Spotlight Case February 2004

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Spotlight Case February 2004

• Delay in Antibiotics
• A Fatal Mistake

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Source and Credits

• This presentation is based on the Feb. 2004 AHRQ
  WebMM Spotlight Case in Medicine
• See the full article at http//webmm.ahrq.gov
• CME credit is available through the Web site
• Commentary by Lisa Bellini, MD, University of
  Pennsylvania School of Medicine
• Editor, AHRQ WebMM Robert Wachter, MD
• Spotlight Editor Tracy Minichiello, MD
• Managing Editor Erin Hartman, MS

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Learning Objectives

• At the conclusion of this educational activity,
  participants should be able to
• Understand the importance of ongoing patient
  re-evaluation to confirm initial clinical
  impression
• Define the role of the attending with respect to
  remote supervision
• Outline the program directors role in processing
  medical errors
• List different forums for processing medical
  errors

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Case Delay in Antibiotics

• A 21-year-old woman with SLE, on long-term
  prednisone, presented to the ED with a few hours
  of fever, chills, myalgias, and vomiting. She was
  hypotensive, but responded to IV fluid
  resuscitation. A blood test revealed an elevated
  white count. Medical housestaff evaluated her,
  contacted the admitting attending by phone, and
  admitted her to a medical ward with a presumed
  diagnosis of viral syndrome vs. food poisoning.

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Case Delay in Antibiotics (cont.)

• On the floor, the patient continued to require
  fluid resuscitation for blood pressure support.
  No antibiotics were given.
• In the morning, 10 hours after admission, her
  condition began to deteriorate. Her hypotension
  no longer responded to fluid boluses, and a
  subtle petechial rash was noted.

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Examples of Petechial Rash

• Petechiae

Purpura
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Case Delay in Antibiotics (cont.)

• At that time, the patient was examined by the
  attending physician. The attending suspected
  meningococcemia, started antibiotic therapy, and
  transferred the patient to the ICU. Despite
  initiation of antibiotics and full supportive
  treatment, the patient had a cardiac arrest and
  died.

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What Went Wrong?

• Issues related to resident education
• Issues related to resident supervision

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Issues Related to Resident Education

• Fund of knowledge deficit
• Chronic prednisone use results in
  immunocompromised state
• Error in clinical judgment
• Differential diagnosis of hypotension should have
  included sepsis and adrenal insufficiency
• Failure to re-consider diagnosis when hypotension
  persisted despite fluid challenges

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Medical Errors Among Residents

• 254 residents surveyed regarding medical errors
• 45 reported a mistake (114/254)
• 22 declined to answer questions
• 33 did not respond

Wu AW, et al. JAMA. 19912652089-94.
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Types of Medical Errors Reported Among Residents
Wu AW, et al. JAMA. 19912652089-94.
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Issues Related to Resident Supervision

• Remote supervision attending physician not
  physically present to evaluate the patient
• Contact via phone
• Dependent on housestaff clinical skills to be
  surrogate
• Only as good as the information you receive

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Rethinking Remote Supervision

• Driving forces
• Cost containment
• Demands for improved quality of care
• Work hours regulations

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Rethinking Remote Supervision

• Hospitalists individuals who practice at least
  25 time in the inpatient setting
• Inpatient ward is the practice venue
• Available more often throughout the day and even
  the night
• Supervision of housestaff no longer remote

Wachter RM. Ann Intern Med. 1999130338-42.
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Impact of Hospitalists
Auerbach AD, et al. Ann Intern Med.
2002137859-65.
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Impact of Hospitalists on Mortality

Auerbach AD, et al. Ann Intern Med.
2002137859-65.
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Impact of Hospitalists

• Impact of hospitalists on errors not known
• One recent study revealed no impact on presence
  of in-house attending trauma surgeons on
  mortality or length of stay
• The Leapfrog Group requires on-site intensivists
  as a marker of quality care in ICU ? whether
  hospitalists might improve safety more generally
  in hospital

Arbabi S, et al. Arch Surg. 200313847-51. The
Leapfrog Group. October 2003.
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Effect of Increased Supervision on Housestaff
Autonomy

• Survey of residents comparing experience on
  traditional service vs. hospitalist service
• No significant differences were found in
  residents satisfaction with
• Relations with attending (p 0.16)
• Autonomy in management decisions (p 0.84)
• Weight given to own decisions (p 0.8)

Chung P, et al. Am J Med. 2002112597-601.
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Percentage of Residents Very Satisfied
Chung P, et al. Am J Med. 2002112597-601.
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Duty Hours Regulations

• July 2003 ACGME mandate
• Resident work hours must be limited to 80 hours
  per week averaged over 4 weeks
• No shift to exceed 24 continuous hours with an
  additional 6 hours for education and transfer of
  care
• A minimum of 1 day off in 7

Resident duty hours ACGME Web site.
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Impact of Duty Hours Regulations on Attending
Involvement

• Increased number of handoffs
• Increased dependency on attending to provide
  continuity of care
• Increase in implementation of non-teaching
  services covered by hospitalists

Morelock JA, Stern DT. Am J Med. 2003115163-9.
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Role of Program Director in Processing Errors

• Individual Level
• Address issue with resident is it a pattern?
• Determine cause fund of knowledge, clinical
  skills, depression, substance abuse, etc.
• Program Level
• Examine curriculum create educational initiative
  to prevent future errors if appropriate (i.e.,
  MM)
• Health Care System Level
• Serve as liaison between the program and the
  hospital administration

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Strategies to Address Medical Errors

• Ensure adequate supervision for housestaff
• Monthly patient safety discussions at residents
  report
• Moderated by VP for quality and patient safety
• Implementation of anonymous web-based medical
  errors reporting system
• All personnel encouraged to report errors
• Information collated centrally
• Systems changes implemented

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Take-Home Points

• Residents should have multiple venues available
  to discuss, report, and process medical errors
• Increased supervision and less reliance on
  remote supervision may result in improved
  patient care
• The Program Director should play a key role in
  identifying and processing medical errors