1. Brought to you by: TRANSITION OF CARE SUMMIT JULY 10, 2014

2. -Admitted to a Senior Living Community January 3, 2014 -87 Years Old -Atrial Fibrillation, Hypertension, Congestive Heart Failure, Dementia Mr. Graham Jones Insert Picture Here

3. Holiday Time 2014  Mr. Jones is diagnosed with Lung Cancer  Mr. Jones designated his daughter as his MPOA  Mr. Jones discussed his desires at the end of life and completed a MOST form and OOH DNR  Mr. Jones decided it was time to stop living at home due to debilitation from chemotherapy.

4. Mr. Jones Favorite Activities  Enjoyed  Men’s Luncheon  Wii Golf  Visiting the community store  Waking up early to read the newspaper At HomeAt Community  Enjoyed:  Cooking & Grilling  Waking up early to read the newspaper  Golf  Spending time with his Granddaughter

5. At the Community  March 12-Mr. Jones had a ground level fall after breakfast  Assessment reveals Mr. Jones has a minor abrasion to scalp  Doctor orders transport to ED for CT scan

6. At the Community  MedStar Contacted  Staff Prepares MARS & Removes Last Given Doses Coumadin 2.5 mg once daily Digoxin 0.125 mg once daily Coreg 2.5 mg once daily Aricept 5 mg once daily  EMS arrives on Scene

7. MedStar Non-Emergent Transport Arrives  Report provided and appropriate transport paperwork including the most recent Medication Administration Record and History & Physical by Physician  Patient found sitting upright in bed without obvious sign of distress or discomfort

8.  Patient complains of only minor injury without tenderness to Cervical Spine or back. Patient placed on stretcher and transport completed without change in status or mentation  V/S: B/P:142/80 P: 70 RR:16nl SPO2:99ra MedStar Non-Emergent Transport Arrives

9. At Hospital  CT exams performed negative  INR results 3.5 with a desired INR of 2.0  Negative Exam  Discharge Order Written with Coumadin decrease to 2.0 with INR rechecks daily  Transport Called  Report is not called  ED Care Summary Sent to Community

10. Return to Community  Mr. Jones arrives via NETI later on March 12 at 8:00 pm  Community greets Mr. Jones and prepares him dinner, while planning to call hospital for missed report  At shift change, evening staff does not realize Mr. Jones went to hospital

11. Return to Community  March 13 th, the evening nurse brings him his daily newspaper and coffee at 5:00 am and Mr. Jones will not wake up  Nurse calls 911  Nurse prepares documents for transfer to hospital

12. MedStar Arrival  Patient found lying supine in bed  GCS: 4 B/P:250/140 P:40 RR:4 SPO2:50%ra  Paramedic determines need for rapid Advanced Life Support

13. MedStar Treatment  BLS Airway Placed and patient transferred to ambulance  ALS interventions in ambulance  Intubation  IV, EKG  Emergent Transport to Trauma center  Report Called to alert trauma staff

14. MedStar Arrival At Hospital  Patient moved to Trauma 1 and Stat Team given report  During transition it was noted that Paperwork was soaked in emesis due to complications during intubation  Paperwork destroyed

15. At Hospital  Mr. Jones has CT head reveals ICH with a midline shift  Neurosurgery is consulted in ED  Staff is unable to contact family  Neurosurgery takes patient to Operating Room for emergency surgery

16. OR to ICU  Mr. Jones arrives to ICU on ventilator support and with ventricular drain  Staff attempts to contact family with continued no response  ICU Staff realizes patient is from Community  ICU staff requests records from Community

17. ICU  Family returns call to ICU  ICU staff speaks with family via phone  ICU staff call Community again regarding paperwork

18. Family Arrives

19. ICU  Paper work received from Community  Out of Hospital DNR/Advance Directives received  Family agrees to withdraw care  Patient begins Palliative Treatment

20. Cost Analysis  ED Costs  $4000  Operating Room Costs  $15,000  ICU Room Costs  $3,500  Total Cost  $22,500

21. Improvements & Discussions