1. 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

2. 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

3. 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

4. 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.

5. Case PMHx COPD HTN DM No prior surgeries FMhx – nothing relevant Meds – Combivent, Lisinopril, HCTZ, Insulin Allergies – none

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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.)

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Traditional AssessmentProblem 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

20. 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

21. 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 Diagnosis 1.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

22. 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!

23. Hospital Medicine Process Improvement and Care Innovation Future topics: The Discharge Process Choosing wisely Thank you! Questions?