PRMC Patient's Perspective on Life-Saving Care

PRMC CASE STUDY: “No distress noted”
One Patient’s Perspective on
Peterson Regional Medical Center
Catherine A. Learoyd
May, 2014
May, 2014
PRMC CASE STUDY: "No Distress Noted"
Catherine A. Learoyd 1

May, 2014
Why a Case Study?
Just over year ago I was a PRMC patient experiencing
a life-threatening medical crisis
having no pain
quite alert and observant
Combined with my background in
technology
corporate management
UNIQUE OPPORTUNITY!
Saw benefit to PRMC and Kerrville community in sharing
my observations and recommendations
… and contribute to PRMC becoming a
**Top-ranked Hospital**

May, 2014
Non-Goals for Case Study
Your fear is litigation
My fear is being ignored
Let’s face our fears and agree neither will happen!
PRMC staff saved my life; I am grateful!
•Focused on Excellence – making PRMC a top-
ranked hospital
Not interested in whether
“Standard of Care” minimum
was met
•Addressing PRMC leadership to improve policy,
technology, and communications as a whole
Not looking to criticize any
individual provider or staff
member
•Recommendations based on my personal sphere
of expertise and singular perspective
Not taking into account hospital
regulatory environment, litigation
protection, financial priorities nor
impact of Obamacare
•Interpretation of events are my own although
have been reviewed by medical experts
Not claiming medical expertise
•Friend of PRMC
Believe litigation generally
detrimental to a hospital’s
ability to provide excellent care.

May, 2014
The Journey to CUSP
Out of curiosity obtained my medical records
wanted to see CT Scan and report
wanted to understand the “seizure” I had
wanted to know logically all that had
happened
Case study presentation evolved
spent the last year studying and analyzing
the data
found opportunities for improvements in
Communications
Policies and procedures
Quality / Training
Technology
Wanted an answer to “What would I recommend to PRMC?”
Friend who was on IRB at Massachusetts General Hospital
(#1 ranked hospital in US 2012-2013) recommended
**Safe Patients, Smart Hospitals**
by Dr. Peter Pronovost

May, 2014
CUSP as the answer!
The CUSP program developed by Dr. Pronovost was the
answer I was looking for!
Contacted Dr. Pronovost at Johns Hopkins
Warm and encouraging reply said
Get the CUSP toolkit at AHRQ website
Get Board to commit to one or two CUSP projects
Asked me to keep him updated
At AHRQ (Agency for Healthcare Research and Quality) website found to
my delight that PRMC was already a success story!
“Stories of Success: Using CUSP To Improve Safety” September 28, 2012
http://www.ahrq.gov/professionals/quality-patient-safety/cusp/using-cusp-prevention/cusp-
success/index.html
Realized had already experienced two CUSP results at PRMC
CUSP: PICC line with meticulous nurse in ICU
CUSP: All team members including patient agreeing on the heart
catheterization procedure we were doing
Updated Dr. Pronovost who forwarded this to the CUSP developers at
Johns Hopkins to motivate his team!
**Congratulations on the early Successes of
the PRMC CUSP Program!**
prmc
CUSPCUSPCUSPCUSP
success

May, 2014
What is CUSP? Comprehensive Unit-based Safety Program
5. Identify
opportunities to
correct defects at the
unit-level
6. Change local
culture through
teamwork and
communications
4. Use scientific methods to
track improvement
3. Make Senior
Managers integral
members of CUSP
teams
2. Use diverse,
multi-disciplinary
teams
1. Learn how to use
CUSP to save lives7. Spread success to
other units

Goals for Case Study
As a former PRMC patient who survived a life-
threatening medical crisis, show how PRMC’s
mortality rate can be lowered through more
effective communications, policies and
procedures
As an M.I.T. trained engineer, recommend
improvements in technology
As a former Fortune 100 corporation senior
executive, recommend action items for your
consideration as possible CUSP projects
May, 2014
**My hope is many of my recommendations become
CUSP projects (or already are!)**
prmc
CUSPCUSPCUSPCUSP
success

U.S. News Regional Hospital Ranking Method by Specialty
May, 2014
Survival scoreSurvival scoreSurvival scoreSurvival score (32.5 percent of total score).
A hospital’s success at keeping patients alive compared with the
number expected to die given the severity of illness.
Patient safety scorePatient safety scorePatient safety scorePatient safety score (5 percent).
Effort in preventing blunders
ReputationReputationReputationReputation (32.5 percent).
Physicians recommending the hospital as best for the specialty
Other careOther careOther careOther care----related indicatorsrelated indicatorsrelated indicatorsrelated indicators (30 percent).
Includes nurse staffing, technology, and other measures related
to quality of care.
Addressed in this case studySource: U.S. News & World Report
In ranking hospitals, mortality rate is one-third of total score
How does one become a top-ranked hospital?

Case Study
Part 1: Synopsis of Patient Experience
The First 24 Hours
May, 2014

May, 2014
Shortness of Breath had become worse and worse over the
preceding 3 days to the point I was immobile and could not walk
even one step without considerable respiratory distress.
My body was starving for OXYGEN!
THE FIRST 24 HOURS: KFD EMS Response FRIDAY 1:51 to 2:40 pm 22 FEB 2013
Called KFD EMS!
During ride to PRMC received
Oxygen
Albuterol
Lasix
to help me breathe
Thank you, EMS techs Jeffrey Neal and Casey Goodman!
**Superb job!**

May, 2014
THE FIRST 24 HOURS: Patient Experience FRIDAY 22 FEB 2013
11070
My body was trying to survive with insufficient oxygen
SaO2 (oxygen saturation) was at a critical 70% when KFD EMS arrived
SaO2 below 85% is critical even for short periods!
Body working in survival mode by
Sending all available oxygen to brain, heart and vital organs
Cutting off oxygen to extremities and digestive system
Why I couldn’t walk!
Any MOVEMENT caused severe distress
Heavy, faster breathing
“Scary feeling” and chest pressure
“Feeling of doom” is a metabolic survival trigger saying
you are in big trouble – life-threatening trouble!
But NO Pain and quite Alert
Highly motivated to stay still and stay calm

May, 2014
Supplemental oxygen not continued after EMS techs left
Patient request for oxygen granted after panting for 4 hours
ECG abnormal indicating Right Ventricular Dysfunction
Means right side of heart under significant strain
Chest X-ray abnormal
Thank you, X-ray tech Ashley Chapman, for the WARM BLANKET!
Blood tests have critical values
D-dimer 4,406 ng/mL (Above 500 is CRITICAL)
Troponin 0.143 ng/mL (Above 0.1 is CRITICAL)
All are indicators of Pulmonary Embolism
Chest CT Scan needed to confirm
ordered STAT (meaning NOW!) @ 4:45 pm
THE FIRST 24 HOURS: Triage Phase in ED FRIDAY 2:40 to 4:45 pm 22 FEB 2013
possible
CUSPCUSPCUSPCUSP
project

May, 2014
When entered in medical record 15 hours15 hours15 hours15 hours later, radiologist’s
conclusion states:
“Massive bilateral pulmonary embolism
with possible right side infarct”
Under the missed diagnosis Dr. ED2 orders patient
transfer to hospital floor in “fair” condition
THE FIRST 24 HOURS: Initial Diagnosis FRIDAY 4:45 to 9:40 pm 22 FEB 2013
CT Scan delayed almost 3 hours to get a larger IV inserted
– finally succeeded in external right jugular
Vascular access difficulties
Shift ends for Dr. ED1 before CT Scan is taken
Continuity of Care and critical information are lost
Dr. ED2 assumes “stable” patient
“No distress noted” stated 4 times in notes while incidents of distress
with movement not communicated nor recorded
Dr. RAD (radiologist) calls Dr. ED2 with CT Scan results who
then tells me I have
“a Pulmonary Embolism”
possible
CUSPCUSPCUSPCUSP
project

THE FIRST 24 HOURS: What is a Pulmonary Embolism? What does Massive mean?
May, 2014
Massive has two definitions:
a) pulmonary vascular obstruction over 50%
b) obstruction creating hypotension and/or cardiogenic shock
HUGE difference in urgency when the word Massive is added - even Sudden Death
Blood clots formed in legs
(Deep Vein Thrombosis)
break loose and travel as
emboli into lungs clogging
pulmonary arteries

May, 2014
At 10 p.m. presented to floor nurse as a patient with
“A Stable PE”
Stable means “resistant to change”
Transfer to Bed triggered Seizure-like episode
Had just warned aides of distress when moved
Sudden violent nausea, yellow fringed purple aura,
loss of consciousness, convulsions
.. but no post-ictal confusion
Treated for Hypovolemic Shock
Extreme drop in blood pressure BP 80/18
Blood pressure started to rise as soon as
I was flat on my back again
Given 500 ml NS bolus after blood pressure already up to 96/49
Admitting, on-call, courtesy staff doctor over an hour away
No record of “seizure” or shock in doctor’s notes
No hospitalist or other provider looked in on patient
Critical information – what triggered shock – not communicated to
Dr. OCC nor recorded
Obstructive shock not considered in PE patient!
THE FIRST 24 HOURS: Transfer to 3W FRIDAY 10:00 pm 22 FEB 2013
possible
CUSPCUSPCUSPCUSP
project
Can be dangerous to add fluids quickly
in obstructive shock

May, 2014
Finally transferred to ICU!
Moved to room a few feet closer to nurses station and then mostly
ignored; vital signs taken once although on telemetry monitoring
Admitting order to take vital signs every four hours not revised after
demonstrated instability of patient
Felt very alone; looked at clock every
few minutes; wanted to toss and turn
but very afraid to move
Could not reach call light
Full length of blood pressure cuff
pinched every hour
Admitting Doctor – Dr. OCC (on-call, courtesy staff) arrived at
hospital shortly before 5 a.m.
Looked at CT Scan and recorded “multiple extensive emboli
involving pulmonary and distal arteries”
Still no radiologist report on CT Scan in Medical Record
“Must get into record” Source: Doctor’s note at 04:47 23 FEB 2013
ABG tests showed more Critical Values
THE FIRST 24 HOURS: Restless Night FRIDAY 11:00 pm 22 FEB 2013 to
SATURDAY 6:00 am 23 FEB 2013
possible
CUSPCUSPCUSPCUSP
project
Telemetry monitoring: 2/22/2013 22:12:13
HR: 109 Minutes after “seizure”

May, 2014
THE FIRST 24 HOURS: Life Saved in ICU SATURDAY 6:00 am to 3:00 pm 23 FEB 2013
Dr. ICU evaluates my condition; consults with experts
Echocardiogram shows right ventricle very dilated
Heart cannot pump against clot burden for much longer
Beautifully and very logically presented the options and their risks;
concludes tPA drug best
“Feeling of Doom” now continuous;
tells me something needs to happen very soon
Immediately gave her the go ahead
**Thank you, Dr. Debra Vasquez, for saving my life!**
PICC line inserted – noticed nurse was meticulous
**1st PRMC CUSP Success Story!**
Radiologist report finally placed in Medical Record at 12:15 23 FEB 2013
Massive conclusion too late to be useful;
but perhaps still within PRMC STAT policy guidelines!
Received tPA drug at 1:00 pm 23 FEB 2013 22 hours after arrival at PRMC
tPA effective before heart failed
…. So I SURVIVED! possible
CUSPCUSPCUSPCUSP
project
prmc
CUSPCUSPCUSPCUSP
success

Case Study
Part 2: Survival Profile
What Massive Means for Mortality
May, 2014
“I don’t think you fully appreciate the seriousness of your condition.”
- ICU nurse

May, 2014
“Management of Massive Pulmonary Embolism”
by Nils Kucher, MD, and Samuel Z. Goldhaber, MD
Circulation (published by the American Heart Association)
Volume 112(2):e28-e32 July 12, 2005
Copyright 2005 © American Heart Association
In-Hospital Mortality:
Acute Pulmonary Embolism
1:12
1:6
1:4
2:3
SURVIVAL PROFILE:
Pulmonary embolisms are the third most common
cause of death in hospitalized patients.
Level 1:
Level 2:
Level 3:
Level 4:

May, 2014
22-FEB-2013 2:46:27 pm
1 in 12 (8%) risk of dying at PRMC
In-Hospital Mortality Level 1:
Right Ventricular dysfunction, no arterial hypotension
SURVIVAL PROFILE: 1:12 - 8% mortality rate
ECG taken within minutes of arrival
Right Ventricular dysfunction indicated three ways on ECG:
Right Axis deviation – I & aVL negative; III & aVF positive
Right Ventricular Conduction delay (QR or rQR’ pattern)
SIQIIITIII - Prominent S in I; Prominent Q and Inverted T-waves in III
BNP result 22 Feb 2013 15:55 2841.2 pg/mL
Over 90 pg/mL is strong indicator of RV dysfunction

May, 2014
During the 7 hours in the ED
Systolic BP steadily dropping
Distress went unrecorded
Upon transfer from EMS stretcher to
ED gurney
Upon sitting up just enough to put
X-ray plate behind back
Upon being DROPPED six inches
from CT Scanner transfer board to
ED stretcher
Seizure-like episode upon transfer
to hospital bed
TimeTimeTimeTime Systolic BPSystolic BPSystolic BPSystolic BP DiastolicDiastolicDiastolicDiastolic
BPBPBPBP
02/22/2013
14:42
148 63
02/22/2013
17:00
108 63
02/22/2013
18:07
105 62
02/22/2013
18:52
104 68
02/22/2013
20:38
99 59
02/23/2013
22:00
80 18
Vital Signs Snapshot
Cardio system is moving toward failure
Arterial Hypotension
22-FEB-2013 9:43 pm
~1 in 9 (11%) risk of dying at PRMC
Heart is tiring; ability to pump weakening
SURVIVAL PROFILE: 1:9 – 11% mortality rate
possible
CUSPCUSPCUSPCUSP
project

May, 2014
Even slight tilting increases blockage – less oxygen even to vital organs
At rest moderately severe blockage allows some blood flow around clots
Obstructive (aka Extrinsic Cardiogenic) Shock – No oxygen going to brain!
Cardiogenic Shock
Seizure episode upon transfer to hospital bed caused by
blockage of pulmonary arteries
Told it was hypovolemic shock due to dehydration –
Another dangerous missed diagnosis!
22-FEB-2013 10:00 pm
~1 in 6 (16 %) risk of dying at PRMC
possible
CUSPCUSPCUSPCUSP
project

May, 2014
THORACIC IMAGING:THORACIC IMAGING:THORACIC IMAGING:THORACIC IMAGING: Predictors of Mortality for Severe Pulmonary Embolism
Radiology:Radiology:Radiology:Radiology: Volume 239: Number 3—June 2006
23-FEB-2013 11:00 am
1 in 3 (35%) risk of dying at PRMC
Predictors of Mortality for
Severe Pulmonary Embolism
Echocardiogram done in ICU shows Right Ventricle twice
the size of the Left Ventricle
Normal RV usually 2/3’s the size of the LV
35%

May, 2014
PRMC Case Study Estimated Mortality Level Timetable
TimeTimeTimeTime ElapsedElapsedElapsedElapsed PlacePlacePlacePlace ConditionConditionConditionCondition EvidenceEvidenceEvidenceEvidence MortalityMortalityMortalityMortality
2/22/2013
14:45
0 hr ED RV dysfunction ECG 1:12
2/22/2013
18:40
4 hrs ED Arterial
hypotension
Systolic BP <100 ~1:9
2/22/2013
22:00
7 hrs ED
3W
Cardiogenic
(Obstructive) Shock
Seizure-like episode,
unconsciousness,
BP 80/18
~1:6
2/23/2013
08:00
17 hrs 3W
ICU
Extensive bilateral
emboli
CT Scan read
by ICU doctor
~1:4
2/23/2013
11:00
19 hrs ICU Right Ventricle
Dilated 3X
Echocardiogram 1:3
2/23/2013
13:00
22 hrs ICU tPA Started CT Radiology report
in MR – MASSIVE
~1:2
2/23/2013
15:00
24 hrs ICU tPA Complete “Feeling of Doom”
diminishing;
Bleeding risk high
Rapidly
Improving
Mortality rate increased 4x as level
of heart compromise worsens!
8% up to 35% or higher

May, 2014
Top Ranked Hospital Hypothetical Mortality Level Timetable
TimeTimeTimeTime ElapsedElapsedElapsedElapsed PlacePlacePlacePlace ConditionConditionConditionCondition EvidenceEvidenceEvidenceEvidence MortalityMortalityMortalityMortality
2/22/2013
14:45
0 hr ED SOB (shortness
of breath)
RV dysfunction
ECG
D-dimer Critical
Troponin Critical
On Oxygen
1:121:121:121:12
2/22/2013
16:45
2 hrs ED CT Scan order
STAT
Larger IV inserted
CT Scan within hour
Transfer smooth
~1:10~1:10~1:10~1:10
2/22/2013
18:45
4 hrs ED
ICU
Massive PE
Protocol -
Heparin started
Radiology Report in
Medical Record -
Massive Bilateral PE
Move to ICU
Treatment options
~1:10~1:10~1:10~1:10
2/22/2013
20:45
6 hrs ICU Right Ventricle
Dilated 1.2x
No “seizure” episode
Echocardiogram
Treatment decision
PICC line inserted
~1:10~1:10~1:10~1:10
2/22/2013
21:45
7 hrs ICU tPA Started ~1:10~1:10~1:10~1:10
2/22/2013
23:45
9 hrs ICU tPA Complete Bleeding risk high RapidlyRapidlyRapidlyRapidly
ImprovingImprovingImprovingImproving
Mortality rate over 3 times improved!
Over 35% down to 10%

Extra hours of extreme stress can
Lengthen the recovery time
Make complications more likely
Possibly shorten life expectancy
Cumulative impact of stress means patient’s mortality risk
(and therefore the hospital’s mortality rate) is higher the
next time they enter the hospital
May, 2014
SURVIVAL PROFILE: Long term impact of increased mortality rate

INTERMISSION
Good time to take a break
May, 2014
TIP: To prevent DVT’s which lead to Pulmonary Embolism,
get up from your desk frequently and walk around!
possible
CUSPCUSPCUSPCUSP
project

Case Study
Part 3: Imperatives for
Improved Mortality Rate!
May, 2014

Imperatives to Improve Mortality Rate
May, 2014
1. Assure all providers communicate as one Synergistic Team
2. Reduce Time to reach the Correct diagnosis and treatment
3. Improve Assessment skills
4. Reduce Stress on patient
5. Assure all pertinent and correct information in Medical Record
6. Through CUSP create a culture of Excellence, TRUST and Integrity

Top Eight Recommendations
May, 2014
RECOMMENDATION 1: Pulmonary Embolism Protocol
RECOMMENDATION 2: Effective Team Communications
RECOMMENDATION 3: Supplemental Oxygen Policy
RECOMMENDATION 4: STAT Policy and Enforcement
RECOMMENDATION 5: On-call/Courtesy Staff Policy
RECOMMENDATION 6: Medical Record Software Upgrade
RECOMMENDATION 7: Patient Assessment Improvement
RECOMMENDATION 8: Expand CUSP Quality Program
possible
CUSPCUSPCUSPCUSP
project

May, 2014
Catherine A. Learoyd
PE Protocol Example
University of Florida College of Medicine
31
PE Protocol Example University of Florida College of Medicine
RECOMMENDATION1: Pulmonary Embolism Protocol Algorithm

May, 2014
Lovenox given
in ED
Wells Criteria –
PE Likely
RV dysfunction
tPA administered
15 hour delay while
mortality rate rising
Not sent to ICU
directlyMassive not stated
until noon next day
Troponin & BNP
critical values
Cardiac echo done in ICU
Stable only at rest
At rest
with movement
SP < 100 mmHg
PE Protocol Example University of Florida College of Medicine
Recommendation 1: Pulmonary Embolism Protocol Algorithm

May, 2014
ACTION: Review PRMC Pulmonary Embolism Protocol Algorithm
Assure PE protocol is based on level of hemodynamic compromise
-- consider cardiologist consult
-- check on instability due to changes of position
Assure patient with suspected or diagnosed submassive/massive Pulmonary
Embolism is sent directly to ICU
Make sure possibility of obstructive shock is monitored
Assure all providers are using the same play book
possible
CUSPCUSPCUSPCUSP
project
RECOMMENDATION 1: Pulmonary Embolism Protocol Algorithm

May, 2014
Assure all providers and medical staff work as
one Synergistic Team
NEED better team communications…and
culture of respect
…between all providers in care chain!
- 5 in first 24 hours
…between providers and nurses
…between nurses especially in hierarchy
…between EMS techs and ED nurses
…between nurses and techs
…between patient and nurses
- only positive statements recorded
…between patient and providers
possible
CUSPCUSPCUSPCUSP
project
“When mutual understanding and respect are present,
the spirit of synergy inevitably starts to develop.”
-- Stephen Covey

May, 2014
possible
CUSPCUSPCUSPCUSP
project
Sender
speaks
Message transmitted
Receiver listens
Confirmation
returned
Lab tech states critical value over phone line to
provider who hears and repeats critical value back to lab tech.
**All four components must be present for effective communications**
**Both sender and receiver responsible for asking questions so
pertinent information isn’t missed**
**Record is easily found and understood by all in the care chain**
Effective communications example – critical value:

May, 2014
What did the KFD EMS techs know?
Chief Complaint Respiratory Distress
NOTE: increased SOB with movement
“Patient stated to Medic3 she was unable to get up without having
increased SOB.”
SaO2 initially at critical 70%
On rebreather mask oxygen at 5 L/min upon arrival at PRMC
Albuterol and Lasix
What was recorded in Medical Record about EMS communications?
Medications given: ALBUTEROL NEB, LASIX 40 MG per EMS
(buried on page 12 of ED Discharge Summary because report is alphabetical
NOT chronological - Triage is late in the alphabet!)
No record of EMS phone call to ED prior to arrival in PRMC patient records
Oxygen not continued in ED despite 70% SaO2 just thirty minutes earlier
Excellent EMS report not faxed to Medical Record until Monday morning
possible
CUSPCUSPCUSPCUSP
project
Example 1: EMS and ED

May, 2014
After CT Scan taken, CT Tech’s assistant let go of
of transfer board; patient rolled and was jolted
onto the bed
DROPPED six inches from CT Scan via transfer
board to ED stretcher
CT Tech stated to me that I went very pale; he did, too!
Felt chest pressure, feeling of doom and respiratory distress
Possibly contributed to “seizure” two hours later.
possible
CUSPCUSPCUSPCUSP
project
Tech’s recruited assistant had poor attitude
NO RECORD of this by anyone
**Can’t fix defects that aren’t reported**
Example 2: CT Tech and ED Nurse

May, 2014
What Dr. ED2 saw in data in front of him:
A patient who “walked-in”
Patient quiet, calm, in no pain, “stable”
Confirmation of a Pulmonary Embolism
ED worksheet - “Normal” nonspecific EKG,
RAD not indicated; Hypertrophy – none,
yet critical BNP and Troponin
What was not communicated:
Patient couldn’t walk
Incidents of severe SOB with movement
No mention of “Massive”
Abnormal ECG, RV dysfunction
Dr. Rad / Dr. ED2
Example 3: ED Worksheet communications
ED Nurse / Dr. ED1
Dr. ED1 / Dr. ED2 / Dr. OCC
Plausible meaning:
CT Chest Positive
for Pulmonary
Vascular bilateral
possible
CUSPCUSPCUSPCUSP
project

May, 2014
Example 4: “Seizure” episode
What was known about “seizure”:
4 people knew transfer to bed triggered “seizure”
– 2 floor aides, LVN receiving nurse, patient
Charge nurse did not witness transfer; came in shortly after
Six people in room when I regained consciousness
- charge nurse, unidentified woman I saw in ICU the
next morning (nursing supervisor? angel?)
The most senior person does not necessarily have the best information.
Both charge nurse and floor nurse needed to enter what they saw
in medical record; LVN had critical information!
What went uncommunicated?
Charge nurse probably didn’t ask LVN what had
happened
Charge nurse probably assumed hypovolemic
although little evidence of dehydration
Dr. OCC probably didn’t ask about JVP (Jugular Venous
Pulse) or possibility it was obstructive shock
Who called unidentified woman; why was she
there?
possible
CUSPCUSPCUSPCUSP
project

May, 2014
possible
CUSPCUSPCUSPCUSP
project
ACTION: EMS to ED communications
Assure EMS phone call immediately recorded in patient record
Assure an EMS hand-off note is put in patient record and respected
Work with KFD EMS to have superb EMS reports immediately available
ACTION: Hand-off communications – Sender responsibilities
Add plan of the day to medical record
Emphasize key findings and changes from the day
Write for clarity to all team members
ACTION: Hand-off communications – Receiver responsibilities
Repeat key findings and changes and ask questions for clarity
Make sure patient understands plan and goals to accomplish
Ask questions about plan of the day
“Active listening is a sign of respect;
Speaking up a sign of courage.”

May, 2014
RECOMENDATION 2: Effective Team Communications
possible
CUSPCUSPCUSPCUSP
project
ACTION: Chain of Care communications
Assure all notes are team notes, not individual notes
Make provider rounds multi-disciplinary if not already happening
Tech and Nurse hand-off needs to be routine and recorded.
ACTION: Improve or replace ED Worksheets
Have each provider (even shift change) make separate records
Consider using tablets so small boxes on worksheet don’t limit clarity
Think WEllness versus Illness

May, 2014
RECOMENDATION 2: Effective Team Communications
possible
CUSPCUSPCUSPCUSP
project
http://www.kevinmd.com/blog/2011/10/hos
pitals-physicians-patientcentered-care.html
ACTION: Patient as the most important team member
To quote Stephen Wilkins, MPH:
Consumer Health Behavior Researcher
“Like a beautiful rainbow, patients and providers will recognize patient-centered care
when they see it. Like rainbows, examples of patient-centered care are few and far
between, but here are some tell-tale signs:
Providers and patients know each others’ names
Patients’ opinions are actively sought, listened to and honored where
possible (no, a suggestion box, patient satisfaction survey or mission statement does not
constitute being patient-centered — if you think they are then you aren’t patient-centered)
Patients tell you that their doctors and other team members really listened
to what they had to say (again if you think satisfaction surveys qualify you aren’t there yet)
Patients are treated as the most important member of their health care
team and taught how they can best contribute to the team’s success
Providers feel that their patients are actively involved in their own care
You see a significant improvement in patient health status, adherence,
engagement, level of utilization and patient/provider experience”
..the beginnings of
a CUSP Checklist?
Patients have a cultural change to make too.

May, 2014
Supplemental oxygen not continued in ED
SO2 a critical 70% just twenty minutes before arrival in ED
Tremendous efforts by EMS raised SO2 to 94%
TimeTimeTimeTime RespRespRespResp PulsePulsePulsePulse OxOxOxOx
14:42 24 94 L
14:54 37 H 93 L
17:00 26 H26 H26 H26 H 94 L
18:07 34 H 94 L
18:52 20 92 L
20:38 22 94 L
21:43 18 92 L
Source: ED Discharge Summary p. 1
Vital Signs Snapshot
Room Air ONLY
PANTING!
Now just huffin’
and puffin’
Oxygen not started by ED nurses since SaO2 now over 90%
My request for oxygen
granted after 4 hrs (18:40)
**Patient better able to survive if any
stresses can be alleviated**

May, 2014
ACTION: Revise Supplemental Oxygen Policy
If patient comes in on oxygen it should not be removed without a
doctor ordering it stopped.
If SO2 had been 70% upon arrival at ED, supplemental oxygen would
have been started immediately and NOT taken away thirty minutes later
even if SO2 was up to 94%.
Oxygen should be used to maintain 94% to 98% SO2.
Should be started if lower than 92% (90% is too low!)
Consider whether oxygen would lower RR so patient is less stressed.
Offer patient lip balm before their lips and throat become so
chapped and raw from the dry oxygen with no humidity added.
Kit lip balm with cannulas.
possible
CUSPCUSPCUSPCUSP
project

Ordered: 02/22/13 16:45
2 hours 47 minutes
Scan performed: 02/22/13 19:32
1 hours 8 minutes
Radiologist call: 02/22/13 20:40
15 hours 36 minutes
Results recorded: 02/23/13 12:16
STAT Total elapsed time: 19 hours 31 minutes
May, 2014
11% of people who die from Massive PE
die in the first 2 hours

May, 2014
ACTION: Improve Vascular Access skills
Call Vascular Access team when “hard sticks”
require STAT procedures (Can ED use VA team?)
Offer advanced training on difficult IV starts
Note: Had 7 IV starts in < 24 hours – 4 unsuccessful
(3 by EMS, 3 by ED, 1 for PICC in ICU)
Offer advanced training on jugular access IV’s
Review policy on External Jugular Access IV insertion
Larger IV required for CT Scan contrast
Two unsuccessful attempts gouging both arms
ED Charge Nurse finally successfully inserts IV in
External Right JugularExternal Right JugularExternal Right JugularExternal Right Jugular!!!!
Had audience of several nurses who had never
seen one done
Vascular access problems delayed STAT CT Scan
2 hours 47 minutes
possible
CUSPCUSPCUSPCUSP
project

May, 2014
ACTION: Review STAT Policy
Require preliminary STAT report communication within
1 hour and final report in medical record within 2 hours
of completed procedure so available to ALL providers
Consider using smart phones to transmit images
If shift ends for radiologist doing preliminary report,
next shift radiologist immediately does final report
Trigger an escalation procedure if report not in record
within 2 hours
Call in second radiologist or head of Radiology
department
To: Dr. ED2 From: Dr. Rad
18:52 Chest CT
Learoyd, Catherine
CRITICAAAAL RESULT: Massive
pulmonary emboli bilateral
in primary and distal arteries
possible
CUSPCUSPCUSPCUSP
project
**A picture can be worth a thousand words!**

May, 2014
ACTION (continued): Review STAT Policy
Assure all related procedures are also ordered STAT
Example: PICC ordered STAT but X-ray to confirm placement ordered
ASAP; PICC line could not be used until confirmation
Curb overuse of STAT
Example: DNA Factor IV and Leiden tests ordered STAT although it had
little bearing on immediate treatment options
Measure % of procedures ordered at STAT level and find out why
Schedule radiology procedures so providers know when to expect results
“Overuse of STAT orders is widespread and is a patient safety
issue because true emergencies can be delayed”
Source: Dept. of Radiology, Massachusetts General Hospital
possible
CUSPCUSPCUSPCUSP
project

May, 2014
RECOMMENDATION 5: On Call and Courtesy Staff Policy
Admitting Provider
Dr. ED2 calls On Call doctor (Dr. OCC) who agrees to be patient’s
Admitting Provider
Dr. OCC is Courtesy Staff and lives in San Antonio – over an hour away
Dr. OCC had never seen patient
ACTION: Review On Call and Courtesy Staff policies
Review best use of On Call staff
Consider expanding role of hospitalists to check-in on patient
when On Call provider is too far away to come in
Encourage nurses to call hospitalist team in emergent situations
Review privileges of Courtesy Staff provider
Why weren’t orders revised after “seizure” episode to take vital
signs more often
Why was Apresoline ordered PRN when not considered very
effective for acute heart failure and even contraindicated for
patients with pulmonary hypertension?
possible
CUSPCUSPCUSPCUSP
project

May, 2014
Proud to lead the Texas Hill Country toward the most
innovative and advanced technology in medicine
while providing exceptional, compassionate,
patient-oriented care.
RECOMMENDATION 6: Upgrade Medical Record Software STAT!
Print version of medical records displays ancient technology
Practically unreadable
Poor formatting creates obfuscation and ambiguity
Includes ED Summary, Patient Notes, MAR, Doctor’s Orders,
Results and Reports, and Financial Statements
Highly redundant boiler plate further obfuscates record

Software originally written 30 years ago in the 1980’s
as evidenced by:
Fonts originate before WYSIWYG (see Example 1 below)
Printing is dot-matrix style
Text ONLY - NO use of graphics
Limited formatting results in overstrikes
Software installed at PRMC in 1995
May, 2014
PRMC MeDicaL RecorDs Software
Shows PRMC has been an innovator in the past!
Example 1: Fonts originate before WYSIWYG
**NOTE: This is NOT a printer problem!**

May, 2014
DEMO
18643
1980 2010
vs.
Example 2: Printing is dot-matrix style
RECOMMENDATION 6: Upgrade Medical Record Software
**Which one is easier to read**

May, 2014
Chemistry Panel for Canine patientCBC Results for PRMC patient
Example 3: Text only; lack of graphics
**My dog gets better medical records!**

May, 2014
Interpreted as the Record HAS BEEN MODIFIED
rather than SOFTWARE PROBLEM !!
**Red Flag to a malpractice lawyer!**
Translation:
Reflex Order generated from ER CARDIAC 4
Manage Transfer – Order is stopped upon transfer
Stop Request
Order is Completed.
Example 4: Overstrike problem
Source: Doctor’s Orders

NOT JUST ANCIENT! -- POORLY FORMATTED
Misleading mix of dates, places, providers…
Printing is dot-matrix style
May, 2014
03/06/13 Date report printed
Emergency Department Discharge – 02/22/13 at ~19:50
Doctor who performed IVC filter
insertion 4 days after I left ED.
Location I was moved to on 2/25/13
ED triage provider – Dr. ED1 - not mentioned
Doctor who was consulted when I
was in ICU - day after I left ED
Prescriptions at discharge from hospital
- 02/27/13 – has nothing to do with ED.
Fair condition – with a Massive PE!
All entries alphabetical by category making it quite
difficult to figure out what happened when

May, 2014
Excerpts from EMS Report Excellent Example of Report formatted for clarity
who, what, when, where, why and how
Time PTA Treatment Who performed Comments
14:07 Oxygen Goodman, Casey Increase SpO2 to 88-90% with
continued SBO
Complication Complication Narrative
Device=Rebreather Mask Indication=Low SAO2 Oxygen Dosage (LPM)=15
Medication Response= Increased SaO2 Oxygen Dosage Unit=LPM Humidified=No
14:12 IV Goodman, Casey Unable to establish access
Length=1.25 Site=Left Hand Size=20 G
Solution=0.9% NSS Successful=No Volume hung=500 ml
Response=Not Applicable Volume infused=0
14:13 IV Goodman, Casey Infiltrated vein
Length=1.25 Site=Left Wrist Size=22 G
Solution=0.9% NSS Successful=No Volume hung=500 ml
Response=Adverse Effect Volume infused=10 ml

May, 2014
Example of EXCELLENT assessment and record:
KFD EMS Assessment
22 February 2013 14:03 to 14:29
From EMS Report:
p1 Chief Complaint
Respiratory Distress
NOTE: increased SOB with
movement
p3 “Patient states increased
SOB with movement.”
p5 “Patient stated to Medic3
she was unable to get up
without having increased
SOB.”
p5 “movement increased
worsening of SOB”
From ED Patient Notes:
p1 “PT REPORTS VIRAL TYPE ILLNESS
ONE WEEK WITH SOME RELIEF AFTER
3 DAYS BUT INCREASING SOB THROUGH
TODAY WITH CONTINUED WORSENING”
p2 “CALL LIGHT IN REACH. NEEDS
DENIED. NO DISTRESS NOTED.”
p2 “PLACE ON 2L O2 AT REQUEST OF PT”
p2 “TO RADIOLOGY VIA STRETCHER
WITH NO DISTRESS NOTED.”
p2 “LIGHTS DIMMED FOR COMFORT.
NO DISTRESS NOTED”
Example of MISSED assessment and record:
ED Assessment
22 February 2013 14:40 to 20:40
RECOMMENDATION 7: Improve Patient Assessment Skills

May, 2014
“No Distress Noted” gave an erroneous impression of the
seriousness of patient’s condition
ACTION: Eliminate the words “No Distress Noted” from patient notes
Replace “No Distress Noted” with descriptive, pertinent words
Examples:
Patient is resting quietly. RR 32 PR 118
Patient remaining still and states “afraid to move
because if I move I have a scary feeling, much greater
difficulty breathing and chest pressure”.
Patient back from radiology. Technician states
“Patient went very pale and SOB increased while we were
using transfer board. Board slipped and jarred patient.”
and ….
Patient remains in coma.
RECOMMENDATION 7: Patient Assessment Skills
possible
CUSPCUSPCUSPCUSP
project

May, 2014
“Self” (the charge nurse) did not witness that it was the transfer to the
bed that triggered syncope/seizure after patient told nurse aides that
movement caused distress and to be very careful.
Convulsions? Arms, legs, right side, left side?
Unconscious? How long? Respirations at 30 –
transferred with no oxygen?
Patient recovering BEFORE bolus started. Doing
nothing would have been safer for patient.
On call courtesy staff doctor made no note of phone
call or incident
What about the JVP? Could differentiate type of shock.
Just a couple of doors closer.

May, 2014
ACTION: Treat patient as unique and special
While “typical” is a likely possibility it is should never be a
foregone conclusion – must be put in context of history and
current situation.
Examples:
Patient having INR test is asked “Having a little atrial fibrillation, are
we?” – Answer: “No, had a massive pulmonary embolism.”
Patient concern with having 12,000 PVC’s per day dismissed with
“Just cut down on the caffeine.” – Right answer: “Eat a banana;
you’re hypokalemic.”
Patient has echocardiogram where right side is “technically difficult”
to read since “typical” interest is left side of heart making test
useless in addressing how much right side had recovered from
dilation during massive PE.
Combo heart catherization delayed since team only prepared to do
the “typical” left side only procedure. Providers report also states
patient given sedative as is typical when patient refused any
sedation.

May, 2014
ACTION: Train and use better patient assessment practices
Record pertinent statements from techs, patient and family
Example: CT Tech reports “patient was jarred when transfer board
slipped and went very pale”
If you don’t know, don’t assume!
Example: Patient walked-in to ED!
Example: “Denies” is an active verb – only use if patient voices denial
Avoid tendency to record only positive statements
Example: Pt… able to sit and reach for things without feeling
shortness of breath and “not feeling pressured.” (ICU nurse note)
Inability to reach never noted.
The computer made me do it.
Incorrect notes erroneously perpetuated many times
Example: Bruising on both arms due to PICC in one arm!
possible
CUSPCUSPCUSPCUSP
project

May, 2014
ACTION: Train and use better patient assessment practices
Put in record only what happened at that time
Example: Patient at PCCC for INR finger prick. Found in record for visit she
had had a full physical examination – palpitations, auscultations and all.
When asked nurse’s assistant shrugged and said it must be from an earlier
visit. It was from six months prior.
Write for Readability
Avoid using all caps!
When using a comparison say to what degree
Example: SOB continual worsening …. until unable to walk
Write in natural sentences
Create guidelines for excellent documentation and revise class syllabus
possible
CUSPCUSPCUSPCUSP
project
And, protect your patients!

May, 2014
Design Health Challenge – submission by Mathew Sanders
Best Medical/Problem History Section – First Place
Source: Design Health Challenge – submission by Mathew Sanders
Design Principles
Avoid label/value approach as much as possible when presenting
information.
Instead, reformat content so that as often as possible it can be
read as a natural sentence.

May, 2014
Design Health Challenge – submission by Mathew Sanders

May, 2014
Mayo Clinic interview technique tracks how many
times a candidate uses “We” vs. “I”
possible
CUSPCUSPCUSPCUSP
project
RECOMMENDATION 8: Expand CUSP Program
Think TEAM!
ACTION: Expand the multi-disciplinary nature of the CUSP teams
Are enough Board members and Senior staff involved?
Are enough physicians involved?
Are Physical Therapists, Radiology Techs and all staff involved in CUSP?
When will CUSP be expanded to the PCCC and ACC?
Is there a way to include volunteers and former patients to add their
perspective
Example: I’ll volunteer to be the “hard stick” at the next IV class!

May, 2014
Red Cross Mission Statement on Diversity
“We are committed to build and maintain a culture of openness and inclusivity
as we leverage the strengths found in the rich diversity of our volunteers,
employees, vendors and business and community partners. We value diversity of
thinking, backgrounds, experiences and culture. We embrace differences and
similarities that can be internal (what we are born with), external (how we were
raised and educated), or situational (vocational or lifestyle choices or
circumstances).”
Think RESPECT and Valuing differences!
ACTION: Help staff speak up
“Old School” nurses have a lot to offer; ask them to mentor
Example: “Old School” nurse showed me IV insertion techniques superior to
Vascular Access team’s skills
Techs see things that the nurses don’t; encourage their observations
ACTION: Help staff empathize with patient
Have staff experience transfer off narrow surgical table!
Example: “Don’t move! We won’t drop you.” (Had experienced being
dropped!)
Help staff learn patience with geriatric patients!

May, 2014
Think EXCELLENCE!
possible
CUSPCUSPCUSPCUSP
project
ACTION: Expect excellence and you’ll get it!
Teach supervisors to expect excellence, look for it and reward it
Make examples of excellence highly visible
Charge nurses need specific training on supervisory skills
Felt absence of good supervision in ED, 3W and PCCC
“All labor that uplifts humanity has dignity
and importance and should be undertaken
with painstaking excellence.”
Martin Luther King, Jr.

Case Study
Part 4: Summary
May, 2014
“If you want to achieve excellence, you can get there today.
As of this second, quit doing less-than-excellent work.”
--Thomas J. Watson

May, 2014
What next?
Congratulations on the successes of the PRMC CUSP program!
Looking forward to seeing continued growth and improvements toward
a synergistic team culture focused on excellence and creating trust
Attending online free course on
“The Science of Safety in Healthcare”
Starts June 2nd with Johns Hopkins faculty including Dr. Pronovost
Sign up at https://www.coursera.org/course/healthcaresafety
As he requested, update Dr. Pronovost on my impressions of this
meeting
If invited, willing to present this case study to PRMC CUSP
committee or others at PRMC
Get commendations written and awarded to EMS techs
Will consider volunteering for the Patient Family Advisory Board
My criteria
Sponsored by Board member
Multi-disciplinary group
PFAC willing to learn about CUSP and use it
**I am grateful you have listened! Thank you!**
prmc
CUSPCUSPCUSPCUSP
success

May, 2014
In the spirit of Sorrel King, I ask you:
** Will every patient have a better
chance of surviving the next time they
come to PRMC in a medical crisis?
(compared to PRMC in February 20(compared to PRMC in February 20(compared to PRMC in February 20(compared to PRMC in February 2013) **
prmc
CUSPCUSPCUSPCUSP
success

PRMC Patient's Perspective on Life-Saving Care

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