Peer Review Problem Prone Scenarios

1. Peer Review Problem Prone Scenarios Laurie J Burton 8/15/07

2. Scope • 1200 cases screened/year • About 50% are ED/IC • 15-20 to monthly subcommittee • Complex • Often multiple visits to review • Purchasing a database that is much more sophisticated. Will provide more stats & feedback

3. Inspiration • ‘It’d be really good to get the word out on what goes on in those meetings to understand what kinds of things are being missed and what a consensus of our peers are expecting’

4. The process Confidentiality Consensus

6. Members • Co-chairs: • Charles Murphy & David Banks • Immediate care: • Krish Eechampati, Bisi Pearse • SR: • Jim Beiter, Paul Johnson, Mike Mallory, Mike Young • Eg/HSoC: • Laurie Burton, Dave Goo, Steve Lanski

7. System Peer Review • Chairs: • Naghma Khan & Bob Harrison • ED reps: • Alesia Fleming & Sujit Sharma • Other: • Medicine, Operative, Community Peds, HSoC, IC, Rads, Path, Presidents elect, Presidents Ex-Officio, “At Large”

8. Trauma subcommittee • ED rep: Wendy King • Other reps: Surgery, Neurosurg, Ortho, Rads, ICU, Anesthesia, “At large”

9. Classifications • Two general types: • Clinical • Behavioral

10. Classifications • Filter: • No issue (no record) • Collegial intervention (no record) • Forward for review

11. Classifications • Review: • Acceptable – most would have done similarly (no record, “SILENT”) • Collegial intervention (no record, you get feedback)

12. Classifications • “Two” (C2 or B2)- marginal deviation / minimal potential for serious morbidity or mortality (to credentialing profile- protected) • “Three” (C3 or B3) – significant deviation / substantial potential for serious morbidity or mortality • To Systems Peer Review • Two “3’s” in 2 years = • To MEC or • Focused review • “Four” (C4 or B4) – directly to MEC

13. You will ALWAYS ALWAYS ALWAYS get a chance to respond in writing before getting assigned anything that goes into your file

14. If you get a letter… • Think of it as a learning process, not a %$&*!!!! • Address each bullet completely • Use information written in the chart to back up your statements • Good attitude, defensiveness and bravado no thanks

15. Feedback • Post letter: • May take 1-2 months for response • Two possibilities: • Letter with a category assignment (eg Acceptable, C2 etc) • Collegial intervention (phone or in person) • No information that could violate confidentiality

16. Problem prone scenarios • Guess…

17. Problem prone scenarios • Every month: • Missed appendicitis • Medication that patient is allergic to

18. Specific scenarios…

20. Transfer for a specific evaluation • Suggestion: If a patient is being sent for a specificdiagnosis, your evaluation should be rigorous, ie • Low threshold to do further testing • Low threshold to involve consultant(s) • Examples: • Testicular swelling case • Intussusception case • Appendicitis case

21. Transfer of care • Notorious for suboptimal care • Borne out in our meetings • MD #2 is held to the standard of care, even if “babysitting” • Examples: • Asthmatic awaiting a bed (not an ED hold)

22. Transfer of care • Suggestions: • Write standing orders on your admissions, especially those that don’t have a bed eg nebs, analgesia Suggest management for likely complications eg seizure patient, what you’d do if has another seizure. complex respiratory patient, what you’d do if decompensates. Idiosyncratic patients eg child on a ketogenic diet, do not give dextrose.

23. Transfer of care • Strong sign-out • Receiving MD able to document, especially if checklist of items • Avoid addendums and “oh by the way on that patient.” Sign out ONCE if possible • Avoid the lengthy “medical student” sign out • With complex patients that you know well, consider leaving your cell phone

24. Drug allergies • Tell a patient every medication you are going to give or prescribe, followed by “Is your child allergic to …” • HSoC- 3 areas of the chart to document allergies • Med reconciliation • Triage • MD note

25. Missed shock • Systems “vulnerability” in area of recognizing shock /decompensation • Techs take vitals, supposed to communicate with patient’s RN, who is supposed to screen and make MD aware • Communication not consistent, especially in busy times

26. Missed shock • Check vitals when disposition a patient • Check vitals when you accept signout on a patient • Check nursing reassessment notes when you disposition a patient • Check nursing reassessment notes before you signout on a patient and when you accept a patient. And check the patient.

27. WATCH OUT FOR GREEN STAFF • Examples: • “lethargic” • “irritable” • “cap refill 3 seconds” • Suggestions: • Ask for charge RN reassessment

28. Learners • Higher risk of medical errors, higher risk of poorer documentation • Vitals not checked, don’t know normals • Parts of history/exam omitted • Triage notes/nursing notes not reviewed • Home care instructions not appropriate • Respiratory, abdominal, systemic complaints too long a period for followup • Good quality followup better than blanket “Call your doctor if not better in 2-3 days.”

29. Verbal orders • Notorious for errors • Borne out in peer review • Examples: • Hurlers child • RSI case

30. Verbal orders • Suggestions: • Do NOT call out doses / no math in your head • RNs to use doses on code sheets • Avoid verbal orders, convert to ibex orders as soon as able • Consider order sheet

31. Bounce backs • High risk population • Usually involve more evaluation than done prior • Often have missed diagnoses • BEWARE the bounce back • If tests were done prior eg XRs, cultures, check the results

32. Bounce backs • Call back system is NOT perfect, and you are responsible if you can get the results of prior visits • PLUG: scribe your prelim readings into PACS (demonstration)

33. “Baseline” or not? • Chronic children, breathing is at baseline or coolness of extremities at baseline • BEWARE • Example: • CP with cool extremities • Signs of shock => treat for shock • Signs of respiratory distress => treat

34. Trauma patients • Checklist of all orders • Labs, plain film readings, CT reads, consults, etc • Problem: getting UA sent off in first hour • Suggestions ??:

35. Retained foreign body • Notorious for medical legal pitfalls • If you cannot see to the depth of the wound, consider re-xraying • Good idea: Explicit discharge instructions regarding possibility of retained foreign body on any laceration

36. Child abuse • Think about it on every patient • Low threshold to consult social services • We are missing cases

37. Pregnancy • Think about it on every patient • Example:

38. PEARLS • Abdominal pain: • Fleets can be falsely reassuring • Transfers should get surgical consultation • “Abdominal pain” discharge instructions • Tight followup. If on weekend, consider scheduled followup in ED

39. PEARLS • High risk populations have risks of bad outcomes/ delay in diagnosis • Neonates/ immunocompromised • Sickle cell • “train wrecks”

40. PEARLS • Check your vitals • Check your nurses notes • Don’t assume you’ll be told of abnormalities

41. PEARLS • Repeat visits: • High risk • Check any test results from prior visit eg xrays, cultures

42. PEARLS • Check learners documentation carefully • Check their discharge prescriptions and instructions in real time

43. PEARLS • Problem prone: As a system we are missing: Shock Child abuse Goo’s Trauma Rounds – Fri 730a