Attachment E1 - Example of Audit Review.pdf

CASE ID

The documents, records, and other information contained herein, which resulted from Risk Management are confidential and privileged under the provisions of 38 U.S.C. § 5705, and its implementing regulations. This material cannot be disclosed to anyone without authorization as provided for by that law or its regulations. The statute provides for fines up to $20,000 for unauthorized disclosures.

PEER REVIEW FOR QUALITY MANAGEMENT REPORT

Case ID: DODID:

Patient Name:

Event date(s) to be reviewed: -

Episode of Care: -

Practitioner to be reviewed:

Credential: MD/DO

Specialty: Hospitalist

LEVEL OF CARE (select one):

Level 1 – Most experienced and competent clinicians would have managed the case in a similar manner.

Level 2 – Most experienced and competent clinicians might have managed the case differently, but it remains within the standard of care.

Level 3 – Most experienced and competent clinicians would have managed the case differently.

ASPECTS OF CARE (Level of Care 2 or 3 Only, select as many as appropriate):

Choice and/or timeliness in ordering of diagnostic tests.

Addressing abnormal results of diagnostic tests.

Timeliness of treatment initiation and/or appropriate treatment choice.

Performance of a procedure or treatment.

Timeliness and/or appropriateness of diagnosis.

Recognition and communication of critical clues to patient’s clinical condition.

Timely initiation of appropriate actions during periods of clinical deterioration.

Health record documentation.

Supervision of health profession trainees.

Attachment E1: Example of Audit Review

The documents, records, and other information contained herein, which resulted from Risk Management are confidential and privileged under the provisions of 38 U.S.C. § 5705, and its implementing regulations. This material cannot be disclosed to anyone without authorization as provided for by that law or its regulations. The statute provides for fines up to $20,000 for unauthorized disclosures.

SPECIFIC QUESTIONS FOR REVIEWER:

y/o transferred to stepdown for hypotension and within hours transferred to ICU for hypotension/hypothermia and family decided comfort measures only. Veteran died 3 days later after being transferred from ICU. Resident: . Questions: Explain if clinical deterioration was addressed appropriately and in a timely manner. Explain from a quality perspective if there was anything that could have prevented an ICU visit. Explain if goals of care were discussed with Veteran/family. Explain if there was adequate resident supervision. What educational or quality improvement opportunities are there to be learned from this case? Any additional comments/feedback?

SPECIAL INSTRUCTIONS:

Nothing Needed

BRIEF CLINICAL SUMMARY/CASE OVERVIEW:

y/o male Hx: PAF/ DM2/ CHF systolic dysfunction/ CAD/ CKD stage 4/ hypothyroidism/ anemia/ HLD/ previous stroke/ leg edema with heel ulcers/ debility. Patient was DNR. Patient was admitted on for hypotension and hypothermia. Initially thought to be septic from possible urinary source. Responded well but developed worsening renal failure requiring initiation of HD on . Patient was progressing slowly.

On , he was found to be more hypotensive 87/51 and hypothermic. At that point it was felt patient should be transferred to ICU for BP support with vasopressors. Per Resident’s note family agreeable for escalation of care at that point on a temporary bases. He had blood cultures/ given IVF and vasopr essors.

Suspicion of septic shock and/or hypovolemic shock since he had had frequent stools for a couple of days prior and fluid removed through HD. The next day patient’s wife opted for ‘comfort measures’. She was informed patient was actually dying, and she did not want him to suffer. Comfort measures were initiated and patient was transferred out of ICU. He came to a demise on . On the day of decompensation, the reviewer did not find a note from the attending (being reviewed) addressing the event but rather the note from critical care. The resident however did comment in the note the case discussed with attending on call.

SALIENT FEATURES OF THE CASE:

1. Elderly y/o male Hx: PAF/DM2/CHF/CAD/HLD/CKD stage 4/ hypothyroidism/ anemia/ heel ulcers.

DNR.

2. Admitted on for hypotension and hypothermia.

3. Treated for presumptive sepsis. Adrenal insufficiency was ruled-out. Slow improvement.

4. Developed worsening AKI requiring initiation of HD on .

5. Change of status in the morning of with worsening hypotension 87/51 and hypothermia.

6. Transferred to ICU for BP support with vasopressors (after discussion with wife).

7. Likely septic shock and possible hypovolemic shock due to frequent BMs and fluid removal through HD.

8. Wife opted for “comfort measures” instead of aggressive care.

9. Patient was transferred to medical floor and expired on .

COMPONENTS OF CARE:

1. Was the choice of diagnostic test(s) appropriate?

Yes

2. Were the test(s) ordered and performed in a timely fashion?

Yes

The documents, records, and other information contained herein, which resulted from Risk Management are confidential and privileged under the provisions of 38 U.S.C. § 5705, and its implementing regulations. This material cannot be disclosed to anyone without authorization as provided for by that law or its regulations. The statute provides for fines up to $20,000 for unauthorized disclosures.

3. Was the management of abnormal test results appropriate?

Yes

4. Was the correct diagnosis made?

Yes

5. Was the medical treatment appropriate?

Yes

6. Was the medical treatment completed in a timely manner?

Yes

7. Were there any complications from the procedure/surgery?

Not Applicable

8. Was the patient monitored adequately?

Yes

9. If there was a change in the patient’s condition (e.g. clinical deterioration), was it recognized and communicated in a timely fashion?

10. If there was a change in the patient’s condition (e.g. clinical deterioration), was it appropriately managed?

11. Was the medical record documentation timely and complete?

Yes

12. Were health professional trainees (e.g. medical residents, nursing students) involved in the patient’s care?

Medical resident

Yes

13. Was supervision appropriate?

Mostly yes. The reviewer did not see a note from the attending physician for the day of decompensation however the resident's note did state case was discussed with attending who agreed with plan of action.

Yes

14. Do you have additional quality improvement suggestions?

Attending in charge could have written a note pertinent to events when there was decompensation or change of status (besides the note form critical care)

Yes

15. Were there any system or process issues that may have influenced the clinician’s ability to provide optimal care?

No

16. Were established standards of care /practice consistent with current literature and relevant/current practice guidelines?

ANALYSIS THAT SUPPORTS LEVEL OF CARE:

The documents, records, and other information contained herein, which resulted from Risk Management are confidential and privileged under the provisions of 38 U.S.C. § 5705, and its implementing regulations. This material cannot be disclosed to anyone without authorization as provided for by that law or its regulations. The statute provides for fines up to $20,000 for unauthorized disclosures.

Medical care was appropriate for this elderly Veteran with multiple comorbidities. The case was discussed with family prior to transfer to ICU. Apparently the wife wanted to see what direction patient would go. The following day the wife opted for ‘comfort care’ in view of the Veteran’s significant disease.

Most experienced and competent clinicians would have managed the case in a similar manner.

CONCLUSIONS/RECOMMENDATIONS:

Chart was reviewed at length. It is the reviewer’s impression that the care provided for this elderly Veteran was appropriate and within standard. Clinical deterioration was addressed appropriately and in a timely fashion.

From a quality perspective, further discussion with the wife regarding quality of life and prognosis was necessary. Per notes, apparently that took place and the wife seemed agreeable with initial plan of action with transfer to ICU for vasopressors. Immediate goals of care were discussed. There was no documentation from the attending regarding supervision of resident on , even though the resident did state discussion with attending prior to transfer to ICU.

REFERENCES, IF APPLICABLE:

N/A

REVIEWER’S CREDENTIAL & SPECIALTY:

MD, Internal Medicine, Hospitalist

All contract reviewers are required to provide an attestation that they are board certified, meet clinical qualification requirements, and have no conflict of interest, prior to being assigned to complete a VHA clinical review.