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Hospital Medicine Process Improvement and Care Innovation Resident Noon Conference July 17, 2013

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Hospital Medicine Process Improvement and Care Innovation Resident Noon Conference July 17, 2013 Rajesh Chandra, M.D. Division Chief General Internal Medicine – PowerPoint PPT presentation

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Title: Hospital Medicine Process Improvement and Care Innovation Resident Noon Conference July 17, 2013


1
Hospital Medicine Process Improvement and Care
Innovation Resident Noon Conference July 17,
2013
  • Rajesh Chandra, M.D.
  • Division Chief
  • General Internal Medicine
  • University Hospitals Case Medical Center

2
Learning Objectives
  • Understand the basic principles practice of
  • General Internal Medicine in the inpatient
    setting
  • in todays healthcare environment
  • Process improvement
  • - Simplifying a complex task
  • - Making Patient Care and management
  • - safe
  • - comprehensive
  • - complete
  • - efficient
  • - high quality
  • - professional

3
Patient Management Process Improvement and Care
Innovation
  • Initial Assessment the H P
  • developing a PROBLEM LIST approach
  • Turning the Problem list into a to do list or a
    checklist
  • CASE STUDY
  • Compare a traditional approach to a
    problem-list approach
  • The d/c summary making it an effective high
    quality document

4
Patient Management Process Improvement and Care
Innovation
  • Case
  • 65 yo male with a h/o COPD presents with a 3 day
    h/o a productive cough, fever and SOB. 2 days
    prior he also noted some right sided CP with
    breathing or coughing. His cough is productive of
    thick tan colored sputum.

5
Case
  • PMHx
  • COPD
  • HTN
  • DM
  • No prior surgeries
  • FMhx nothing relevant
  • Meds Combivent, Lisinopril, HCTZ, Insulin
  • Allergies none

6
Case
  • Social history
  • Smokes 1 ppd and has been smoking since he was a
    teenager
  • Drinks alcohol 1- 2 beers 4 5 days every
    week started drinking in is mid-twenties
  • No h/o alcohol withdrawal symptoms when he hasnt
    drank for a few days.
  • Occupational hx
  • Works as a car salesman

7
Case
  • ROS
  • Decreased exercise capacity over the past 2
    months can walk only 2 blocks before he has to
    stop to catch his breath
  • Anorexia over the past month
  • Weight loss 15 lb over the past 4 - 5 weeks
  • Occasional BRBPR painless bleeding usually
    occurs with straining

8
Case
  • Physical Exam
  • Awake, alert and lucid in NAD but appears ill
  • T 38.3, P 109, R 24, BP 110/70, pox 88 on RA,
    95 on 2L
  • Oral dry, coated tongue
  • No raised JVP No neck lymphadenopathy
  • Lungs Right side basilar crackles and diffuse
    b/l expiratory wheezing
  • CVS S1, S2 nl no murmurs
  • Abd soft, NT, ND
  • Rt. groin non-tender irreducible 3cm x 3cm lump
  • Liver edge felt 2cm below RCM with liver span
    14cm
  • No ascites

9
Case
  • Significant Labs Radiology
  • Blood Glucose 353
  • Na 130 Cl 89 K 3.5 CO2 28 BUN 40 Cr 1.7
  • WBC 17000 Hgb 10.7 Hct 31 MCV 90
  • Platelets 105,000
  • LFTs AST 256 ALT 120 TBil 1.3
  • CXR Right LL infiltrate
  • LLL nodule

10
Case Summary (traditional)
  • 65 yo male with a h/o COPD, DM and HTN presenting
    with a 3 day h/o a productive cough, SOB, fever
    and right sided pleuritic CP.
  • PE remarkable for - looks dry and weak, Right
    basilar crackles and diffuse expiratory wheezes.
  • Has a leucocytosis, elevated BUN and Cr and CXR
    shows a RLL infiltrate.
  • Working diagnoses RLL Pneumonia
  • COPD Exacerbation
  • Dehydration
  • AKI secondary to dehydration

11
Problem list approach
  • The problem can be
  • a symptom
  • a sign
  • an abnormal lab or radiology finding either
    consistent with
  • the acute illness or an incidental finding
  • It can be a specific disease or diagnosis
  • Patients chronic illnesses need to be included
    especially
  • if active or needs regular monitoring or
    assessment or
  • medications
  • (DM, HTN, GERD, PUD, OA, RA, Cirrhosis etc.)

12
Problem list approach
  • Case
  • HPI
  • 65 yo male with a h/o COPD presents with a 3 day
    h/o a productive cough, fever and SOB. 2 days
    prior he also noted some right sided CP with
    breathing or coughing.
  • His cough is productive of thick tan colored
    sputum.
  • PROBLEM LIST
  • 3 day h/o a productive cough, fever, Rt.
    pleuritic CP and SOB

13
Case
  • PMHx
  • COPD
  • HTN
  • DM
  • No prior surgeries
  • FMhx nothing relevant
  • Meds Combivent, Lisinopril, HCTZ, Insulin
  • Allergies none
  • PROBLEM LIST
  • 3 day h/o a productive cough, fever, Rt.
    Pleuritic CP and SOB
  • COPD
  • HTN
  • DM

14
Case
  • Social history
  • Smokes 1 ppd and has been smoking since he was a
    teenager
  • Drinks alcohol 1-2 beers 3 4 days every
    week started drinking in is mid-twenties
  • No h/o alcohol withdrawal symptoms when he
    hasnt drank for a few days.
  • Occupational hx
  • Works as a an auto salesman
  • PROBLEM LIST
  • 3 day h/o a productive cough, fever, Rt.
    Pleuritic CP and SOB
  • COPD
  • HTN
  • DM
  • Chronic Alcoholism
  • Nicotine Addiction

15
Case
  • ROS
  • Decreased exercise capacity over the past 2
    months can walk only 2 blocks before he has to
    stop to catch his breath
  • Anorexia over the past month
  • Weight loss 15 lb over the past 4-5 weeks
  • Occasional BRBPR painless bleeding usually
    occurs with straining
  • PROBLEM LIST
  • 3 day h/o a productive cough, fever, Rt.
    Pleuritic CP and SOB
  • COPD
  • Anorexia, Weight loss
  • Decreased exercise capacity
  • HTN
  • DM
  • Occasional hematochezia
  • Chronic Alcoholism
  • Nicotine Addiction

16
Case
  • Physical Exam
  • Awake, alert and lucid in NAD but appears ill
  • T 38.3, P 109, R 24, BP 110/70,
  • pox 88 on RA, 95 on 2L
  • Oral dry, coated tongue
  • No raised JVP No neck LAN
  • Lungs Right side basilar
  • crackles and diffuse expiratory
  • wheezing
  • CVS S1, S2 nl no murmurs
  • Abd soft, NT, ND
  • Rt. Groin non-tender irreducible
  • 3cm x 3cm lump
  • Liver edge felt 2cm below RCM
  • liver span 14cm no ascites
  • Ext no edema
  • Neuro no focal motor deficit
  • PROBLEM LIST
  • 3 day h/o a productive cough, fever, CP, SOB
    Lung crackles and hypoxia
  • COPD active wheezing
  • Oral dry, coated tongue
  • Anorexia, Weight loss
  • Decreased exercise capacity
  • HTN - controlled
  • DM
  • Occasional hematochezia
  • Chronic Alcoholism hepatomegaly
  • Rt. groin lump Inguinal hernia
  • Nicotine Addiction

17
Case
  • Labs
  • Blood Glucose 353
  • Na 130 Cl 89 K 3.5 CO2 28
  • BUN 40 Cr 1.7
  • WBC 17000
  • Hgb 10.7 Hct 31 MCV 90
  • Platelets 105,000
  • LFTs AST 256 ALT 120 TB 1.3
  • CXR Right LL infiltrate
  • LLL nodule
  • PROBLEM LIST
  • 3 day h/o a productive cough, fever, SOB Lung
    rales and hypoxia RLL Infiltrate ?WBC
  • COPD active wheezing
  • Oral dry, coated tongue mild hyponatremia
    ? BUN Cr
  • Anemia (normocytic)
  • Thrombocytopenia likely 2 ETOH
  • LLL Pulmonary Nodule
  • Anorexia, Weight loss
  • Decreased exercise capacity
  • HTN
  • DM - ? BG Uncontrolled without DKA
  • Occasional hematochezia
  • Chronic Alcoholism hepatomegaly ?LFTs
  • Rt. groin lump Inguinal hernia
  • Nicotine Addiction

18
Problem List
  • 3 day h/o a productive cough, fever, SOB Lung
    rales and hypoxia RLL Infiltrate ?WBC ? RLL
    PNEUMONIA
  • COPD active wheezing ? COPD Exacerbation
  • Oral dry, coated tongue mild hyponatremia ?
    BUN Cr ? Dehydration with AKI
  • Anemia (normocytic)
  • Thrombocytopenia hepatomegaly ? Transaminases
    likely 2 Chronic Alcoholism
  • LLL Pulmonary Nodule
  • Anorexia, Weight loss
  • Decreased exercise capacity
  • HTN - controlled
  • Uncontrolled DM without DKA
  • Occasional hematochezia
  • Rt. groin lump Inguinal hernia
  • Nicotine Addiction

19
Traditional Assessment Problem List Approach
  1. RLL Pneumonia
  2. COPD Exacerbation
  3. Dehydration
  4. AKI secondary to dehydration
  1. RLL Pneumonia
  2. COPD Exacerbation
  3. Dehydration AKI
  4. Uncontrolled DM
  5. Anemia h/o hematochezia
  6. LLL Nodule wt. loss DOE
  7. Hepatomegaly ?LFTs
  8. HTN controlled
  9. Thrombocytopenia
  10. Chronic alcoholism
  11. Nicotine Addiction
  12. Rt Inguinal Hernia - asymptomatic

20
Problem List ? To Do List
(Assessment) (Plan)
  • Pneumonia
  • COPD Exacerbation
  • Dehydration AKI
  • Uncontrolled DM
  • Anemia h/o hematochezia
  • LLL Nodule wt. loss DOE
  • Hepatomegaly ?LFTs
  • HTN controlled
  • Thrombocytopenia
  • Chronic alcoholism
  • Nicotine Addiction
  • Rt Inguinal Hernia - asymptomatic
  • ? Antibiotics Cultures Oxygen
  • ? Steroids Bronchodilators
  • ? IVFs Monitor UO lytes
  • ? Hydration Insulin Accu v
  • ? Monitor Fe studies /- GI w/u
  • ? Consider inpatient Chest CT
  • ? Liver U/S v Hepatitis serologies
  • ? Resume home BP meds
  • ? Review old labs Monitor
  • ? Chemical Dependency consult
  • ? Smoking cessation counseling
  • ? Outpatient Gen Surg referral

21
Problem List ? Discharge Summary
  • Pneumonia
  • COPD Exacerbation
  • Dehydration AKI
  • Uncontrolled DM
  • Anemia h/o hematochezia
  • LLL Nodule wt. loss DOE
  • Hepatomegaly ?LFTs
  • HTN controlled
  • Thrombocytopenia
  • Chronic alcoholism
  • Nicotine Addiction
  • Rt Inguinal Hernia - asymptomatic
  • Discharge Diagnosis
  • RLL CAP
  • COPD Exacerbation
  • Dehydration
  • AKI secondary to dehydration
  • Uncontrolled DM
  • Anemia of chronic disease
  • LLL Pulmonary nodule - benign
  • Alcoholic Liver disease
  • Thrombocytopenia (85K 105K) related to ETOH
  • HTN
  • Nicotine Addiction
  • Asymptomatic Right Inguinal hernia
  • Discharge Meds and F/U advice
  • Hospital course

22
Problem List Approach Benefits
  • Organized and professional
  • Its Comprehensive Care (VBP, ACO, HACs, EMR)
  • Provides a medicolegal safety net for physicians
  • A master document or clinical guide to work off
    from
  • Follow problems daily use as template for daily
    progress notes, modify as necessary add any new
    issues
  • Organizes daily rounds and makes them efficient
  • Can be incorporate into the discharge summary
  • Simplyits just good medicine!

23
Hospital Medicine Process Improvement and Care
Innovation
  • Future topics
  • The Discharge Process
  • Choosing wisely
  • Thank you!
  • Questions?
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