hospital medicine process improvement and care innovation “the problem list” resident noon...
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Hospital Medicine Process Improvement and Care Innovation
“The Problem List”
Resident Noon ConferenceJuly 15, 2015
Rajesh Chandra, M.D.Associate Professor of Medicine
Division ChiefGeneral Internal Medicine
University Hospitals Case Medical Center
Learning Objectives
• Understand the basic principles & practice of General Internal Medicine in the acute care setting in today’s healthcare environment
• Process improvement
- Simplifying a complex taskSimplifying a complex task
- Making Inpatient Care and management - comprehensive & complete- competent & efficient- safe - high quality - professional
Overview of Hospital Medicine
Treatment Plan
Problem List
History Physical Data
Discharge!!
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
60 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 6 – 8 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 133 Cl 92 K 3.5 CO2 30 BUN 40 Cr 1.7
WBC 17000 Hgb 10.7 Hct 31 MCV 90
Platelets 105,000
LFTs – AST 256 ALT 120 TBili 1.3
CXR – Right LL infiltrate + LLL nodule
Case Summary (traditional)60 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
The “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, HF, GERD, PUD, OA, RA, Cirrhosis etc.)
Problem list approach
Case HPI
60 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
Problem list generationPMHxCOPDHTNDMNo prior surgeries
FMhx – nothing relevant
Meds – Combivent, Lisinopril, HCTZ, Insulin
Allergies – none
Social historySmokes 1 ppd since age of 16Drinks alcohol – 1-2 beers 3 to
4 times a week. Started in his mid twenties. No h/o alcohol withdrawal.
PROBLEM LIST 3 day h/o a productive cough, fever, Rt. Pleuritic CP and SOBCOPD HTN DM Chronic Alcoholism Nicotine Addiction
Problem list generation
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
PROBLEM LIST
3 day h/o a productive cough, fever, Rt. Pleuritic CP and SOB COPD Anorexia, Weight loss Decreased exercise capacity HTN DM Chronic Alcoholism Nicotine Addiction
Problem list approachPHYSICAL 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
Liver edge felt 2cm below RCMliver span ~ 14cm; no ascites
Rt. Groin non-tender irreducible3cm x 3cm lump
Ext – no edema Neuro – no focal motor deficit
PROBLEM LIST
3 day h/o a productive cough, fever, CP, SOB
+ Lung crackles and hypoxiaCOPD
+ active wheezingOral – dry, coated tongueAnorexia, Weight lossDecreased exercise capacityHTN - controlledDMChronic Alcoholism
+ hepatomegalyRt. groin lump – Inguinal herniaNicotine Addiction
Case Problem ListLabs:
Blood Glucose – 353
Na 133 Cl 92 K 3.5 CO2 30 BUN 40 Cr 1.7
Hgb 10.7 Hct 31 MCV 90Platelets 105,000WBC 17000
LFTs – AST 256 ALT 120 TB 1.3
CXR – Right LL infiltrate + LLL nodule
3 day h/o a productive cough, fever, SOB + Lung rales and hypoxia
↑WBC + RLL Infiltrate COPD + active wheezing Oral – dry, coated tongue + mild hyponatremia + ↑ BUN & Cr Anemia (normocytic) LLL Pulmonary Nodule Anorexia, Weight loss Decreased exercise capacity HTN DM ↑ BG – Uncontrolled & without DKA Chronic Alcoholism + hepatomegaly Thrombocytopenia likely 2° ETOH ↑LFTs Rt. groin lump – Inguinal hernia Nicotine Addiction
Problem list generation 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 Thrombocytopenia + hepatomegaly
+ ↑ Transaminases DM HTN – controlled Anemia + h/o hematochezia LLL Pulmonary Nodule Anorexia, Weight loss
Decreased exercise capacity Rt. groin lump Nicotine Addiction
RLL PNEUMONIACOPD Exacerbation
Dehydration with AKI Likely 2° Chronic Alcoholism and Alcoholic Liver diseaseUncontrolled DM without DKAHTNAnemia (normocytic)LLL Pulmonary Nodule + Wt Loss
Inguinal hernia (asymptomatic)Nicotine Addiction
Traditional Approach Problem List (a Hospitalist’s view)
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. Right 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 + Outpt 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 Community Acquired Pneumonia
2. COPD Exacerbation
3. Dehydration
4. AKI secondary to dehydration
5. Uncontrolled DM
6. Anemia (Normocytic – Hgb 10.7)
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 medico-legal 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 incorporated into the discharge summary• Simply……it’s just less chaotic and safe medicine!
Hospital MedicineProcess Improvement and Care Innovation
Future topics:
• The Discharge Process• Choosing wisely
Thank you!
Questions?