Anatomy of a Verdict - ECI Partner Portal - ECI Healthcare Partners

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Anatomy of a Verdict - ECI Partner Portal - ECI Healthcare Partners

VERDICT

Lessons Learned

and Medical

Wrap-Up

Rade B. Vukmir, MD, J.D., FCCP, FACEP, FACHE

Chief Clinical Officer,

ECI PSO, LLC

Chairman,

Risk Management and Education


Objectives

• Be familiar with recommended testing for

chest pain patient

• State which biomarkers are most sensitive

• Recognize that even normal ECG can be

ACS

• Identify the abnormal presentations that

may represent cardiac disease or AMI


Quality Management (QM)

1950 Japan - W. Edwards Deming

1. Break down barriers

2. Management learn responsibilities

3. Supervision help people and

technology

4. Constant improvement of processes

5. Vigorous education


Total Quality Management (TQM)

• 1986 Motorola

• 1995 General Electric

• Six Sigma (DMAIC)

1. Define

2. Measure

3. Analyze

4. Improve

5. Control

• Entire chain contributes including consumer


Quality Improvement (QI)

1. Healthcare modification

2. Formal approach to analysis of

performance

3. Systematic efforts to improve

4. Continual process


Continuous Quality Improvement

(CQI)

What Does Quality Mean to Me?

Industrial

Product defect

Production

failure

Cost

Medical

Mistakes

Medical errors

Outcome

Administration

Efficiency

Effectiveness

Integration


ECI PSO, LLC

June 17, 2009 - Designation of

the ECI Patient Safety

Organization (ECI PSO), LLC

by the Agency for Healthcare

Research and Quality (AHRQ),

on behalf of the Secretary of

Health and Human Services.


ECI PSO, LLC

• The first physician-focused, acute care

management and staffing organization

to earn the federal designation as a

listed Patient Safety Organization.

• Regional Quality Executive Committees

• Cases reviewed upon referral

• Objective, evidence-based review


Quality Executive Committees

Karol Vanderhoff, Execu;ve Director

Jennie Perke@e, PSO Coordinator

Current

1. VEP QEC

2. St. Louis QEC

3. Northeast QEC

4. Heartland QEC

5. ICP QEC

Future

6. HCI QEC

7. Great Lakes QEC

8. Ohio Valley QEC

9. Plains QEC

10. Gulf Coast QEC

11. AEP QEC


VEP QEC

Chairman: John Carmack, MD

Members: Nevan Chang, MD

Kevin Connelly, MD

Stephanie Anderson, MD

Charles Shields, MD

Dorothy Lester, PA-C

Greg Sandine, PA-C

Mina Tabibi, PA-C

Kimberly McFadden, PA-C


St. Louis QEC

Chairman: Shamim Amini, MD

Members: Paul Omondi, DO

Michael Clippard, MD

Megan Connick, MD

David Davis, MD

Alicia Haywood, MD

Joseph Karre, DO

Scott Landry, MD


Northeast QEC

Chairman: LouAnne Ten Kate, MD

Members: William Rosenfeld, MD

James Blythe, MD

Lynn Miller, MD

Jeffrey Corsetti, MD


Heartland QEC

Chairman: Kevin Oliver, DO

Members: Janda Stevens, MD

Serge Golber, MD

Faisal Lala, DO

Bruce MacKenzie, MD

April Bisaga, DO

Eric Schulz, MD


ICP QEC

Chairman: Christine Langemo, MD

Members: George Thomas, MD

Mark Hamed, MD


PSO Sample

All visits

Referral rate 1:10,000 (< 0.01%)

Chest Pain – 10%

Action 1/3 Advisory/None 2/3


Case Analysis

Case Action

1. 80 F Weak and Dizzy Cardioversion

2. 52 M Bilat Shoulder Pain Musculoskeletal

3. 96 F SOB for days Flu Treatment

4. 85 F Shaking Fluids

5. 61 M Chest pain/pressure Reproducible chest pain–

single set enzymes


Case Analysis

Case Action

6. 37 F SOB, chest pain, sore Outpatient mgt

throat, itchy ears

7. 71 F COPD, SOB, anxiety Xopenex

8. 49 F Chest Pain x 2 wks Ativan

“Lots of stress”

9. 55 M Chest discomfort Lovenox, Tenormin

Woke from sleep


Case Analysis

Case Action

10. 69 M SOB after discharge Solumedrol, atrovent

COPD

11. 57 F SOB, headache, dizzy Admit – VTE prophylaxis

12. 64 M Fever, vomiting, SOB Admit - Dx UTI -

Ciprofloxacin

13. 47 F Abd pain, nausea, SOB, PICC Line Referral

S/P Gastric Bypass

14. 80 M Chest pain 9/10, anxiety STEMI


Evidence Based Practice -

History

Acute Myocardial Infarction

• 22% of patients describe symptoms as being sharp or

stabbing in character

• Up to 6% describe pain that is pleuritic

• No identifiable symptom complex allows for the safe

discharge of the chest pain patient without objective

testing

Tin;nalli's Emergency Medicine: A Comprehensive Study Guide, 7e


History

• Atypical presentations of ACS occur

more frequently in

– women

– nonwhite minorities

– diabetics, the elderly

– psychiatric disease

– altered mental status

Tin;nalli's Emergency Medicine: A Comprehensive Study Guide, 7e. Chapter 52.


Evidence Based Practice - History

• Atypical presentations of ischemia in women

include

– pain relieved by antacids

– Pain unrelated to exercise

– Pain not relieved with rest or nitroglycerin

– Palpitations without chest pain

– Fatigue as a chief complaint

– Painless presentations are more common in women

(37.5%) versus men (27.4%)

Tin;nalli's Emergency Medicine: A Comprehensive Study Guide, 7e. Chapter 52.


Atypical AMI Presentation

Bayer Tinker Uretsky Pathy

Typical 66% 58% 74% 19%

Atypical 34% 42% 26% 81%

SYMPTOMS

Dyspnea Fa;gue Diaphoresis

Syncope Nausea Abdominal Pain

Confusion Emesis

Stroke Anxiety


Diagnostics - ECG

Missed AMI 2 – 4 %

50% Diagnostic changes

20% – 30% New ST - T changes

10% – 20% Old ST – T changes

10% Non-specific

1% - 7% Normal


Diagnostics – The ECG

1. Single ECG

Sensitivity 60%

Specificity 90%

2. Serial ECGs in pain setting

Increase the diagnostic utility

3. Initial ECG is nondiagnostic

50% of patients

4. Nondiagnostic or normal ECGs

does not exclude AMI

Tin;nalli's Emergency Medicine: A Comprehensive Study Guide, 7e. Chapter 52.


Diagnostics - AMI

• Typical rise and gradual fall (troponin) or more

rapid rise and fall (CK-MB)

• With at least one of the following

– Ischemic symptoms

– Development of pathologic Q waves on the ECG

– ECG changes indicative of ischemia

– Coronary artery intervention

American College of Cardiology / European Society of Cardiology


Diagnostics – Serum

Markers

Chest pain onset Sensitivity

0 – 3 hr 25% - 50%

3 – 16 hrs 40% - 100%

0 – 3 h

0 – 6h

0 - 9 h


Serum Markers in AMI

Single Presenta;on Serial

CK 37% 69 -­‐ 99%

Troponin I 39% 90-­‐11%

Troponin T 39% 93%

CKMB 42% 79%

Myoglobin 49% 89%

Combina;on

CKMB/Myo 83% 100%

TNI/Myo 97% McCord 90 min

Myo/CKMB/TNI 100% Ng 90 min


Serum marker sensi;vity rela;ve to the ;me of onset of chest pain in the pa;ent

with acute myocardial infarc;on. Data obtained from the medical literature. AMI,

acute myocardial infarc;on; CK-­‐MB, crea;ne phosphokinase MB frac;on.

Marx. Rosen's Emergency Medicine -­‐ Concepts and Clinical Prac;ce, 7e.


Evocative Testing in ACS

ACS AMI

Exercise Stress 65 -­‐ 70

Rest echo 70 93

Stress echo 90

Nuclear stress 81 67

Cardiac CT 86%

Catheteriza;on 95 -­‐ 97%


ED Stress Testing

Gibler

Low risk (


Conclusion

Bad things can happen to good

people.

Be careful out there!

31


This presentation is part of the education program

that has been prepared by ECI Healthcare Partners for its clients.

Information contained herein may address emergency medical practice in general,

but it is not a substitute for the physician’s judgment, knowledge,

and skill in the care and treatment of any individual patient.

This information is a guide to assist the physician in a wide variety

of circumstances and is not intended to establish a standard of care.

ECI Healthcare Partners is a corporation providing management

and administrative support to limited liability partnership clients.

It is not a direct provider of professional medical care services. ©2012

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