Use and Misuse of Clinical Data

Use and Misuse ofClinical Data Focus Conference May 15, 2014 David Chang Professor Cardiorespiratory Care University of South Alabama

Quiz #1 The normal cerebral perfusion pressure (CPP) is _______ . The mortality rate increases by _______ for each 10 mm Hg drop in CPP. A. 8 to 12 mm Hg; 10% B. 8 to 12 mm Hg; 20% C. 70 to 80 mm Hg; 10% D. 70 to 80 mm Hg; 20%

Quiz #2 An arterial blood gas sample was collected from a patient with COPD 10 minutes after initiation of mechanical ventilation. The results are: pH = 7.47, PaCO2 = 40 mm Hg, HCO3- = 28 mEq/L. This ABG most likely represents : A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis E. None of the above

Quiz #3 The results of an arterial blood gas sample drawn from a mechanically ventilated patient are: pH = 7.47, PaCO2 = 33 mm Hg, PaO2 = 68 mm Hg, FIO2 = 40%. No PEEP. The therapist should: A. decrease the frequency B. increase the FIO2 C. decrease the frequency and increase the FIO2 D. increase the frequency and increase the FIO2 E. increase the frequency or pressure support

Quiz #4 The pressure / volume loop is typically used to evaluate a patient’s _______ status. A. airflow resistance B. compliance C. oxygenation D. ventilatory

Outline 1. Clinical Data and Patient Care 2. Types of Clinical Data 3. Reasons for Using Clinical Data Correctly 4. Incorrect Use of Clinical Data 5. Causes of Invalid Clinical Data 6. Application of Clinical Data

Data Pleural of Latin datum Related to “give” “something given” Data represent information

Data Pleural of Latin datum Related to “give” “something given” Data represent information (more than numbers) Clinical errors are strongly related to (1) misuse of clinical information, or (2) use of incomplete or invalid clinical information

Data Everywhere Daily: Time, newspaper, place, people, email, TV Clinical: Breath sounds, vital signs, physical exam

Clinical Data and Patient Care 1. Decision making (initiate, change, discontinue) 2. Best patient care vs. defensive medicine 3. Errors in health care in the U.S. alone cause between 44,000 and 98,000 deaths every year (Ref: Mechanical Ventilation - H.M. 2011) 4. Non-use of patient clinical data presents a greater risk than misuse (Ref: St. Clair, 2008)

Clinical Data and Patient Care 1. Decision making (initiate, change, discontinue) 2. Best patient care vs. defensive medicine 3. Errors in health care in the U.S. alone cause between 44,000 and 98,000 deaths every year (Ref: Mechanical Ventilation - H.M. 2011)(+100,000s of unreported deaths and injuries) e.g., 3 fetal errors in incorrect breath sound assessment 4. Non-use of patient clinical data presents a greater risk than misuse (Ref: St. Clair, 2008)

Clinical Data and Patient Care 1. Decision making (initiate, change, discontinue) 2. Best patient care vs. defensive medicine 3.Errors in health care in the U.S. alone cause between 44,000 and 98,000 deaths every year (Ref: Mechanical Ventilation - H.M. 2011) (+100,000s of unreported deaths and injuries) 4. Non-use of patient clinical data presents a greater risk than misuse(Ref: St. Clair, 2008)

Types of Clinical Data 1. Data from history and admitting workup 2. Ongoing assessment and monitoring 3. Routine and special laboratory data (patient is passive) 4. Data from clinical procedures (patient is active)

Reasons for Using Clinical Data Correctly 1. Prevent harm (e.g., false-positive, false-negative) 2. Reduce malpractice 3. Reduce healthcare cost 4. Protect professional license 5. Improve professionalism

Incorrect Use of Clinical Data 1. Unfamiliar data or procedure 2. Carelessness 3. Incorrect interpretation 4. Incomplete information

Quiz #1 The normal cerebral perfusion pressure (CPP) is _______ . The mortality rate increases by _______ for each 10 mm Hg drop in CPP. A. 8 to 12 mm Hg; 10% B. 8 to 12 mm Hg; 20% C. 70 to 80 mm Hg; 10% D. 70 to 80 mm Hg; 20%

Quiz #1 The normal cerebral perfusion pressure (CPP) is _______ . The mortality rate increases by _______ for each 10 mm Hg drop in CPP. A. 8 to 12 mm Hg; 10% B. 8 to 12 mm Hg; 20% C. 70 to 80 mm Hg; 10% D. 70 to 80 mm Hg; 20% CPP = MAP - ICP

Incorrect Use of Clinical Data A 34-year-old woman was incorrectly diagnosed with a rare and aggressive form of neuroendocrine cancer. Her entire lower jaw and teeth were removed and her face was reconstructed with bones taken from lower legs, suffering permanent disfigurement. It turned out that her lab sample was contaminated with another patient’s sample.

Quiz #2 An arterial blood gas sample was collected from a patient with COPD 10 minutes after initiation of mechanical ventilation. The results are: pH = 7.47, PaCO2 = 40 mm Hg, HCO3- = 28 mEq/L. This ABG most likely represents : A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis E. None of the above

Incorrect Interpretation An arterial blood gas sample was collected from a patient with COPD 10 minutes after initiation of mechanical ventilation. The results are: pH = 7.47, PaCO2 = 40 mm Hg, HCO3- = 28 mEq/L. This ABG most likely represents : acute respiratory alkalosis superimposed on chronic respiratory acidosis. pH PaCO2 HCO3- Chronic respiratory acidosis ↓ NL ↑↑ ↑↑ Acute respiratory alkalosis ↑↑ ↓↓ ↓ NL Combined ↑ NL ↑

Incorrect Use of Clinical Data 1. Unfamiliar data 2. Carelessness 3. Incorrect interpretation 4. Incomplete information

Quiz #3 The results of an arterial blood gas sample drawn from a mechanically ventilated patient are: pH = 7.47, PaCO2 = 33 mm Hg, PaO2 = 68 mm Hg, FIO2 = 40%. No PEEP, SIMV f = 10/min, total f = 34/min, average spontaneous VT = 120 mL.The therapist should A. decrease the frequency B. increase the FIO2 C. decrease the frequency and increase the FIO2 D. increase the frequency and increase the FIO2 E. increase the frequency or initiate pressure support

Causes of Invalid Clinical Data 1. Human/machine errors 2. Data from incorrectly done procedures 3. Missing / incomplete information - Lab errors 1 to 3% in 1976 (Am J Med Tech, 1976) - Lab errors 3 to 5% in 2006 (Post Gazette, 2006)

Causes of Invalid Clinical Data 1. Human/machine errors 2. Data from incorrectly done procedures 3. Missing / incomplete information - Sample mixed up - Analytical/technical errors - Inaccurate calibration and poor quality control - Incorrect auto-interpretation

Causes of Invalid Clinical Data 1. Human/machine errors 2. Data from incorrectly done procedures 3. Missing / incomplete information • - Maximal Inspiratory Pressure (MIP) • - Rapid Shallow Breathing Index (RSBI) • Sputum Gram Stain or Culture

Causes of Invalid Clinical Data 1. Human/machine errors 2. Data from incorrectly done procedures 3. Missing / incomplete information pH = 7.47, PaCO2 = 40 mm Hg, HCO3- = 28 mEq/L Normal: Metabolic alkalosis COPD: Acute respiratory alkalosis superimposed on chronic respiratory acidosis. pH PaCO2 HCO3- Chronic respiratory acidosis ↓ NL ↑↑ ↑↑ Acute respiratory alkalosis ↑↑ ↓↓ ↓ NL Combined ↑ NL ↑

Application of Clinical Data Sample must be valid - repeat if necessary (change of FIO2 , air bubble, venous admixture, wrong settings) Results must be valid (calibration, QA) Reporting must be complete (FIO2, ventilator settings) Procedure must be consistent (MIP, RSBI, FVC) Clinical data should be applied (MAP and CPP)

Use and Misuse of Clinical Data