Morbidity and Mortality

1. Morbidity and Mortality Deepa Mocherla

2. Purpose • ACGME requirement • Clinical quality improvement • Identifying and correcting errors in a medical system of care • Modify behavior and judgment based on previous experiences • Prevent repetition of errors

3. Severity Index • Not a clinical quality of care issue • Care appropriate • Predictable event • Anticipated and widely reported • Unpredictable event • Unanticipated event, infrequent but know to occur • Identified quality of management concern • Care identified that may be outside the expected standard that did not result in significant harm • Identified serious quality or management concern • Outside the expected standard of care that may have contributed to morbidity/mortality

4. Aims for improvement • Safe: Avoiding injuries to patients • Effective: Providing care based on scientific knowledge and avoiding care that does not benefit the patients. • Patient centered: Providing care that is respectful and based on patient preferences, needs, and values. • Timely: Avoiding harmful delays • Efficient: Avoiding waste of supplies, equipment, energy. • Equitable: Consistent care regardless of gender, ethnicity and socioeconomic status.

5. June 2009 • Total number of deaths in UMC: 25 • Total deaths in UNSOM IM service: 6 (24%) • Autopsies: 1 • Distribution: • ICU Service – 5 • Medicine Team - 1 • Total charts reviewed 6 Severity index 1: 0 Severity index 2: 4 Severity index: 3: 2 Severity index 4 & 5: 0

6. Case • 38yr Hispanic male with unknown medical history was brought to ER from jail for ingestional error. • Possibly methamphetamines or PCP as per police • Pt swallowed several “pills or rocks of drugs” • He had seizure like episode and collapsed in jail • He stopped breathing and had no pulse • In Jail: CPR • Patient was brought to the ER

7. In the ER • Patent was pulseless, no respiration • BP 50/6 • Code ran in the ER • Received Epinephrine and atropine • Intubated • Transvenous pacer placed • Femoral venous line and arterial line • Started on Levophed and Neosynephirne

8. Patient then transferred to ICU • Temp 96.3 (oral) , pulse 80, BP 77/43 and O2 96% on vent • CVS: faint heart sounds, weak carotid pulses and no distal pulses • Respiratory: coarse breath sounds bilaterally • Abdomen: distended and no bowel sounds • Extremities: bluish discoloration

9. Neurological exam • Patient was not sedated but unresponsive • Fixed and dilated pupils • No dolls eye response • No cornea reflex, gag reflex • No response to pain • Reflexes absent and does not withdrawal to painful stimuli

10. Initial labs • Basic metabloic panel: • Na 151, K 5.7, Cl 112, Co2 5, BUN 13, Creat. 1.3, Glucose 325 • AG 34, Mg 4.7 • CBC • WBC 9.6, Hb 11.7, Plt 20, MCV 92.2 • LFTs • Alb 3.4, AST 159 (5-34), ALT 172 (0-55), Alk 82, TB 0.1, DB 0.1, TP 5.6 • Levels checked • Acetaminophen level: <3.0 • ETOH 14 • Salicylates <5 • Lactic acid: 16 • ABG: PH 6.9, Co2 81, O2 93 on Fio2 100

11. Assessment and plan • CNS: will test to confirm brain death • CVS: continue supportive care with pressors and IVF • Respiratory: continue vent care, repeat ABG • Electrolytes: • AG metabolic acidosis with high lactic acid levels. Placed on IV fluids and sodium bicarbonate drip • Hyperkalemia: started treatment • GI: • Elevated LFT’s likely due to shock liver secondary to cardiac arrest • As per friends, pt has no family in USA. All family in Cuba and no contact information

12. Labs ordered but not done • Urine toxicology • Patient too unstable to get the following • Apnea test • CT brain without contrast • Cerebral perfusion study

13. Hospital course • Patient condition remained labile • Contacted a person claiming to be the patients brother. • Primary spoke to the brother with the help of a Spanish translator. • Explained in detail about the patients current condition including fixed and dilated pupils, abdominal distension, development of groin hematoma, blood pressure support and possible brain death • Brother agreed to categorized patients as CAT II • Patient coded 2hrs later and was declared dead.

14. Follow up note • Primary spoke to the brother in person to explain the status. • Brother then admitted that he was not really the patients brother • Efforts then started to locate the patient’s true family member without success • Autopsy done: Cause of death and toxicology reports pending

15. Questions? • What could have been done differently? • How do you pronounce someone brain dead? • How do you categorize patients?

16. How do you pronounce someone brain dead?

17. Brain Death • Definition: Irreversible loss of all function of the brain, including the brainstem. • Three essential findings: • Coma • Absence of brainstem reflexes • Apnea • Diagnosis is primarily clinical • Detailed clinical exam • Apnea test New York state department of health, guidelines for determining brain death; December 2005

18. Prerequisites before determining brain death • Rule out complicated medical conditions that may confound clinical assessment • Severe electrolyte disturbances • Acid base abnormalities • Endocrine disturbances • Absence of sever hypothermia (core temp <32) • Hypotension • Absence of evidence of drug intoxication, poisoning or neuromuscular blocking agents The Diagnosis of Brain Death; Eelco F.M. Wijdicks; NEJM April 2001, numb 16, volume 344:1215-1221

19. Reversibility • Irreversibility of brain death is required • Rule out other causes that mimic brain death • Is the condition going to resolve? • What is the prognosis of the patient if the recovery is not complete? • Performance of any confirmatory lab tests • Reexamining after a set waiting period is optional in adults (>18 years) Continuum Lifelong Learning Neurol 2009 15(3)

20. Clinical Criteria for Brain Death in Adults and Children Wijdicks E. N Engl J Med 2001;344:1215-1221

21. Decision algorithm: prognostication of comatose survivors after CPR Coma Exclude major confounders No brain stem reflexes yes –bran death test Or Day 1 Myoclonus status epilepticus Yes – poor outcome FPR 0% Or Day 1-3 Negative SSEP (evoke potential) Yes – poor outcome FPR 0.7% Or Day 3 Absent pupil or corneal reflexes; Yes – Poor outcome FPR 0% extensor or absent motor response No Indeterminate outcome Continuum Lifelong Learning Neurol 2009 15(3)

22. Testing • Demonstration of brain death should be supervised and/ or performed by: • Trauma Physician, Critical Care Physician, Neurologist, Neurosurgery Physician, and/or ED Physician • Physician performing the clinical exam may be an attending or consulting physician UMC Administrative policy and procedures 2008

23. Confirmatory Tests • In patients with skull or cervical injuries, cardiovascular instability or other factors make it difficult to complete parts of the assessments safely • Angiography ( CT or MRI): absence of intracerebral filling at the lever of circle of willis. • Difficult in critically ill patients • Electroencephalography: Absence of electrical activity for at least 30min • False reading due to background noise The Diagnosis of Brain Death; Eelco F.M. Wijdicks; NEJM April 2001, numb 16, volume 344:1215-1221

24. Somatosensory Evoke potentials: Bilateral absence of response with median nerve stimulation • Transcranial doppler ultrasound • Nuclear medicine studies: with tracers and SPECT brain scintigraphy (Cerebral Blood Flow) The Diagnosis of Brain Death; Eelco F.M. Wijdicks; NEJM April 2001, numb 16, volume 344:1215-1221

25. Confirmatory Testing for a Determination of Brain Death Wijdicks E. N Engl J Med 2001;344:1215-1221

26. Responsibilites of physicians • Evaluate the irreversibility of potential cause of coma • Hospital policy and notifying the next of kin • Conduct and document first assessment of brain stem reflexes • Observe the individual during a defined waiting periods • Conduct and document second clinical assessment of brain stem reflexes New York state department of health, guidelines for determining brain death; December 2005

27. Perform confirmatory testing if indicated • Patients family must be given full information concerning brain death determination process • Patient religious or moral objective to brain death standard, if known • Certify brain death • Withdraw cardio-respiratory support according to hospital policies • UMC policy: Consent is not required, nor is it to be requested from patients next of kin New York state department of health, guidelines for determining brain death; December 2005 UMC Administrative policy and procedures 2008

28. How do you categorize patients?

29. Categorization • Class I: Maximum therapeutic efforts without limitations • Class II: Maximum therapeutic effort with specific limitations • Class III: Diagnostic and therapeutic efforts will be limited to comfort with no attempt to prolong life.

30. When to consider DNR in patients • Seriously ill or terminally ill patients • CPR may not be effective or partially effective • Leaving patient in worse medical state then before

31. How to discuss DNR with family • Assess the need for DNR orders • Choose an appropriate time and place with the patients family • Explain fully the illness, prognosis and existing risk factors • Proposed treatment, likely outcomes and alternative options • Discuss and answer any questions • Describe DNR and present DNR option Dr. Anthony Miller and Bernard Lo, How do doctors discuss do-not-resuscitate orders?, West J Med. 1985 August; 143 (2): 256-258 ?

32. Who can request it? • Patient, advance directive • Health care proxy, power of attorney • If patient can not decide and there is no appointed person by the patient. • Next of kin closest relatives close friend • Family members can decide if • Patient is terminally ill • Permanently unconscious • CPR will not be effective • CPR will impose extraordinary burden on the patient • Court appointed guardian Nevada Revised Statutes

33. When can a docotr decide on DNR? • Two physicians should determine that the patient will not benefit from CPR • Court approved DNR orders.

34. Do privacy rights survive death? • Yes • HIPPA survive death and lasts forever • Accessible only to the legally authorized executor or administrator • Family member become the executors of patients information • If autopsy is performed: cause of death is public information but the details and reports are not public Nevada Revised Statutes

35. How do you triage ingestional errors?

36. Ingestional errors • Three phases • Preclinical Phase: following exposure but before signs and symptoms • Toxic phase: period from onset to peak of clinical or laboratory manifestations • Resolution phase: from peak toxicity to recovery

37. Initial evaluatoin • Stabilization of patient: A, B, C’s • Patients with AMS • Rapid IV Thiamine 100 mg and Dextrose • Naloxone IV if suspicion of opiate intoxication • EKG: for diagnostic and prognostic information • Imaging studies useful in some situations • Radiopaque toxins • Ingestion of drug packets • Enteric coated pills and sustained release formulations • Pulmonary edema and respiratory distress due to exposure to toxins

38. Urine toxicology: For drugs such as opiates, benzos, cocaine, barbiturates, TCA, tetrahydrocannabinol and PCP • Other lab workup • ABG • If anion gap: check for salicylates, ethylene glycol, methanol, isopropyl alcohol, check urine for oxalate crystals, serum creatinine, glucose, ketones and lactate

39. Decontamination: • The sooner the better • Gastric lavage • Activated charcoal • Antidotes • Used if certain toxins suspected • No contraindication for antidotes • Reduce morbidity and mortality in certain intoxications • Supportive care • Seizures: treat with benzodiazepines Clinical practice guidelines; management of drug overdose and poisoning; MOH clinical practice guidelines 2/2000

40. ICU Admission • Presence of any of these eight clinical criteria predict a complicated course • PaCo2 >45 • Need for Intubation • Postingestion seizures • Unresponsive patients • Non sinus cardiac rhythm • Second or third degree AV block • SBP <80 • QRS > 0.12 seconds Predicting the clinical course in intentional drug overdose. Implications for use of the intensive care unit. Brett AS; Rothschild N; Gray R; Perry M; Arch Intern Med 1987 Jan;147(1):133-7.

41. References: • Clinical practice guidelines; management of drug overdose and poisoning; MOH clinical practice guidelines 2/2000 • Predicting the clinical course in intentional drug overdose. Implications for use of the intensive care unit. Brett AS; Rothschild N; Gray R; Perry M; Arch Intern Med 1987 Jan;147(1):133-7. • New York state department of health, guidelines for determining brain death; December 2005 • The Diagnosis of Brain Death; Eelco F.M. Wijdicks; NEJM April 2001, numb 16, volume 344:1215-1221 • How do doctors discuss do-not-resusciate orders?, Dr. Anthony Miller and Bernard Lo, West J Med. 1985 August; 143 (2): 256-258 • Continuum Lifelong Learning Neurol 2009 15(3) • Nevada Revised Statutes • UMC Administrative policy and procedures 2008