Hospital Medicine Process Improvement and Care Innovation “The Problem List” Resident Noon Conference July 15, 2015 Rajesh Chandra, M.D. Associate Professor.

Hospital Medicine Process Improvement and Care Innovation

“The Problem List”

Resident Noon ConferenceJuly 15, 2015

Rajesh Chandra, M.D.Associate Professor of Medicine

Division ChiefGeneral 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 taskSimplifying a complex task

- Making Inpatient Care and management - comprehensive & complete- competent & efficient- safe - high quality - professional

Overview of Hospital Medicine

Treatment Plan

Problem List

History Physical Data

Discharge!!

Patient ManagementProcess 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 ManagementProcess 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.

CasePMHxCOPDHTNDMNo prior surgeries

FMhx – nothing relevant

Meds – Combivent, Lisinopril, HCTZ, Insulin

Allergies – none

CaseSocial 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

CasePhysical 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, NDRt. groin non-tender irreducible 3cm x 3cm lumpLiver edge felt 2cm below RCM with liver span ~ 14cm No ascites

• Ext – no edema

• Neuro – no focal motor deficit

CaseSignificant 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 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.

PROBLEM LIST

3 day h/o a productive cough, fever, Rt. pleuritic CP and SOB

Problem list generationPMHxCOPDHTNDMNo prior surgeries

FMhx – nothing relevant

Meds – Combivent, Lisinopril, HCTZ, Insulin

Allergies – none

Social historySmokes 1 ppd since age of 16Drinks 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 SOBCOPD 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 approachPHYSICAL 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 expiratorywheezing

CVS – S1, S2 – nl; no murmurs Abd – soft, NT, ND

Liver edge felt 2cm below RCMliver span ~ 14cm; no ascites

Rt. Groin non-tender irreducible3cm 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 hypoxiaCOPD

+ active wheezingOral – dry, coated tongueAnorexia, Weight lossDecreased exercise capacityHTN - controlledDMChronic Alcoholism

+ hepatomegalyRt. groin lump – Inguinal herniaNicotine Addiction

Case Problem ListLabs:

Blood Glucose – 353

Na 133 Cl 92 K 3.5 CO2 30 BUN 40 Cr 1.7

Hgb 10.7 Hct 31 MCV 90Platelets 105,000WBC 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 PNEUMONIACOPD Exacerbation

Dehydration with AKI Likely 2° Chronic Alcoholism and Alcoholic Liver diseaseUncontrolled DM without DKAHTNAnemia (normocytic)LLL Pulmonary Nodule + Wt Loss

Inguinal hernia (asymptomatic)Nicotine Addiction

Traditional Approach Problem List (a Hospitalist’s view)

1. RLL Pneumonia

2. COPD Exacerbation

3. Dehydration

4. AKI secondary to dehydration

1. RLL 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. Right Inguinal Hernia - asymptomatic

Problem List → To Do List(Assessment) (Plan)

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

→ 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 → Discharge Summary

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 Diagnosis1. RLL Community Acquired Pneumonia

2. COPD Exacerbation

3. Dehydration

4. AKI secondary to dehydration

5. Uncontrolled DM

6. Anemia (Normocytic – Hgb 10.7)

7. LLL Pulmonary nodule - benign

8. Alcoholic Liver disease

9. 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 ApproachBenefits

• 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 MedicineProcess Improvement and Care Innovation

Future topics:

• The Discharge Process• Choosing wisely

Thank you!

Questions?