonic
    epilepsy, now admitted to Pediatrics with
    cryptogenic localization related epilepsy
    manifested by multiple complex-partial seizures
    for 36 hours prior to admission. Plan is brain
    MRI and EEG, then discharge home with parents
    taking Trileptal 15 mg/kg/day divided twice daily
    for one week then 30 mg/kg/day divided twice
    daily thereafter. Follow-up with Dr. Ng of Child
    Neurology in 4-6 weeks for MRI and EEG results.

36
CASE SUMMARYEXAMPLE 5 (98 WORDS)
  • 2-year-old, previously healthy boy admitted to
    Pediatrics April 13 for episodic left hemiparesis
    due to complex-partial seizures with postictal
    state due to small right traumatic subdural
    hematoma April 9. Episodes manifested by staring
    spells, behavioral arrest, preferential use of
    right extremities. MRI brain showed small
    subdural hematoma overlying right temporal
    convexity and diffuse right cerebral edema. EEG
    showed diffuse right hemispheric slowing with no
    spikes, consistent with cerebral edema, not
    inherent epilepsy. After Keppra loading dose,
    seizures resolved, hemiparesis significantly
    improved. Discharge with parents, obtain
    outpatient rehabilitation, follow-up with Dr. Ng
    of child neurology in 1 month.

37
THE END
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