Download Hospital Medicine

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
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
Overview of Hospital Medicine
History
Physical
Data
Problem List
Discharge!!
Treatment Plan
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
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.
Case
PMHx
COPD
HTN
DM
No prior surgeries
FMhx – nothing relevant
Meds – Combivent, Lisinopril, HCTZ, Insulin
Allergies – none
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
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
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
Case
Significant Labs & Radiology:
Blood Glucose – 353
Na 133 Cl 92 K 3.5 CO2 30 BUN 40 Cr 1.7
WBC 17000 Hgb 10.7 Hct 31 MCV 90
Platelets 105,000
LFTs – AST 256 ALT 120 TBili 1.3
CXR – Right LL infiltrate +
LLL nodule
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
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.)
Problem list approach
Case
PROBLEM LIST
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.
 3 day h/o a productive
cough, fever, Rt. pleuritic
CP and SOB
Problem list generation
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.






PROBLEM LIST
3 day h/o a productive
cough, fever, Rt. Pleuritic
CP and SOB
COPD
HTN
DM
Chronic Alcoholism
Nicotine Addiction
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
Problem list approach
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
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
Case
Labs:
Problem List

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 17000






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
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
Traditional Approach
Problem List
(a Hospitalist’s view)
1.
2.
3.
4.
RLL Pneumonia
COPD Exacerbation
Dehydration
AKI secondary to
dehydration
1.
2.
3.
4.
5.
RLL Pneumonia
COPD Exacerbation
Dehydration + AKI
Uncontrolled DM
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. Right Inguinal Hernia asymptomatic
Problem List
(Assessment)
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
→
→
To Do List
(Plan)
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
Problem List
→
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 Summary
•
Discharge Diagnosis
1.
2.
3.
4.
5.
6.
7.
8.
9.
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
10. HTN
11. Nicotine Addiction
12. Asymptomatic Right Inguinal hernia
•
•
Discharge Meds and F/U advice
Hospital course
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!
Hospital Medicine
Process Improvement and Care Innovation
Future topics:
• The Discharge Process
• Choosing wisely
Thank you!
Questions?