Hospital Medicine Process Improvement and Care Innovation

Resident Noon ConferenceJuly 17, 2013

Rajesh Chandra, M.D.

Division ChiefGeneral Internal Medicine

University Hospitals Case Medical Center

Learning Objectives

• Understand the basic principles & practice of General Internal Medicine in the inpatient setting

in today’s healthcare environment

• Process improvement

- Simplifying a complex task

- Making Patient Care and management - safe- comprehensive

- complete- efficient - high quality - professional

Patient ManagementProcess 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

Patient ManagementProcess 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.

CasePMHxCOPDHTNDMNo prior surgeries

FMhx – nothing relevant

Meds – Combivent, Lisinopril, HCTZ, Insulin

Allergies – none

CaseSocial 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 hasn’t drank for a few days.

Occupational hx Works as a car salesman

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

CasePhysical 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, NDRt. groin non-tender irreducible 3cm x 3cm lumpLiver edge felt 2cm below RCM with liver span ~ 14cm No ascites

• Ext – no edema

• Neuro – no focal motor deficit

CaseSignificant 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

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

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

- Patient’s 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.)

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

1. 3 day h/o a productive cough, fever, Rt. pleuritic CP and SOB

CasePMHxCOPDHTNDMNo prior surgeries

FMhx – nothing relevant

Meds – Combivent, Lisinopril, HCTZ, Insulin

Allergies – none

PROBLEM LIST

1. 3 day h/o a productive cough, fever, Rt. Pleuritic CP and SOB

2. COPD

3. HTN

4. DM

Case

Social history

Smokes 1 ppd and has been smoking since he was a teenagerDrinks alcohol – 1-2 beers 3 – 4 days every week; started drinking in is mid-twenties; No h/o alcohol withdrawal symptoms when he hasn’t drank for a few days.

Occupational hx Works as a an auto salesman

PROBLEM LIST

1.3 day h/o a productive cough, fever, Rt. Pleuritic CP and SOB

2. COPD

3. HTN

4. DM

5. Chronic Alcoholism

6. Nicotine Addiction

CaseROS

• 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

1. 3 day h/o a productive cough, fever, Rt. Pleuritic CP and SOB

2. COPD

3. Anorexia, Weight loss

4. Decreased exercise capacity

5. HTN

6. DM

7. Occasional hematochezia

8. Chronic Alcoholism

9. Nicotine Addiction

CasePhysical 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 expiratorywheezing

• CVS – S1, S2 – nl; no murmurs• Abd – soft, NT, ND

Rt. Groin non-tender irreducible3cm x 3cm lumpLiver edge felt 2cm below RCMliver span ~ 14cm; no ascites

• Ext – no edema• Neuro – no focal motor deficit

PROBLEM LIST

1. 3 day h/o a productive cough, fever, CP, SOB + Lung crackles and hypoxia

2. COPD + active wheezing

3. Oral – dry, coated tongue

4. Anorexia, Weight loss

5. Decreased exercise capacity

6. HTN - controlled

7. DM

8. Occasional hematochezia

9. Chronic Alcoholism + hepatomegaly

10. Rt. groin lump – Inguinal hernia

11. Nicotine Addiction

CaseLabs:

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 90Platelets 105,000

LFTs – AST 256 ALT 120 TB 1.3

CXR – Right LL infiltrate + LLL nodule

PROBLEM LIST

1. 3 day h/o a productive cough, fever, SOB + Lung rales and hypoxia + RLL Infiltrate + ↑WBC

2. COPD + active wheezing

3. Oral – dry, coated tongue + mild hyponatremia + ↑ BUN & Cr

4. Anemia (normocytic)

5. Thrombocytopenia likely 2° ETOH

6. LLL Pulmonary Nodule

7. Anorexia, Weight loss

8. Decreased exercise capacity

9. HTN

10. DM - ↑ BG – Uncontrolled & without DKA

11. Occasional hematochezia

12. Chronic Alcoholism + hepatomegaly + ↑LFTs

13. Rt. groin lump – Inguinal hernia

14. Nicotine Addiction

Problem List

1. 3 day h/o a productive cough, fever, SOB + Lung rales and hypoxia + RLL Infiltrate + ↑WBC → RLL PNEUMONIA

2. COPD + active wheezing → COPD Exacerbation

3. Oral – dry, coated tongue + mild hyponatremia + ↑ BUN & Cr → Dehydration with AKI

4. Anemia (normocytic)

5. Thrombocytopenia + hepatomegaly + ↑ Transaminases likely 2° Chronic Alcoholism

6. LLL Pulmonary Nodule

7. Anorexia, Weight loss

8. Decreased exercise capacity

9. HTN - controlled

10. Uncontrolled DM without DKA

11. Occasional hematochezia

12. Rt. groin lump – Inguinal hernia

13. Nicotine Addiction

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

Problem List → To Do List (Assessment) (Plan)

1. 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

→ Antibiotics + Cultures + Oxygen

→ Steroids + Bronchodilators

→ IVFs + Monitor UO + lytes

→ Hydration + Insulin + Accu √

→ Monitor + Fe studies +/- GI w/u

→ Consider inpatient Chest CT

→ Liver U/S + √ Hepatitis serologies

→ Resume home BP meds

→ Review old labs + Monitor

→ Chemical Dependency consult

→ Smoking cessation counseling

→ Outpatient Gen Surg referral

Problem List → Discharge Summary

1. 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

• Discharge Diagnosis1. RLL CAP

2. COPD Exacerbation

3. Dehydration

4. AKI secondary to dehydration

5. Uncontrolled DM

6. Anemia of chronic disease

7. LLL Pulmonary nodule - benign

8. Alcoholic Liver disease

9. Thrombocytopenia (85K – 105K) related to ETOH

10. HTN

11. Nicotine Addiction

12. Asymptomatic Right Inguinal hernia

• Discharge Meds and F/U advice

• Hospital course

Problem List ApproachBenefits

• Organized and professional• It’s 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• Simply……it’s just good medicine!

Hospital MedicineProcess Improvement and Care Innovation

Future topics:

• The Discharge Process• Choosing wisely

Thank you!

Questions?