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Hospital Medicine Process Improvement and Care Innovation “The Problem List”
Resident Noon Conference July 15, 2015 Rajesh Chandra, M.D. Associate Professor of Medicine Division Chief General Internal Medicine University Hospitals Case Medical Center
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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 task - Making Inpatient Care and management - comprehensive & complete - competent & efficient - safe - high quality - professional
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Overview of Hospital Medicine
History Physical Data Discharge!! Problem List Treatment Plan
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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
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Patient Management Process 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.
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Case PMHx COPD HTN DM No prior surgeries FMhx – nothing relevant
Meds – Combivent, Lisinopril, HCTZ, Insulin Allergies – none
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Case Social history Occupational hx Works as a car salesman
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
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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
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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
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Case Significant Labs & Radiology: Blood Glucose – 353
Na 133 Cl 92 K 3.5 CO2 30 BUN 40 Cr 1.7 WBC Hgb 10.7 Hct 31 MCV 90 Platelets 105,000 LFTs – AST 256 ALT 120 TBili 1.3 CXR – Right LL infiltrate + LLL nodule
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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
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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.)
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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
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Problem list generation
3 day h/o a productive cough, fever, Rt. Pleuritic CP and SOB COPD HTN DM Chronic Alcoholism Nicotine Addiction PMHx COPD HTN DM No prior surgeries FMhx – nothing relevant Meds – Combivent, Lisinopril, HCTZ, Insulin Allergies – none Social history Smokes 1 ppd since age of 16 Drinks alcohol – 1-2 beers 3 to 4 times a week. Started in his mid twenties. No h/o alcohol withdrawal.
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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
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Problem list approach PHYSICAL EXAM PROBLEM LIST
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 Liver edge felt 2cm below RCM liver span ~ 14cm; no ascites Rt. Groin non-tender irreducible 3cm 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 hypoxia COPD + active wheezing Oral – dry, coated tongue Anorexia, Weight loss Decreased exercise capacity HTN - controlled DM Chronic Alcoholism + hepatomegaly Rt. groin lump – Inguinal hernia Nicotine Addiction
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Case Problem List Labs: Blood Glucose – 353 Na 133 Cl 92 K 3.5 CO2 30 BUN 40 Cr 1.7 Hgb 10.7 Hct 31 MCV 90 Platelets 105,000 WBC 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
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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 PNEUMONIA COPD Exacerbation Dehydration with AKI Likely 2° Chronic Alcoholism and Alcoholic Liver disease Uncontrolled DM without DKA HTN Anemia (normocytic) LLL Pulmonary Nodule + Wt Loss Inguinal hernia (asymptomatic) Nicotine Addiction
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Traditional Approach Problem List (a Hospitalist’s view)
RLL Pneumonia COPD Exacerbation Dehydration AKI secondary to dehydration RLL Pneumonia COPD Exacerbation Dehydration + AKI Uncontrolled DM Anemia + h/o hematochezia LLL Nodule + wt. loss + DOE Hepatomegaly + ↑LFTs HTN – controlled Thrombocytopenia Chronic alcoholism Nicotine Addiction Right Inguinal Hernia - asymptomatic
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Problem List → To Do List (Assessment) (Plan)
Pneumonia COPD Exacerbation Dehydration + AKI Uncontrolled DM Anemia + h/o Hematochezia LLL Nodule + wt. loss + DOE Hepatomegaly + ↑LFTs HTN – controlled Thrombocytopenia Chronic alcoholism Nicotine Addiction 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
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Problem List → Discharge Summary
Pneumonia COPD Exacerbation Dehydration + AKI Uncontrolled DM Anemia + h/o hematochezia LLL Nodule + wt. loss + DOE Hepatomegaly + ↑LFTs HTN – controlled Thrombocytopenia Chronic alcoholism Nicotine Addiction Rt Inguinal Hernia - asymptomatic Discharge Diagnosis RLL Community Acquired Pneumonia COPD Exacerbation Dehydration AKI secondary to dehydration Uncontrolled DM Anemia (Normocytic – Hgb 10.7) LLL Pulmonary nodule - benign Alcoholic Liver disease Thrombocytopenia (85K – 105K) related to ETOH HTN Nicotine Addiction Asymptomatic Right Inguinal hernia Discharge Meds and F/U advice Hospital course
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Problem List Approach Benefits
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!
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Hospital Medicine Process Improvement and Care Innovation
Future topics: The Discharge Process Choosing wisely Thank you! Questions?
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