Risk Management in an Office Setting: Who are we sending home?

Transcription

1 Risk Management in an Office Setting: Who are we sending home? October 1, 2016 Niagara Falls, NY The threat of litigation following a misdiagnosis or improper treatment presents a challenge to healthcare providers. Subtle mistakes can lead to poor patient outcomes. According to a 2009 study in the Journal of the American Medical Association; Diagnostic errors were the No. 1 reason for adverse events that resulted in malpractice payouts in outpatient settings. Avoid costly and time-consuming litigation by anticipating such situations and appropriately managing the medical needs of the patient. Topics Include: 1. Patient presenting with a headache misdiagnosis of an acute bleed. 2. Abdominal pain in an office setting missed appendicitis. 3. Patient comes with back pain missed abscess. Learning Objectives At the end of the presentation, participants should be able to: 1. Recognize that all providers play a role in the successful outcomes of patient care 2. Describe the pitfalls involved in an outpatient setting and how to avoid them 3. Draw parallels from previous cases and identify what not to miss 4. Appreciate the subtle changes in patient responses throughout the assessment and reassessment process. Incorporate evidence-based medicine into their daily practice Kayur V. Patel, MD, MRO, FACP, FACPE, FACHE, FACEP Chairman Access2MD

2 Disclosures I have no relevant financial relationships to disclose in regard to the content of this presentation Current Chairman, Access2MD Associate Professor, IU School of Medicine Past 1.Director, Health Care Excel 2.CMO, Terre Haute Regional Hospital 3.Regional Medical Director, Team Health 1) Senior Vice President, Team Health Midwest 2) Regional Medical Director, Team Health Midwest 3) Associate Professor, Indiana School of Medicine 4) Clinical Instructor : 1. Kaplan, NY 2. Indiana School of Medicine Residency Program

3 Scenario 57 year old Mr. JMW presents to your office with history of vomiting in the bathroom and complained of a little dizziness. Their son was also sick that day and so the family thought that perhaps JMW had gotten the flue, and they hoped that JMW would feel better in the morning. Next day still felt nauseous, sick to his stomach and felt dizzy. Had one episode of vomiting overnight. Called you for same day appointment. Set for He needed help going downstairs to the car. Need a wheelchair to get into the office building. Signed in. RN noted JMW was your balance is off. Do you want to step on the scale or wait until you feel better on a later appointment?

4 Scenario 240/ /120 on right 224/115 on left You spend nearly 20 minutes during your exam. Plan Labs drawn a) Meclizine 25 mg PO every 6 hours PRN b) Metoprolol 50 mg BID c) Hydrochlorothizide 12.5 mg BID Follow up in 3 days

5 Scenario That day he slept a lot Next 17:00 found unresponsive 911 activated CT: Left cerebellar acute intraparenchymal hemorrhage 10 days later JMW passed away in the ICU.

6 Hypertensive Emergencies Diastolic pressure of > 140, acute progressive end-organ damage Diagnosis Essential workup Exclusion of other causes of severe symptomatic hypertension Laboratory BUN, creatinine (acute elevation if renal damage) Serum electrolytes Urinalysis (proteinuria and casts) Imaging/Special Test EKG Head CT LP when CT is negative to exclude subarachnoid and intracerebral hemorrhage. Intra arterial line

7 Hypertension Pulse Pressure Controlled Gray Zone = Cry for Help End Organ = Too Late Unsteady gait Sudden vomiting Confusion Wheel chair 240/116 BP 1) CT no contrast 2) EKG 3) Labs T o o L a t e Old Teaching Papilledema Lack of resources Encephalopathy technology MI CHF Focal neurological signs or symptoms Herniation Dilated Pupil Same Side Nimodipine Stroke T o d a y s S t a n d a r d o f C a r e Hypertensive Crises Urgency SBP > 180 DBP > 110 Emergency SBP > 180 DBP > 120

8 A 23 year old presented to the ER for shortness of breath and cough. Fever 102, WBC 16,000, left shift, chest x-ray shows right lower lobe infiltrate. Admitted for pneumonia on a regular floor. Few hours after admission he vomits vigorously and complains of headache. What is going on? Scenario

9 Scenario Headache: intensity 7/10, global Zofran 4 mg IV, Toradol 30mg IV, One hour later: Headache continues and now has more episodes of vomiting. What is going on? Next step?

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11 Scenario CT negative What have you ruled out? Headache 5/10, nausea but no more vomiting Next?

12 SAH? Not the worst headache Got better with medications CT negative

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14 Myths Headache Negative Documentation Labs SAH Worst headache of my life Sudden Maximal soon after onset Different than previous CT LP Angiogram Meningitis Pre-eclampsia Kernig s Brudzinski s BP is normal She is not pregnant Fever Neck stiffness Immune compromise Head/neck infection Jolt Accentuation test Temporal Arteritis ESR is negative Jaw claudication Temporal tenderness/nodularity Visual symptoms Acute Glaucoma CT first LP CBC Chemistry UA Coagulation Biopsy Cervical Artery Dissection Cranial nerve deficits Facial pain SAH like onset Angiography 17 17

15 6 Pitfalls 5 The RBC count decreased from tubes 1 to 3

16 Misinterpreting the LP What you were taught. 25% decrease from tubes 1 to 4 Less than 1,000 RBCs in tube 4 No xanthochromia

17 Risk of True SAH S T U D Y O U T C O M E Misinterpreting the LP?. 10,000 1,

18 S T U D Y Misinterpreting the LP? Xanthochromia O U T C O M E RBC. Xantho-chromia 0 Hour 12 Hours Timing of LP 2 Weeks

19 61 year old male seen by you at our medical center for the first time today for headache of 3 days. He has not seen a provider for past 10 years. Headache is severe. No vomiting. You started him on Lopressor. He took his first Lopressor in our medical center as his BP was 210/146 Goes home Headache is worse Wife calls PMD Advice?. Scenario

20 Scenario In route his BP is 224/144 While starting IV he becomes cold and clammy. BP is 140/100?? BP in ER is 134/90 CT Head BP now 90/60 CT Head negative?? SBP is now 80??.

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23 Scenario 48 year old with flu like symptoms for past three days. Now develops fever, headache Her history reveals no past headaches On exam she has mild tenderness on the frontal sinuses and low grade temperature She request you get a CT You start her on antibiotics for sinusitis Out patient CT consistent with sinusitis.

24 Scenario 48 year old with flu like symptoms for past three days. Now develops fever, Calls 911. On exam she has mild tenderness on the frontal sinuses and low grade temperature. A. CT scan was consistent with sinusitis B. Started on antibiotics and decongestants What would you have done different?

25 Meningitis? No fever No vomiting No nuchal rigidity No Kernig s sign No Brudzinski s sign CT negative.

26 Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 0

27 an involuntary flexion of the hip and knee when the neck is passively flexed

28 Myths Kernig s Sign Brudzinski s Sign 45

29 Headache Myths Negative Documentation Labs SAH Worst headache of my life Sudden Maximal soon after onset Different than previous CT LP Angiogram Meningitis Pre-eclampsia Kernig s Brudzinski s BP is normal She is not pregnant Fever Neck stiffness Immune compromise Head/neck infection Jolt Accentuation test Temporal Arteritis ESR is negative Jaw claudication Temporal tenderness/nodularity Visual symptoms Acute Glaucoma CT first LP CBC Chemistry UA Coagulation Biopsy Cervical Artery Dissection Cranial nerve deficits Facial pain SAH like onset Angiography 46 46

30 THANK YOU