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
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 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
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.
Case
PMHx
COPD
HTN
DM
No prior surgeries
FMhx – nothing relevant
Meds – Combivent, Lisinopril, HCTZ, Insulin
Allergies – none
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 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
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
• Ext – no edema
• Neuro – no focal motor deficit
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
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
PROBLEM LIST
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.
1. 3 day h/o a productive cough,
fever, Rt. pleuritic CP and SOB
Case
PMHx
COPD
HTN
DM
No 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
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 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
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
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
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
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
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
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
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
Traditional Assessment
1.
2.
3.
4.
RLL Pneumonia
COPD Exacerbation
Dehydration
AKI secondary to dehydration
Problem List Approach
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
RLL 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
Problem List
→
(Assessment)
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
To Do List
(Plan)
→ 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
→
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 Summary
•
Discharge Diagnosis
1.
2.
3.
4.
5.
6.
7.
8.
9.
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
10. HTN
11. Nicotine Addiction
12. Asymptomatic Right Inguinal hernia
•
•
Discharge Meds and F/U advice
Hospital course
Problem List Approach
Benefits
•
•
•
•
•
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 Medicine
Process Improvement and Care Innovation
Future topics:
• The Discharge Process
• Choosing wisely
Thank you!
Questions?