Medical Emergencies

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Medical Emergencies
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CPR

• For more information, please go to
  www.americanheart.org or www.redcross.org.
• Use of AED
• Keep certification current

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Case Study

• Mrs. G is 76 years old. She is receiving
  physical therapy due to a total knee replacement.
  She is presently doing well with the walker and
  will be discharged home in two days. You have
  applied a gait belt to Mrs. G and she requires
  minimal assist during gait training. Suddenly,
  she reports she is getting dizzy and feels as if
  she is going to faint. Her knees start to sink.
  No one is around to assist you. How do you
  handle this situation?

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Case Study

• Mr. L is 54 years old. He is coming to your
  hospital outpatient facility for treatment of hip
  osteoarthritis. He is riding the stationary
  bicycle. He suddenly stops and grabs at his
  chest. He is sweating profusely and then passes
  out. You lower him to the floor. You do not
  detect a pulse. How do you handle this situation?

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Case Study

• Mrs. Q is 60 years old. She has an extensive
  medical history which includes Diabetes Mellitus.
  One of her medications is insulin. She had an 8
  am appointment for therapy. She rushed in this
  morning and stated that she had not had
  breakfast. She is performing her lower extremity
  strengthening exercises. She begins to complain
  of hunger and describes having a headache. She
  appears anxious and is sweating. You check her
  pulse and it is elevated to 110 beats per minute.
  How do you handle this situation?

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Case Study

• Mrs. Z is in the hospital secondary to ankle
  surgery. She is 46 years old and has a history
  of epilepsy for which she takes medication. She
  is learning to use crutches as she is only
  allowed 25 weight bearing on the affected side.
  She is in the physical therapy department when
  she experiences a tonic-clonic seizure. How do
  you handle this situation?

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Case Study

• Mrs. V is 68 years old. She is in the hospital
  due to abdominal surgery. She has an IV attached
  to her left arm. During a bed to chair transfer,
  the IV gets caught and pulls out of her arm. She
  is bleeding and extremely anxious. How would you
  handle this situation?

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Bariatric Care
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Associated Readings

• Pathology (Goodman Fuller), pages 32 39
• Acute Care Handbook (Paz West), pages 315 316

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Complications Associated with Obesity

• Metabolic Syndrome
• Type 2 Diabetes Mellitus
• Liver Disease
• Osteoarthritis
• Sleep Apnea
• Atherosclerosis
• Hypertension
• Cardiovascular Disease
• Stroke

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Complications Associated with Obesity

• Asthma
• Cancer
• Menstrual Disorders and Infertility
• Impaired Mobility
• Gallbladder Disease
• Psychological Disturbances
• Premature Death

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Gastric Bypass Surgery

• NIH established criteria for bariatric
• surgery (1998)
• Careful patient selection
• Failed less invasive weight loss measures
• At risk for obesity associated illness
• Clinically Severe Obesity
• BMI of 40 or greater
• BMI of 35 or greater with obesity related
  co-morbidities

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Types of Bariatric Surgery

• Please see Paz West, pages 319 - 320, for a
  description of gastric bypass procedures
• Roux-en-Y
• Vertical banded gastroplasty
• Adjustable gastric banding

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Physical Therapy Precautions

• Knowledge of patients prior level of function
• Advanced mobility planning
• Sufficient assistance
• Bariatric equipment

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Bariatric Care
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Bariatric Care
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Bariatric Equipment
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Ruby
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Preventing Medical Errors
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Course Objectives

• Following this presentation, participants
• will be able to . . . . . . .
• Accept that medical error prevention is an
  essential component of patient management
• Define terminology related to medical error
  prevention
• Recognize the medical errors associated with the
  practice of physical therapy
• Based upon a patient case scenario, perform a
  root cause analysis

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Course Objectives

• Promote safety and develop a medical error
  reduction plan
• Describe how pharmacology related issues impact
  patient treatment and assessment
• Improve communication skills
• Adapt physical therapy intervention to the
  patients level of health literacy
• Review the concepts of indications and
  contraindications as related to patient care

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Course Objectives

• Produce effective documentation
• Formulate a personal plan to prevent the spread
  of infection
• Assist patients to become self-advocates

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Medical Errors

• 1995 Tampa, Florida. Patient with diabetes has
  the wrong leg amputated.
• 2003. Duke University. Patient dies after
  receiving a heart-lung transplant of the wrong
  blood type.
• 2007. California. Twin infants were given
  massive doses of heparin. The labels of the
  different doses of the drug looked very similar.

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Medical Errors

• Licensure requires a mandatory
• two hour course!!!!

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Board of Physical Therapy Practice 64B17-8.002

• Requirements for Prevention of Medical
• Errors Education
• Two contact hours
• Study of root cause analysis
• Error reduction and prevention
• Patient safety
• Medical documentation and communication
• Contraindications and indications for physical
  therapy management
• Pharmacological components of physical therapy
  and patient management

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Alarming Statistics

• The November 1999 report of the Institute of
  Medicine (IOM) entitled To Err is Human Building
  a Safer Health System highlighted the issue of
  medical errors and patient safety

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Alarming Statistics

• The report indicated that 44,000 to 98,000 people
  die in hospitals each year, the result of medical
  errors
• Medical errors are the eighth leading cause of
  death in the USA
• Estimated financial costs 37.6 billion each
  year, 17 billion of those costs associated with
  preventable errors
• Reference Agency for Healthcare Research and
  Quality

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Medicare

• Grants bonuses to doctors and hospitals that
  report quality measures
• Medicare will not pay for reasonably
  preventable conditions related to medical
  errors. Included are incompatible blood
  transfusions, infections related to particular
  surgeries, or needing a second surgery to
  retrieve a sponge left behind. Also included are
  serious bed sores, injuries from falls, and
  urinary tract infections from catheters.
• Reference New York Times, October 1, 2008.

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Medicaid

• Aligning state Medicaid programs with the
  Medicare policy to refuse payment for certain
  preventable errors
• Concept of never events
• Different policies from state to state

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Institute of Medicine

• Emphasized that most medical errors are systems
  related, not individual negligence
• Focus should be on improving systems, not blaming
  individuals
• Research has indicated that system improvements
  can reduce error rates and overall quality of care

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Institute of Medicine

• Defines medical error as the failure to complete
  a planned action as intended or the use of a
  wrong plan to achieve an aim.

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Types of Medical Errors

• Medication errors
• Mishandled surgeries
• Diagnostic error
• Equipment failure
• Infections, including nosocomial
• Blood transfusion injuries
• Misinterpretation of medical orders
• Errors of omission

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Physical Therapy Errors

• Diagnostic errors
• Intervention errors
• Lack of prevention
• Communication failure
• Equipment failure or misuse
• Misuse of ancillary personnel

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Current Correctional Emphasis

• Establishing a root cause of the error
• Correcting a systems failure
• Avoiding future occurrences

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Definitions

• Sentinel Event An occurrence unplanned, not
  scheduled or anticipated, resulting in death,
  serious harm, or the risk for physical or
  psychological harm.
• Near misses Would have resulted in a sentinel
  event if chance or intervention had not occurred.

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Definitions

• Adverse Event An injury caused by the medical
  treatment or management that was not anticipated
  or planned during the medical care of a patient.
  Adverse events can be preventable or
  unpreventable.
• Adverse Drug Event Death or injury from a wrong
  medication, wrong dosage, or from multiple
  pharmaceutical interactions/reactions.

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Definitions

• Overuse Providing medical care that its use has
  potential for more harm than good.
• Underuse Not providing a medical intervention
  that could have been helpful to the patient.
• Misuse An intervention is scheduled but a
  preventable complication occurs and the
  intervention is not given the opportunity to work.

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Definitions

• Root Cause Analysis A process to study a
  situation, circumstances, or problem in a
  prescribed method to allow actual determination
  of the primary (root) cause in a sequence of
  events. Root cause analysis requires an
  investigation/review, collaboration, an action
  plan, implementation process, and follow-up for
  monitoring the effectiveness of the corrective
  action plan.

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Charles Vincents Framework for Categorizing the
Root Causes of Errors

• Institutional
• Regulations
• Medicolegal environment
• Organization and Management
• Financial issues
• Policy standards and organizational goals
• Organizational safety culture
• Work Environment
• Staffing patterns and workload
• Equipment issues
• Administrative support

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Charles Vincents Framework for Categorizing the
Root Causes of Errors

• Team
• Written and verbal communication
• Supervision and leadership
• Seeking assistance
• Individual Staff Member
• Knowledge and skill set
• Motivation and attitude
• Staff health
• Task
• Use of protocols
• Availability and accuracy of test results

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Charles Vincents Framework for Categorizing the
Root Causes of Errors

• Patient
• Complexity
• Language and communication
• Personality
• Social issues
• Reference Understanding Patient Safety, page 19.

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Framework for Root Cause Analysis

• What happened?
• Why did it happen?
• What were the causative factors?
• Human factors
• Environmental factors
• Equipment factors
• What systems are related to those factors?
• Human resource issues
• Communication
• Environmental management
• Leadership issues

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Framework for Root Cause Analysis

• Analyze Data
• Risk Reduction Strategies
• Planned Action
• Implementation Dates
• Quality Measurements

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How can systems work to reduce medical errors?

• Simplifying processes
• Improving communication
• Increasing management support
• Decreasing punitive punishment environments
• Instituting protocols, pathways, and policies to
  support error reduction

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Important Question

• How can we, while providing physical
• therapy, ensure our patients safety
• while reducing the opportunity for medical errors?

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Prevention Strategies

• P Partnership of all Stakeholders
• R Reporting Errors Without Fear
• O Open-Ended Focus Groups
• C Cultural Shift
• E Education and Training Programs
• S Statistical Analysis of Error Data
• S System Redesign
• Reference Perspectives on Assessment of
  Physical Therapy Error
• in the New Millennium by JC Anderson and ER
  Towell. 2002.

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Prevention Strategies

• Partnership of all Stakeholders
• Clinicians, patients, students, faculty
• Facilitate communication
• Reporting Errors without Fear of Punishment
• Offer incentives for reporting
• Open-Ended Focus Groups
• Reduce secrecy
• Discuss therapy protocols and problem areas

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Prevention Strategies

• Cultural Shift
• Open identification of errors
• Participation in quality protocols
• Differentiate between errors and ethics
• Education and Training Programs
• Use error analysis to guide training

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Prevention Strategies

• Statistical Analysis of Error Data
• Continuous process
• Systems Redesign
• Adjust systems
• Eliminate or decrease potential error situations

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Strategies for Preventing Medical Errors

• Establish a procedure for dealing with medical
  errors
• Increase organizational structure toward system
  responsiveness for medical error reduction
• Simplify
• Supportive and involved management
• Improve effective communication

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Communication

• Verbal, non-verbal, and written
• With rehabilitation colleagues
• Interdisciplinary communication
• Confidentiality
• Patient education
• Informed consent
• Health literacy

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Health Literacy

• IOM indicated that nearly half of all adults have
  inadequate health literacy
• Address the patients understanding
• Use multiple informational methods
• Effective Patient Education
• Explain, Ask, and Listen
• Write it Down
• Demonstration and Repetition

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Strategies for Preventing Medical Errors

• Standardize
• Protocols
• Policies and Procedures
• Pathways

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Strategies for Preventing Medical Errors

• Increase technological support
• Provide evidence-based treatment

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Other Issues to Consider

• Pharmacological concerns (medication,
  chemotherapy, radiation, etc)
• Awareness of treatment protocols and precautions
  with different diagnoses
• Equipment and facility assessment
• Documentation
• Contraindications/Indications

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Pharmacology Issues

• Awareness of the patients medications
• Potential side effects and interactions
• Knowledge of how medication may impact
  rehabilitation activities and/or exercise
  response
• Pain management issues
• Contributory risk factor for falls
• Allergic reactions (iontophoresis)

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Physical Therapy Assessment
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Treatment Protocols and Precautions

• Diagnosis specific precautions
• Surgical protocols
• Safety equipment, such as gait belts
• Safety policies and procedures

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Equipment

• Proper Use and Application
• Equipment Inspections
• Equipment Hygiene
• Policies and Procedures

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Facility Assessment

• Environmental approach
• Equipment storage
• Walking surfaces
• Traffic pathways
• Accessibility issues

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Documentation

• Complete and Timely
• Proper use of Abbreviations
• Legible
• Use of Electronic Documentation
• Use of Forms
• Verbal Orders
• Incident Reports

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Indications and Contraindications

• Diagnostic Issues
• Treatment Protocols
• Surgical Protocols
• Manual Therapies
• Exercise Programs
• Physical Agents

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Infection Control

• Hand hygiene
• Use of protective equipment
• Cleanliness and disinfection techniques

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Empower Patients
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Case Study

• Mrs. C is 82 years old. She fell and broke her
  hip while in the hospital. She had a total hip
  replacement and is now in a SNF. You get a call
  in the physical therapy department that she had
  potentially dislocated her hip while doing a
  toilet transfer with her aide. The toilet seat
  was low. You dont understand how this could
  have happened as the patient had a bedside
  commode of the proper height in her room. The
  patient is sent to the hospital for evaluation
  where it was confirmed that she had indeed
  dislocated her total hip replacement.

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Case Study

• Mr. P is 28 years old. He is receiving treatment
  for his right knee (ACL repair). As part of your
  muscle re-education program with him you are
  using electrical stimulation. As you turn on the
  machine, the patient screams out in pain and
  accuses you of trying to shock him to death. You
  turn off the machine and remove the electrodes.
  As you place the machine next to the wall,
  another therapist walks by and states Dont use
  that machine, its broken. Well have to call
  the repairman.

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Case Study

• Mrs. C is 85 years old. She was admitted to the
  hospital with a diagnosis of severe dehydration.
  Her hospital stay was complicated by cardiac
  issues which resulted in bed rest. The patient
  did not receive any rehabilitation services. The
  patient was discharged home alone. The patient
  fell the next day and was re-admitted to the
  hospital with a fractured pelvis.

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Case Study

• Mr. G is 64 years old with a diagnosis of COPD.
  He is in the hospital due to complications
  resulting from the flu. He developed respiratory
  distress and pneumonia. He currently requires
  supplemental oxygen. He is brought down to the
  physical therapy gym and is using the
  departmental portable tank. He begins gait
  training with you. After about ten minutes, he
  begins to have respiratory distress. His oxygen
  saturation rates are dropping quickly. He is
  brought back to his room and transferred into
  bed. He is placed on the room oxygen supply. He
  begins to breathe with increased ease and his
  oxygen saturation rates are improving. You bring
  back the portable oxygen tank and only then
  realize it was empty. Later you discover that
  five other patients had used the tank this
  morning.

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Case Study

• A physical therapist is working in the hospital
  rehab gym. She has a new patient scheduled this
  morning. Upon chart review it is noted that the
  patient had a MVA and fractured both lower legs.
  He is currently NWB bilaterally. The therapist
  requests that the rehab tech transport the
  patient down to the gym. When the tech returns
  with the patient, she says that the nurses were
  very busy so she transferred the patient into the
  wheelchair. The tech reports that the patient
  did very well as he stood up from the bed and
  walked a few steps to the wheelchair.

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Case Study

• Mr. G is 45 years old. He was referred to the
  outpatient physical therapy clinic for treatment
  of left shoulder pain. The therapist examines
  the shoulder and implements the PT plan of care.
  It is noted in the chart that Mr. Gs pain was
  unchanged following the treatment intervention.
  He is scheduled for therapy 3 times per week.
  The next day his wife calls to cancel his
  appointments as he was admitted into the hospital
  with a heart attack and underwent coronary bypass.

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References

• Medical Errors presented by Karen G. Kendall,
  FPTA Conference, 8/23/03.
• INFORMED Physical Therapist Update 2006,
  http//www.PT.cme.edu.
• Prevention of Medical Errors by Linda Greenfield
  and Renée Neville. Consultants for the Future,
  2004, www.consultantsforthefuture.com.

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References

• Patient Education Health Literacy by Michelle
  Vanderhoff. American Physical Therapy
  Association. Available at www.apta.org.
• United States Department of Health Human
  Services. Agency for Healthcare Research and
  Quality. Available at www.ahrq.gov.
• Video clip from Remaking American Medicine
  Health Care for the 21st Century. 2006. PBS
  Home Video available at www.pbs.org.

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References

• Perspectives on Assessment of Physical Therapy
  Error in the New Millennium by Judith Anderson
  and Elizabeth Towell. Journal of Physical
  Therapy Education, Winter 2002. Vol 16, No 3,
  54-60.
• Understanding Patient Safety. Robert Wachter.
  2008. McGraw Hill Medical New York.
• To Err is Human Building a Safer Health System.
  Institute of Medicine. 2000. National Academy
  Press Washington, DC.
• Clip Art and Pictures found at www.google.com.

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Any Questions?
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Thank You for Your Attention