(R)esults : We finally issued circulars borrowing from global guidelines that have been shared in detail below along with the minutes of of each meeting in the results section of this raw pre print that will need to be thematically analyzed further.
[4/20, 8:19 PM] Rakesh Biswas: Nostalgia 2018
[4/20, 8:40 PM] Metacognitist Mover and Shaker1: Got badly torn apart for this case sir 😖
[4/20, 9:12 PM] Rakesh Biswas: Should have preserved that 'getting torn apart' video!
[4/20, 9:19 PM] Metacognitist Mover and Shaker1: Yes. Good example of how not to treat a PG.
[4/20, 9:51 PM] Rakesh Biswas: We need to do a series of videos on it! I have forgotten the exact incidence though. Any leads to what actually happened that day?
[4/20, 10:07 PM] Metacognitist Mover and Shaker1: We did not intubate a patient with ARDS and nor did we let them go to Gandhi. So they chose to stay there and overnight he worsened rapidly and passed away.
I was the PGY1 in the firing line. There was some sympathy at the end and they placed all blame on the senior(s) and that a PGY1 cannot handle such a case by themselves.
[4/20, 10:12 PM] Metacognitist Mover and Shaker1: Felt bad for several days. Reflected on it and simy accepted that I did not have the power to make certain decisions (at that stage of career) and had to let it go. Took weeks though.
Not at all nostalgic for me sir.
[4/21, 11:18 AM] Rakesh Biswas: Have you preserved those reflections or do you have a link to the patient's case report oblique deidentified open access EMR?
Answers to a few questions would add to further learning around this revisited experience such as why didn't we intubate the patient and if it was due to the family's wishes/resistance, what good would it have done by referring him to Mr Gandhi? Just demonstrate how to best practice defensive medicine?
I remember there was another elective student intern from Vijaywada around that time who chose to take on the morbidity meeting presentation challenge here for a patient of fluorosis, got similarly berated and also went home with a scar that may have influenced her PG career choice although she subsequently finished her PG from Guntur.
Learning can sometimes take unexpected turns and create permanent scars imprinted in our associative memories.
As a PGY1 or fresh intern, it's much more difficult to navigate diagnostic and therapeutic uncertainties that lie in a patient's and his her physicians journeys, rife with clinical complexity.
You shone through in your journey by taking up the challenge again with another patient of traumatic brain injury who the same professors had referred out from their unit and the patient relatives self referred themselves back again to us and you had the courage to present it back to them again in a morbidity meeting as to how we had managed to support his improving outcomes from coma and finally you published it in BMJ as your first publication!
@Rahul healthcare 2.0 Our early foray into developing the EMR ecosystem, when we didn't even have the current discharge summary typing EMR interface was marred by the usual challenges such as getting the interns and residents to accept the E log book as an important way to learn around their patients.
We are still not out of the woods yet and may have been actually set back further by a recent policy decision by the administrative authorities but somewhere down the line, I feel, many of the members in our ecosystem would have realized the utility of documentation and retrieval toward reflective thematic analysis and learning.
[4/21, 11:49 AM] Rahul healthcare 2.0: The tide is turning and hopefully such an open discussion and learning sharing through elogs will be common.
Take a look at the Institutional Development Plan Guidelines that UGC just released for Higher Educational Institutions
See Page 29, Annexure 2, "Online Blogs & sites for every course - To provide course information and day to day progress of the students who enrolled in the course to stakeholders and public."
Unless we share and discuss, we don't learn and hence this mode is very important.
[4/21, 12:19 PM] Rakesh Biswas: Good to see UGC joining in this track that can promote better learning in the nation through transparency and accountability as first steps.
After the issues faced while our department was entrusted by the administration to manage the morbidity and mortality meetings for over a year and after meeting with frequent disruptions especially when we tried to implement 'real patient centered learning toward improving their outcomes as the pivot of our academic workflow,' I finally issued circulars and guidelines borrowing from global guidelines and I paste that below :
Note the point about :
"Safe, blame-free environment
The moderator tries to keep it safe and blame free but some old school participants sometimes may have other ideas and become combative although it's generally taken care of"
Also note the expected learning outcomes from the meeting at the bottom of the circular particularly in the minutes of the meeting, a sample of which from that time I shall share in the next message.
Date: Sun, Feb 17, 2019, 11:14 AM
Subject: re: M&M morbidity meeting enablers
To:
Cc: Medical Superintendent <med.supdt@...
This is based on "Guideline reference document for conducting effective Morbidity and Mortality meetings for Improved Patient Care" circulated by the Royal Australasian College of Surgeons Research, Audit and Academic Surgery (PDF shared earlier) :
FORMAT
Structured case identification
All cases coming to our hospital one week before the meeting where "competency gaps" have been identified in the form of difficulty, delay in diagnosis or therapy necessitating referral to another hospital or protracted stay in this hospital where the treating team have faced substantial challenges (during which time the case may have decided to leave against medical advice LAMA).
Even cases where the treating team have been able to fill in the "competency gaps" and overcome the challenges will be discussed sometimes as an illustration of our competencies.
Consistent, structured meeting format
This is structured to be a blended learning, online-offline meeting format with cases being shared and discussed online by the students and faculty 24x7 throughout the week and twice a week in an offline face to face meeting in the auditorium to validate the online case based discussion already done over the week.
Regular meeting occurrence and duration
As mentioned above the online component is 24x7 and the offline component is for one and a half hours twice a week.
Written terms of reference
Apart from this document itself which contains a large number of terms of reference for our M&M meeting we also circulate other written terms of reference weekly such as:
What is to be achieved?
Identify "hospital competency gaps" and improving patient care services using "Evidence based medical audit."
. who will take part in it?
An entire learning ecosystem of a tertiary care medical college center including students and faculty
Over the next three years
success factors, risks and constraints.
Prior dissemination of meeting agenda and cases to be presented
Being done but current involvement of all the departments leaves a lot to be desired
Inter-profession and multidisciplinary involvement
Being done but current involvement of all the departments leaves a lot to be desired
Appointment of specific M&M meeting personnel to manage administration and completeness of data
Done by the GM, MS and entire hospital administration team
Self-nomination of cases
This is our weakest link which reflects our inability to get the faculty and students of all the other departments interested in this activity. Most are far away from self nomination of cases and hardly ever express the enthusiasm to share their cases online as well as offline
CONDUCT
Consistent, structured case presentation
This has been evolving and is often jeopardized by some of the presenters who appear to make it a point to present it so badly that we don't ever call them to present again but then perhaps it just reflects the failure of our training program.
Safe, blame-free environment
The moderator tries to keep it safe and blame free but some old school participants sometimes may have other ideas and become combative although it's generally taken care of
Systems-focus
The moderator tries to keep it focused on identifying the gaps in the system but often participants tend to meander and digress
Review of close-calls as well as formal M&M cases
Over the last few weeks we have evolved to make it inclusive into adding other cases that need auditing, particularly those that are referred or leave against medical advice.
OUTCOMES
Assigning a timeline (where necessary) to recommendations for
improvement
It hasn't been done yet because we are still in the early phases of identifying the gaps and although we issue recommendations based on the minutes of the last meetings we are yet to actually think of how quickly we can fill them
Assigning an individual/group to carry out recommendations for
improvement
Yes this too hasn't been assigned although it's assumed that the hospital administration Team will look after this
Detailed record keeping
The minutes of the meeting and list of cases ran into six pages for this week
Audit of M&M meeting procedures
Again the hospital administration Team provides continuous feedback
Follow-up on implementation of recommendations for
improvement
This is currently a weak link and we are completely dependent on the hospital administration for this
Ensuring recommendations for individual/systems improvement
are made for each case
Done in the minutes of the meeting which is circulated both online and offline
Results (chronology from 2019-18) pending thematic analysis :
Detailed minutes data date wise :
Date: 5.06.2019
M&M clinical audit, Minutes of Meeting for 14th May 2019
These meetings are solely focused on identifying "hospital competency gaps" and improving patient care services using "Evidence based medical audit," through a blended learning, online E log and offline meeting platform.
Blended conversational learning Updates:
Advance notice through the referral register images for discussion audit of the same in M&M meeting was posted in the web log central group for concerned PGs and faculty on May 13, 2019:
a) Foreign body esophagus referred because he couldn't be taken for GA as blood pressure was 170/100?
b) How can a cerebral venous thrombosis be not managed here?
There was no response from the concerned PGs or faculty and some of these cases were posted for detailed discussion in the coming M&M meetings.
Case discussion minutes on Tuesday 14 May, 2019
1) Chronic Morbidity:
50 years old man with inability to walk due to weakness and pain during walking, admitted in GS II suspecting peripheral vascular disease on 30/4/19 and transferred to GM VI on 10/5/19.
IP number: 201915921
Presenters: Dr Sasank, Dr Meena, Dr Santosh, Dr Murthy and other PGs and staff from the department of Surgery
Discussion points: Evidence of peripheral vascular disease in this patient, outcomes achieved in 14 days of hospital admission.
Inputs from GM VI, Dr Ramesh, Dr Vamshi, Dr Vijaylaxmi and other PGs and staff of department of Medicine.
Detailed hand written minutes are available with MS office and Medicine department office and a brief summary of the conversations are as below:
The initial diagnosis of the surgery treating team was peripheral vascular disease. Some factual questions on peripheral vascular disease were thrown at the presenting PG such as critical ABI values and some questions related to incomplete neurological examination of the patient. Later the diagnosis shifted to that of a myopathy followed by a possibility of muscle cramps and hypokalemic paralysis that is quite commonly seen in this season around our hospital villages.
https://www.ncbi.nlm.nih.gov/m/pubmed/27735149/
2) Acute Morbidity
40 year old man with right lower lobe pneumonia and severe metabolic acidosis admitted in GS 1, on 29/4/19 , IP 201915753
Presenters: PGs and staff of GS 1
Detailed hand written minutes are available with MS office and Medicine department office and a brief summary of the conversations are as below:
It was brought out by the audience that the cause of death in this 40 year old man was not clear as a simple consolidation may not have cause this rapid deterioration and another possibility kept was that of a missed pancreatitis and the inability to get a pathological autopsy was lamented.
CHAIRMAN
MORTALITY / MORBIDITY MEETING
Copy to:
· Principal
· Medical Superintendent
· HOD’s of Bio-Chemistry, Pathology, Microbiology
· All Department HODs
Minutes of today's meeting 11th may 2019
presented in the last meeting by Dr Bhawani, Intern and Dr Anusha, SR.
Currently the patient is still comatose on ventilator and his sepsis has again worsened.
The handwritten referral register kept with the Nursing superintendent, where residents from all departments make a note of the reason for referral was studied to identify the competency gaps with a plan to make it a regular real time audit presentation from each PG during the audit component of the meeting.
In today's meeting we read out from the images of the referral register shared in advance in the web log central group for the PGs to prepare their answers.
Referral 1:
The referral done in view of lack of equipment here to isolate a tuberculosis patient was explained in detail by Professor and HOD Microbiology and it was concluded that an N95 mask for the caregivers and ordinary mask for the patient would suffice. It was decided to make a note of this to the administration and ma'am shall also share a link to the guidelines for active TB isolation here. Later in the online shared guideline it was pointed out that the N95 is mandatory for MDR TB and not all TB.
Prof of Microbiology: "Proper control of ventilation to lessen the load of bacteria in AIIR is required. This is through proper engineering control of isolation room. But CDC recommend Respirator usage as infection preventive measure for HCW working in isolation room for Tuberculosis . One more thing is whether it is MDR or non MDR, it is Mycobacterium that will get transmitted by air born route .
Prof Medicine: Thanks ma'am. Let's specify our requirements to prevent TB contagion to the administration here so that we don't have to refer our active TB patients to higher centers who are assumed to be currently able to meet those requirements better than us.
Let's find out and specify here what equipment they have which we don't and then let's debate the evidence based justification for that equipment here.
Referral 2
The referral for anterior abdominal wall necrotising fascitis was due to unfamiliarity with the condition and inability to take the decision on further management around this patient as it was a relatively rare presentation. This was as discussed by Dr Nikhil SR Surgery and Prof Prabhakar, Pediatric Surgery.
Discussion minutes on cases presented on May 11, 2019
Two mortality cases were discussed for two hours and the third case of morbidity couldn't be discussed due to time and was postponed.
The first was around a 76 year old man who had a hollow viscus perforation and OT was held up as there were no family members to provide consent. Meanwhile the patient went into hypotension and severe metabolic acidosis and collapsed. Rest of the detailed hand written conversation during the meeting around this patient is available in MS office as well as Medicine office with Mr Saidulu.
The second patient was a 55 year old man with an adrenal incidentaloma revealed post road traffic accident and a possibility of hypertensive encephalopathy. Questions were raised around the arrhythmia in the patient's ECG as well as his pneumothorax as to the degree of his pneumothorax and if it merited ICD insertion. For rest of the discussion and conversations please refer to the hand written minutes available in MS office as well as Medicine office
Discussion minutes on cases presented April 23, 2019
39M with a chronic cheek ulcer and post operative pancytopenia with cheek excision biopsy results still awaited.
Presenters: PGs and staff from the department of Otolaryngology along with PGs and staff of pathology.
Questions were raised around necessity of removal of the mandible in this patient and it was brought out that the mandible appeared to be macroscopically involved to merit removal. Also on the question of why tracheostomy was done, it was mentioned that it was a defensive tracheostomy.
19 year old woman with recent onset fever, shortness of breath, abdominal pain treated as cerebral malaria underwent ventilation for ARDS along with tracheostomy.
Insert images of chest X-ray
Presenters: Dr Vinuthna, Dr Deepak, PGY-2 from department of Medicine along with Dr Sudheer, consultant incharge of the patient from department of Medicine.
Questions around indications for dialysis in this patient were raised and the treating team mentioned it was due to refractory hyperkalemia.
b) 70 year old man with altered sensorium, left sided flailing involuntary movements and a blood sugar of 700 along with renal failure
Presenters: Dr Pavani, Intern, ICU, Dr Deepak, PGY 2, Dr Keerti, PGY2 and Dr Anusha, Dr Sudheer from the department of Medicine
Patient was on ventilator for almost 25days and developed nutritional edema during hospital stay along with persistent encephalopathy following his initial presentation with hyperosmolar non ketotic coma along with Hemiballismus. The Hemiballismus subsided after the blood sugars were controlled. The cause of his encephalopathy and collapse consolidation remained unknown till death and the patient's autopsy consent couldn't be taken so the cause of death remained unknown.
The M&M meeting also continues in a blended learning online Web log central platform frequented by faculty (few) and students (lurkers) and following are some of the online conversational minutes shared in and around the date of the "face to face" meeting on April 21, 2019:
"The piece here by veekayvee (kindly shared by our medical superintendent) makes this important point that "Evidenced based medicine" is never taught in our medical schools. How many of us or our students know the NNTs of any of the drugs we keep prescribing with godlike impunity each day? Isn't it time we started teaching and learning "Evidence based Medicine" in both UG and PG at least in our own Institute?
The first step to learning EBM is to encourage our students to ask questions as to what is the efficacy of an intervention that we are about to deliver (in a godlike manner perhaps at an ungodly hour).
The second step would be to structure the question in a PICO format such as how many (P)atients had been trialled on with this intervention in the past? What was the exact (I)ntervention they received? How many people were there in the (C)omparator (placebo) group and finally what were the (O)utcomes in the placebo vs the intervention group.
All our M&M meetings are held with the sole purpose of instilling this question asking ability in our students. After one year we have been able to push some of them to at least start asking questions even if not in the PICO format. We have a long way to go.
All our PG presenters are encouraged to ask us these questions around the patient they are supposed to present way before the meeting date but they are almost always unable to communicate their questions on whatsapp well in advance before the presentation. We can help them to formulate the PICO questions and search the answers to the questions only if they share their patient data with us way before the presentation."
The handwritten referral register kept with the Nursing superintendent, where residents from all departments make a note of the reason for referral was studied to identify the competency gaps with a plan to make it a regular real time audit presentation from each PG during the audit component of the meeting.
No sample E-log notices to concerned PGs were shared that week.
Discussion minutes on cases presented April 23, 2019
25 yr old primi gravida with 31wks 4 days gestational age with severe preeclampsia with oligohydromnios with IUGR with absent diastolic flow on 4/4/2019
Presenters: PGs and faculty of unit 4, OBGy
Additional discussion inputs by pre eclampsia and oligohydramnios thesis students Dr Alekhya and Dr Anjali
Blended learning discussion:
Some general queries as well as queries that may be relevant to Evidence based gynecology and raise suitable questions in the PICO format.
1) General query: Severe hypoalbuminemia in this patient is due to her proteinuria alone or due to any other factor?
2) EBM query: What is the evidence for giving iv albumin (I) in severe hypoalbuminemia? Can you find any trial where they tried to answer this question? How many patients (P) were there in that trial? How many in the placebo (C) group? What were the outcomes (O) in both these two groups?
Why did you choose Cardace and Aldactone as antihypertensives and why not something else? How much was the proteinuria? Guess it was not estimated quantitatively?
OBG PG presenter: No sir quantitatevly it was not measured
OBG Pg presenter: Bcoz patient was having edema sir...so reduce both edema and hypertension
Medicine Faculty: Maybe it was not necessary for this particular patient where we were anticipating recovery following the delivery but given her apparent disproportionately severe hypoalbuminemia can you review the literature and find out the reasons for hypoalbuminemia in patients with pre-eclampsia?
Medicine faculty: Can you share some similar precedence in past literature where lasix has been used in severe pre eclampsia in this manner as you suggest (to kill two birds with one stone)?
For more detailed offline meeting minutes please refer to the attached hand written notes with this typed minutes.
49 year old woman presented to pulmonary medicine department on 2/4/2019 with diabetes mellitus and miliary tuberculosis and also had a sudden myocardial infarction.
Presenters and discussants:
PGs and staff of the department of Pulmonary Medicine.
NO PG or FACULTY from the planned presenting department attended the meeting on that day and subsequently for the next one month.
April 16, 2019:
The M&M meeting also continues in a blended learning online Web log central platform frequented by faculty and students and following are some of the online conversational minutes shared in and around the date of the "face to face" meeting on April 16, 2019:
A published report Posted by Medical Superintendent for the benefit of the PGs managing our patients:
Cardiac arrest associated with ranitidine and ondansetron combination in day care gynecologic surgery, J Anaesthesiol Clin Pharmacol. 2013 Oct-Dec; 29(4): 563–564. Authors: Vinit K Srivastava, Parineeta Jaisawal, Sanjay Agrawal,1and Diwakar Kumar, Department of Anaesthesia, Apollo Hospitals Bilaspur, Chhattisgarh, India and Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
Responses:
Medicine Prof: We had a similar patient with ondansetron alone and we had to deliver CPR in the general ward and luckily she survived
OBGy Prof: Very useful and elaborate information (in response to Medical Superintendent's post), we need to be very careful while using these drugs.
The handwritten referral register kept with the Nursing superintendent, where residents from all departments make a note of the reason for referral was studied to identify the competency gaps with a plan to make it a regular real time audit presentation from each PG during the audit component of the meeting.
No sample E-log notices to concerned PGs were shared that week.
Discussion minutes on cases presented April 16, 2019
1) Chronic Morbidity:
A father, daughter and grandson with squint since childhood.
Discussants: PGs and faculty from department of Ophthalmology
A form of isolated Duane's retraction syndrome was diagnosed and discussed by the Ophthalmology PG and the following learning points were shared:
"Less commonly, isolated Duane retraction syndrome can run in families and this is what brought the case to our attention in the first place.
As in our patient, Familial cases most often have an autosomal dominant pattern of inheritance, which means one copy of the altered gene in each cell is sufficient to cause the disorder.
When isolated Duane retraction syndrome is caused by CHN1 mutations, it has an autosomal dominant inheritance pattern."
There was no input from the genetics department.
2) Acute Morbidity (with mortality)
60 year with type 2 diabetes since 6 years presents with complaints of fever since 4 days, decreased urine output since 2 days, burning micturition since 2 days and loose stools since 2 days. Is currently on Hemodialysis.
Discussants: Dr Sandeep, Dr Ramesh, Dr Arvind and faculty of Nephrology and Gen Medicine.
Questions raised during the blended learning discussion:
"Why was the patient started on Meropenem when her urine E Coli appeared to be also sensitive to Ceftazidime Clavulunate?
"What is the efficacy of Tablet Nodosis, injection Erythropoetin and tablet Calcium in renal failure? Are they useful or unnecessary?"
The presenter was not prepared with the answers although the questions were posted in advance in the web log central group.
The M&M meeting also continues in a blended learning online Web log central platform frequented by faculty and students and following are some of the online conversational minutes shared in and around the date of the "face to face" meeting on April 9, 2019:
Prof Medicine: "The tug of war between guideline based defensive medicine and "evidence based medicine" continues."
Prof ENT: "Guidelines must have been on proper evidence only. Why will responsible associations give wrong guidelines."
Prof Medicine: "Yes very good question.
EBM trains us to read between the guidelines. Very often you can find type 1 strong recommendations for level C or D (weak and poor) evidence. It signals that better research is needed if we need better quality of evidence.
However most of us like to just go by the guideline thinking that it is gospel as they come from responsible associations.
EBM encourages us to think for ourselves. It encourages us to do better quality research and the first step is questioning the status quo.
EBM is more popular in Europe (as you can see how they have upturned the guidelines) and Guideline based medicine GBM is more popular in India due to the colonial hangover of our schooling which discourages questioning and encourages slavery."
Prof Pediatrics: "Guidelines we believe are meant to "guide" /provide uniformity in management of cases in general. But there could be variations/exceptions/co morbid conditions wherein modification of a guideline could be justified in that particular patient. Documentation for justification should be done with care."
Medical Superintendent: "Once again these guidelines, EBMs, recommendations, come to the fore when some drug company pushes their agenda and these big associations of doctors endorse them and we follow them.
So many would have been labelled as hypertensives before, put on medication too and a few yrs later only to be told that they are not hypertensives.This is true of statins, H1bAc, and many more such things, companies made money and scooted leaving the patient and his doctor high and dry."
The handwritten referral register kept with the Nursing superintendent, where residents from all departments make a note of the reason for referral was studied to identify the competency gaps with a plan to make it a regular real time audit presentation from each PG during the audit component of the meeting.
No sample E-log notices to concerned PGs were shared that week.
Discussion minutes on cases presented April 9, 2019
1) Chronic Morbidity:
A 15 years old girl with involuntary movements and inability to walk since five years.
Discussants: PGs and faculty from department of Orthopedics 2nd unit
Referrals:
Opthal PGs and faculty to discuss corneal findings in this patient along with it's differentials
Pediatric PGs and faculty to discuss the diagnosis and management of a common differential for this disorder.
The Orthopedic Resident Dr Vivek presented a bare bones history of the patient and it was supplemented well by the pediatric resident Dr Navya who had not only taken the detailed history but also presented a deidentified video of the patient's involuntary movement that was very useful. She also discussed the various differentials for the movement disorder before the discussion moved over to diagnosing and treating the topmost differential in this case it Wilson's disease.
The medicine and pediatric faculty suggested that further tests in the form of 24 hour urinary copper as well as liver biopsy for copper could be attempted if the parent unit was interested to transfer the patient. The patient was eventually referred to NIMs Hyderabad by the Orthopedic parent unit.
2) Acute Morbidity (with mortality)
59M admitted in Pulmonary Medicine with acute hypotension and respiratory distress on 24th March with chronic cough and shortness of breath since last 5 years.
Discussants: PGs and staff of department of pulmonary medicine regarding critical care management and diagnosis of the reason for his acute exacerbation and hypotension.
Referrals:
General Medicine PGs and faculty of general medicine to discuss the possible causes for his severe hepatitis and hypotension.
Nephrology PGs and faculty to discuss the reason for his renal failure and hypotension.
The pulmonary medicine PG, Dr Mudassir presented the patient followed by a few factual questions from the students and faculty in the audience which was answered by the pulmonary medicine PG.
The question about the cause for his Hepatitis was answered in detail by the Nephro PG Dr Manasa as she went into the etiology and diagnostic clues to ischemic hepatitis and it's associations such as heart failure.
M&M clinical audit, Minutes of Meeting for 26th March, 2019
These meetings are solely focused on identifying "hospital competency gaps" and improving patient care services using "Evidence based medical audit," through a blended learning, online E log and offline meeting platform.
Following are the past presentation minutes of the offline face to face meeting.
Minutes of meeting on 26th March, 2019:
Patient Updates: None shared by any department.
The handwritten referral register kept with the Nursing superintendent, where residents from all departments make a note of the reason for referral was studied to identify the competency gaps with a plan to make it a regular real time audit presentation from each PG during the audit component of the meeting.
Although the audit system in our current workflow appears to be suboptimal we continue to hold this slot to reiterate the vital need in the hope of a clinical audit program with more volunteer trainees.
The current failures of the audit meeting was discussed in the past as being due to non-participation in the form of poor sharing of the departmental cases that didn't allow the audit team any opportunity to prepare the cases for discussion as well as derive meaningful insights from the number of cases presenting to the hospital every week. A dedicated clinical audit team formed from members like interns or any other volunteers from every department unit to ensure case sharing was proposed and it was suggested that one could even develop the first clinical audit academic program in India pending approval from the management.
Discussion minutes on cases presented tuesday 26tj March 2019
1) Chronic Morbidity:
" An 8 year old boy with refractory seizures was presented and discussed both by the PGs of the pediatrics and Psychiatry department and many PGs from different departments were made to ask questions which ranged from factual ones such as what does one do if a child has seizures at home to evidence based ones such as efficacy of certain antiepileptics. The treatment of this child was optimized in a manner to reduce the frequency of his seizures.
2) Acute Morbidity (with mortality)
This was a 30 year old woman with pain abdomen admitted under surgery as acute cholecystitis but later as the patient developed sepsis and ARDS the patient was transferred to pulmonary medicine for management of ARDS.
There were some questions raised by department of surgery faculty as the presentation appeared deficient in certain clinical information around the patient.
Minutes of meeting on 23rd March, 2019:
The meeting began with many of the faculty objecting to a late paper based notice. They were informed that the notice had been deposited in MS office for circulation on the 20th of March but they had perhaps forgotten to circulate it. The notice had at the same time been circulated in the Web log central group on the 20th of March itself. Faculty members were requested to check our notices from the Web log central group.
Patient Updates: None shared by any department.
There was a plan and request for the Microbiology department in auditing the current sterilization practices around simple day to day usage of plastic and fibre optic devices such as PFT mouthpieces, endoscopes and biopsy guns. This plan was generated around discussing the first case who was retrovirus positive once it was clarified that universal precautions were the only intervention necessary for all such patients with viral marker positivity.
Although the audit system in our current workflow appears to be suboptimal we continue to hold this slot to reiterate the vital need in the hope of a clinical audit program with more volunteer trainees.
The current failures of the audit meeting was discussed in the past as being due to non-participation in the form of poor sharing of the departmental cases that didn't allow the audit team any opportunity to prepare the cases for discussion as well as derive meaningful insights from the number of cases presenting to the hospital every week. A dedicated clinical audit team formed from members like interns or any other volunteers from every department unit to ensure case sharing was proposed and it was suggested that one could even develop the first clinical audit academic program in India pending approval from the management.
Discussion minutes on cases presented tuesday 23rd March 2019
1) Chronic Morbidity:
"A 45 years old woman living with retroviral disease since 6 years of husband’s diagnosis, on HAART since 4 years presented to DVL currently complaining of swollen digits, stiffness of skin and shortness of breath since 2 years.
Discussants: Dr. Shravya, Dr. Praveen, Dr. Swetha, PGY1, Dr. Vennela, Dr. Ravikanth PGY2, Dr. Navaneetha and Dr. Vijay Bhaskar, Asst. Professor and Associate Prof Dr. Vidya Sagar and Professor, Dr. (Col) Ashok Rao Matety, Department of DVL with inputs from Psychiatry around this patient’s coping strategies for living with retroviral disease.
Soon after the case presentation by Dr Shravya the PGs were asked to put forward their queries and just one or two PGs came forward spontaneously. This can be made a regular feature so that the discussion around the patient can develop further based on the queries of the PGs especially if they are well prepared by reviewing the case details even as they receive the circular for the meeting. All PGs need to be given an equal opportunity to ask their questions and provide their inputs, serially one by one based on their seating arrangement. We look forward to developing this learning arrangement further positively over the coming months.
2) Acute Morbidity (with mortality)
50 year old man admitted in Medicine from 07.03.19 to 15.03.19 with past history of low backache and arthritis and presently progressive left thigh pain for one month followed by on current admission gangrene developing in muscles of the vastus medialis that was sent for biopsy by Orthopedic team and patient had to be ventilated for ARDS and dialyzed for AKI. He was later noted to have peripheral gangrene in limbs due to critical limb ischemia due to bilateral femoral artery thrombosis by the Surgery and Radiology team that was thrombolyzed intra-arterially by EMD team.
Discussants: Dr. Satish, PGY 1, Dr. Vinuthna PGY-II, and Dr. Anusha, Senior Resident/Asst. Professor department of Medicine along with inputs from Dr. Bhanu Rekha Department of Orthopedics, Dr Khatija, Dr Kaarthik, Dr Fatima, Department of Pathology, PGs radiology around the patient’s skeletal X ray findings as well as Doppler and EMD team around the intra-arterial thrombolytic therapy procedure in comparison to femoral end-arterectomy.
Soon after the case presentation by Dr Satish, the PGs were asked to summarize the learning points from the case and share their queries but none was forthcoming. The Orthopedic consultant who had seen this patient during life related his experience with the case and various hypothesis for his cause of the disease was put forward by members of the audience (also in the pharma E log group) but no definitive conclusion could be reached. A proper post mortem autopsy would have been necessary to understand his problem better.
M&M clinical audit, Minutes of Meeting for 19th March, 2019
These meetings are solely focused on identifying "hospital competency gaps" and improving patient care services using "Evidence based medical audit," through a blended learning, online E log and offline meeting platform.
Following are the past presentation minutes of the offline face to face meeting.
Minutes of meeting on 19th March, 2019,
Patient Updates: None shared by any department.
Audit: Although the audit system in our current workflow appears to be suboptimal we continue to hold this slot to reiterate the vital need in the hope of a clinical audit program with more volunteer trainees.
The current failures of the audit meeting was discussed in the past as being due to non-participation in the form of poor sharing of the departmental cases that didn't allow the audit team any opportunity to prepare the cases for discussion as well as derive meaningful insights from the number of cases presenting to the hospital every week. A dedicated clinical audit team formed from members like interns or any other volunteers from every department unit to ensure case sharing was proposed and it was suggested that one could even develop the first clinical audit academic program in India pending approval from the management.
Discussion minutes on cases presented tuesday 19th March 2019
1) Chronic Morbidity:
"20 yrs old woman/G2A1/32 weeks of GA/hypothyroidism/ with thrombocytopenia and leucocytosis
Discussants: Dr Sindusha PGY1 and Dr Amrita, Asst Professor, OBG
The OBG faculty were absent due to sudden MCI inspection and the PGs discussed the case well and highlighted how they had managed to overcome the diagnostic dilemma of hyperleucocytosis and thrombocytopenia by focusing on the 31 week mother's immediate issues and terminating the pregnancy followed by a dramatic recovery that led to the conclusion that it was an atypical presentation of pre eclampsia given the past history of her eclampsia where she lost her first child. However the PGs or the pediatric faculty were unable to trace what happened to the premature baby in terms of outcome. It would have been better if the OBG presenters had inquired about this from the pediatrician before the meet.
2) Acute Morbidity (with mortality)
36 M EMD 02.03.19 to 09.03.19 06:05 AM ? EPTOIN OVER DOSE WITH AKI WITH RESPIRATORY FAILURE REFRACTORY HYPOTENSION and METABOLIC ACIDOSIS Dr.Ravi PG-II
This was a patient where there was considerable uncertainty about the nature of his phenytoin ingestion if it was due to homicide or suicide. The result of police investigation was not obtained before presenting. It was requested that it be shared once the meeting was over. We are still awaiting that report.
Discussion minutes on cases presented tuesday 12th March 2019
1) Chronic Morbidity:
"60 yr old male pt agricultural laborer residing at Nalgonda District presented to the OPD with shortness of breath and pedal edema since three weeks and on examination had findings in the respiratory, cardiovascular, musculoskeletal and neurological systems.
Discussants: Elective Intern Sanjana Kurimella, Dr Keerti, PGY2 and Dr Sufiya along with medicine senior residents and faculty along with Orthopedics faculty, Dr Haranadh.
The discussion proceeded to ask the following questions:
what is the cause of this transudative effusion?why did he develop right heart failure?
is that due to pulmonary arterial hypertension?? what is the reason for developing PAH? just his ankylosing spondylitis causing restrictive lung disease? is ankylosing spondyloarthropathy because of fluorosis? if so, whats the diagnostic criteria to confirm its because of fluorosis?just epidemology? just bony changes? Are there any differentiating features in the skeletal changes of ankylosing spondylosis and that of fluorosis? if so, what are they? what more can be added to diagnostic criteria? How to manage this patient??
These were answered competently by the participant interns, pgs and faculty.
Dr Sufiya was asked about the LVEDP and RVEDP in addition while she was discussing pulmonary hypertension and she promised to look it up and let us know in the next meeting.
Dr Menon raised a very interesting possibility of tackling the persistent fluoride in the patient's body using novel techniques. Dr Haranadh emphasized the importance of prevention. Another faculty member from orthopedics pointed out the possibility of fluoride exposure from crops and agricultural activities even while the patient may be on DE fluorinated water. The entire case is E logged and shared in the central E log group for future reference.
2) Acute Morbidity (with mortality)
48 M RESP 18.02.19 20.02.19 02:15 AM B/L CONSOLIDATION DUE TO PTB WITH RVD +VE WITH TYPE I RESPIRATORY FAILURE WITH ? SEPTIC SHOCK RESPIRATORY FAILURE Dr.Anusha Rao PG-I
Dr Anusha presented the case and questions were raised by the Surgery faculty around font size and RVD, septic shock and need for mentioning stool for ova cyst in the same line.
The presentation was stopped and the faculty commented that these presentations could be detrimental to everyone.
One solution to this is to make the junior faculty responsible for the presentation of their PGs and the senior faculty responsible for their junior faculty. All departments can be given a twice weekly fixed slot on a roster to present their own M&M cases similar to what is currently existent with the clinical meeting (although in clinical meetings competencies are highlighted rather than competency gaps). The other solution which has already failed currently is to encourage more E logging of their cases by the PGs so that the M&M Team can help select and guide the PGs well in advance. We are miles away from the ideals of "inter professional education" in the WHO document circulated weeks back with the minutes and notice of a past M&M meeting but we need to keep moving.
Minutes of meeting on 9th March, 2019,
Patient Updates: Chronic peritonitis patient operated and gall bladder perforation with thick pus around the gall bladder fossa peritoneum confirmed.
Cases for discussion on Saturday 9th March 2019
1) Chronic Morbidity:
"45 yr old man with chronic renal failure and on dialysis for 1 year that was stooped since last four months after becoming HCV positive. Discussants: PGY 2 Dr Keerti, PGY1 Dr Radha, Dr Sufiya along with medicine senior residents and faculty along with Nephrology faculty.
The discussion proceeded to ask the following questions:
what is source of HCV for this patient? Is it because of dialysis machine? dialysate? tubing?
what are the screeing and confirmatory tests done for HCV detection?
what is the sensitivity and specificity of the tests used for HCV detection?
why do we have to isolate HBsAg+ patients undergoing HD but not HCV pt's??
is it because of particle size??
what about HIV+ patients? do we need to isolate them as well?
what precautions are to be taken while dialysing so that we can prevent transmission of HCV?
2) Acute Morbidity (with mortality)
57 M NEPH 21.02.19 22.02.19 04:37AM AKI ON CKD WITH PRERENAL SEPSIS DUE TO BRONCHO PNEUMONIA SEVERE HYPOVOLEMIC SHOCK WITH METABOLIC ACIDOSIS AND AKI ON CKD WITH SEPSIS WITH BRONCHO PNEUMONIA, Dr.Siphora PG-II
Dr Siphora presented the case and questions were raised by the anesthesia faculty around CPR methodology. She promised to update us on the recent advances in the next M&M meeting.
Minutes of meeting on 5th March, 2019,
Patient Updates: Colonic carcinoma patient operated and developed a post operative complication of right upper limb monoparesis with MRI showing pneumocephalus. The pneumocephalus was assumed to be unrelated to the monoparesis and possibly related to his epidural catheter. The update was also shared in the central Web log group on March 2nd 2019
Case discussion on Tuesday 5th March 2019
1) Chronic Morbidity:
"65 yr old male came with complaints of abdominal distention and ascites with signs of peritonitis and a diagnosis of gall bladder perforation was confirmed by the radiology on the third CT abdomen within a month of his initial presentation. Discussants: PGY 1 Dr Sufiya and senior resident Dr Anusha and PG Radiology.
The discussion proceeded to dissect the patient's problems and focused on the possibility of gall bladder perforation and a decision was made to operate him the very next day.
2) Acute Morbidity (with mortality)
35 year old woman with ZN phosphide poisoning and anterior wall myocardial infarction along with atrial fibrillation. Discussants PG and SR EMD.
The discussion focused on causes of myocardial infarction in phosphide poisoning and a consensus was reached that it was possibly a direct effect on the myocardium. A question was raised on the usage and utility of streptokinase in this patient as one member from audience said there were studies where empirical administration of streptokinase was shown to be effective in patients presenting with cardiac arrest with EcG not showing changes of definitive MI. This approach was discouraged by another member of the audience and a proper trial in this phosphide poisoning group would be needed to reach a better conclusion.
Minutes of meeting on 23rd February, 2019,
Patient Updates: There were no patient updates shared by any department
Audit: The audit meeting had been E logged as a prescription audit and had been discussed in the pharmacology E log group. It was about a patient who presented to ENT department with Methotrexate toxicity and her previous prescriptions showed glaring issues during the audit.
Case discussion 23rd February
1) 44F Nullipara with incidental adnexal mass. Diagnostic and therapeutic challenges.
Discussion expert: OBG Team managing this patient. Dr Sindhu and Dr Amrita
Discussion Expert: Radiology Team interpreting the USG and MRI of this patient. Dr Venkat, Dr Harish.
The first case was very well presented by the PG and discussed by the consultant OBG with regard to the challenges faced during meeting the patient's diagnostic requirements also in response to the questions posed by the moderator. The Radiology consultant felt that the minor issue for which this lady had to undergo MRIs twice was not worth discussing.
2) 60M with colonic carcinoma (long distance patient) with emergency ileostomy to relieve intestinal obstruction done one month ago is back since one week and awaits definitive surgery in the form of resection anastomosis and tumor removal but OT has been delayed due to poor fitness as the patient is malnourished from his chronic disease.
Discussion Experts: Anesthesia Department, Dr Gopal Reddy, Dr. Vinay, Senior Resident and PG Surgery department and senior resident and Professor Transfusion Medicine department.
The second case was well discussed by the three departments and the consensus was in favor of enteral nutrition than parenteral. There was a debate on the half life of commercially available albumin with the Transfusion Medicine senior resident asserting that it was 19-21 days while the moderator said that it was just 12-16 hours and promised to share a reference for the same which is now shared below:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719274/#!po=91.9580
Quoting below from the article linked above:
"The half-life of endogenous albumin is about 3 weeks, while that of blood-derived albumin is only 12–16 hours and is reduced notably in conditions of increased capillary permeability."
Quoting from another article below that explores why natural in vivo endogenous albumin half life is different from commercially available blood derived albumin
"Albumin has an extended serum half-life of 3 weeks because of its size and FcRn-mediated recycling that prevents intracellular degradation, properties shared with IgG antibodies* Engineering the strictly pH-dependent IgG-FcRn interaction is known to extend IgG half-life. However, this principle has not been extensively explored for albumin."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036356/
3) An 18 year old woman with chronic diarrhoea, significant weight loss, hypoalbuminemia and poorly defined colonic granulomas.
Discussion Expert: Department of Medicine managing this patient Dr Vinuthna, Dr Sufiya, Dr Anusha
The third case was well presented by Dr Sufiya, Medicine PG and the consensus arrived for her patient's diagnostic and therapeutic uncertainty was that the patient can be treated with antitubercular therapy as in our country as the chances of it's being TB are high and treating it as Crohn's particularly with immunosuppresives may result in exacerbation of underlying TB.
Cases for discussion on Tuesday 5th March 2019
1) Chronic Morbidity:
"65 yr old male came with complaints of abdominal distention and ascites with signs of peritonitis and a diagnosis of gall bladder perforation was confirmed by the radiology on the third CT abdomen within a month of his initial presentation. Discussants: PGY 1 Dr Sufiya and senior resident Dr Anusha and PG Radiology.
2) Acute Morbidity (with mortality)
35 year old woman with ZN phosphide poisoning and anterior wall myocardial infarction along with atrial fibrillation. Discussants PG and SR EMD.
Date: 09.02.2019
Morbidity Mortality Clinical Audit Meeting Notice
9th February (Tuesday) 2.00 pm, Mini Auditorium.
These meetings are solely focused on improving hospital patient care services using "Evidence based medical audit," through a blended learning, online E log and offline meeting platform.
Following are the past presentation minutes and future presentation plans for the offline face to face meeting.
Minutes:
Patient Updates: ENT department recovery of their parotid abscess patient. Fluctuant blood sugars.
E log patient update: Patient of peritonitis with a diagnostic dilemma around spontaneous bacterial peritonitis vs secondary bacterial peritonitis with sealed perf. Positive patient response to antibiotics as one point of distinction discussed.
Audit: OPD to IPD conversions presented for various departments
LAMA and Referrals discussed. One patient of upper GI bleed who was referred was briefly discussed and it was suggested that such patients can be sent in our ambulance to LB Nagar and brought back after the diagnostic therapeutic intervention after communicating with the GM Narketpally and Gastroenterologist in LB Nagar.
Two clinical cases discussed
1) 28 year old woman with progressive loss of vision due to optic atrophy, possible reasons and available solutions discussed. Queries were raised about referral to other centers and why certain therapeutic options couldn't be developed here.
2) 30 year old man with chronic renal failure and graft versus host, cholestatic hepatitis after autologous stem cell transplant. Attitudinal barriers to organ transplantation in our current govt approved center here discussed and ways to tackle them through psychological counselling discussed. Our new organ transplant coordinator was introduced to everyone in the meeting.
The format of the "Patient Informed consent forms" for E logging was shared in all E log groups for input from faculty and PGs and there was one input from faculty pediatrics. It is hoped that soon it will become a regular feature in OP and IP with dedicated teams to obtain this consent (similar to current video counselling).
Once the above activity starts happening on a regular basis, it will help us develop the necessary competencies to tackle the challenges to our hospital workflow on a case by case basis.
Please find attached a tentative list of cases for coming saturday, 9th February. The list of referrals and LAMAs to be discussed coming saturday, will be shared with the departments in their individual E log groups as well as central E log group.
Minutes of meeting on 9th and 12th February 2019:
Patient Updates:
E log patient update: Patient of peritonitis with a diagnostic dilemma around spontaneous bacterial peritonitis vs secondary bacterial peritonitis with sealed perf. Positive patient response to antibiotics as one point of distinction discussed and CECT of abdomen with oral contrast revealed no intestinal leakage of CT contrast into peritoneum but some abnormalities of GB wall suggestive of a perforation was noted and repeat fasting CECT abdomen advised but patient was subjectively better enough to request discharge and go home feeling cured.
Audit: OPD to IPD conversions along with LAMAs and referrals presented and discussed for various departments
It was felt that discussion around LAMA patients was confounded by the fact that the patient and relatives were unavailable for verifying our assumptions about why they left. On the other hand discussing referrals were a more objectively feasible way to assess competency gaps.
Referral case discussion 12th February
Pulmonary Medicine
A young man with Massive hemoptysis
Competency gaps: referred for ?bronchial artery embolization and or surgical bronchial artery ligation with lobectomy?
Suggestions to address the above competency gaps: Identify general surgeons keen to learn lobectomies and bronchial artery ligations. Identify radiologists keen to take up emergency bronchial artery embolization and also provide basic resources such as angiography equipment for the same.
Referral case discussion 12th February
PICU/Ped 06/F
05-02-19 (
10.am)
05-02-19 (01.00pm 2Hrs 15Mins
Chronic ITP admitted and treated here one year back with pulse steroids and this time referred to higher centre due to a decision to give iv Ig and due to unavailability of IVIG here as well as cost. Referring physician Dr. Mounika 1st Year PG
Queries raised
1) What is the advantage of iv Ig over pulse steroids? Asked for review of literature in E log.
2) Where was the patient referred to and what is the follow up? What did the referral center achieve that we may not have achieved here? (standard general queries for every referral to identify our competency gap).
We still await the online discussion from the concerned PG around the advantage in efficacy of iv Ig vs high dose iv steroids.
Clinical cases discussed 9th February
A 25M patient with pseudoseizures admitted under medicine and transferred to Psychiatry and presented by the PGs and discussed by consultant Psychiatry.
A 30M with road traffic accident who was assessed for organ procurement but apnoea test was repeatedly negative. A debate ensued between routine reduction of suspected raised intracranial pressures with craniectomy. An intracranial pressure monitor was felt desirable for better management of such cases. Also a trauma team in EMD comprising of general surgeons regularly practicing burr holes and craniectomy was suggested to address the current competency gap of neurosurgical interventions for trauma. It's an important gap to be filled in view of the high incidence of road traffic accidents in the vicinity of our catchment area.
Overall both the clinical case discussions revealed good competency of both departments in managing those cases and proved that our PGs and faculty could take up the challenge if when they are required to.
Clinical cases discussed 12th February
Obstructive sleep apnoea 60M: Brief discussion on definition and competency gaps as to why we couldn't diagnose this patient to our satisfaction.
The need for good clinical evaluation, ENT referral which was missed, polysomnography to rule out central sleep apnoea were discussed. The patient was later evaluated by the ENT department and no anatomical narrowing was detected.
Psychiatry 25M with alcoholism and withdrawal after losing family members. Rehabilitation issues discussed and recent changes to deaddiction center workflow even for demotivated patients noted where provisions for admitting and motivating them with regular counseling sessions in psychiatry ward stressed.
Young man with sudden cardiac death brought in pulseless situation discussed where the duration of CPR before declaring death was discussed.
Following are the potential mortality and morbidity (referrals and LAMAs) for discussion in the coming week
All the PGs named here in the case list prepared by MRD are requested to be prepared with their focused
presentation (identifying the competency gaps).
Three to six cases from this list will be picked at random for discussion during the meeting.
Those PGs who can discuss the cases as E logs previously may be able to finish the discussion online and those cases may not require discussion during the Tuesday-Saturday offline meeting.
Hospital Administration PGs are requested to carry all these patient files to the meeting venue in mini auditorium.
LAMA, DEATHS & REFERRALS
HOSPITAL DEATH REPORTS from 02.02.19 to 10.02.19
TOTAL CASES 11
Dated 11th FEBRUARY 2019
Sno. AGE SEX DEPT/UNIT DOA DOD & TIME DIAGNOSIS CAUSE OF DEATH Doctor
1 70 M General Medicine- IV/ Nephrology 01.02.19 02.02.19 06:30 PM AKI ON CKD LEADING TYPE I RESPIRATORY FAILURE CARDIO RESPIRATORY ARREST SECONDARY TO SEVERE METABOLIC ACIDOSIS Dr.Manasa PG-I
2 40 M General Medicine-VI 02.02.19 03.02.19 10:08PM ACUTE GASTRO ENTERITIS WITH ASPIRATION PNEUMONIA WITH TYPE I RESPIRATORY FAILURE ASPIRATION PNEUMONIA WITH TYPE I RESPIRATORY FAILURE WITH METABOLIC ACIDOSIS Dr.Vamshi PG-I
3 84 M General Medicine-VI 02.02.19 04.02.19 4:50AM ? SIADH & RECURRENT HYPOGYCEMIA SECONDARY TO MALIGNANCY : CKD : MODS REFRACTORY METABOLIC ACIDOSIS SECONDARY TO RENAL FAILURE Dr.Aditya PG-I
4 27 M General Surgery/PUL. 03.02.19 04.02.19 5:54AM ?? TRAUMA CAUSING ARDS RESPIRATORY FAILURE Dr.Sailendra PG-I
5 45 F PUL 21.01.19 06.02.19 1:35PM BRONCHIECTASIS IN RT UL, ML, LL WITH DENOVO DM II WITH TYPE I RESPIRATORY FAILURE ? LIVER ABSCESS RESPIRATORY FAILURE TYPE I SECONDARY TO BRONCHIECTASIS Dr.Mudassir PG-I
6 70 M General Medicine -II 05.02.19 07.02.19 1:02AM ACUTE ON CKD WITH MILD METABOLIC ACIDOSIS WITH SEPSIS ( BRONCHIAL CARCINOMA ) MASSIVE PULMONARY HEMORRHAGE Dr.Sufia PG-I
7 55 M EMD 05.02.19 06.02.19 8:56 PM PNEUMONIA WITH ARDS WITH RESPIRATORY FAILURE WITH SEPTIC SHOCK REFRACTORY HYPOTENSION WITH SEVERE METABOLIC ACIDOSIS Dr.N.Ravi PG-II
8 65 F Nephrology 06.02.19 07.02.19 5:20PM ARF ON CKD, PULMONARY OEDEMA WITH METABOLIC ACIDOSIS SEVERE HYPOTENSION WITH METABOLIC ACIDOSIS CARDIO PULMONARY ARREST Dr.Arvind PG-I
9 75 M General Medicine-IV 07.02.19 08.02.19 1:20AM SEVERE MIXED ACIDOSIS MI WITH VENTRICULAR TACHYCARDIA Dr.Manasa PG-I
10 65 M NEPH 08.02.19 09.02.19 5:51PM ACUTE TUBULAR NECROSIS WITH SEPTIC SHOCK SEVERE HYPOTENSION WITH METABOLIC ACIDOSIS Dr.Natasha Rao PG-I
11 75 F General Medicine-IV 10.02.19 10.02.19 3:51PM SEVERE HYPOTENSION WITH HIGH ANIONGAP METABOLIC ACIDOSIS CARDIO RESPIRATORY ARREST Dr.Manasa PG-I
REFERRALS
From :13-02-2019 To:14 -02-2019 (08.00am)
S.No. Ward/Dept Age/Sex DOA/Time Ref DT/Time Stay In Hosp. Diagnosis Reason/Remarks Referred By
1 EMD 29/M 13-02-19 (01.34am) 13-02-19 (04.00am) 2Hrs 26Mins RTA with Traumatic Head Injury for Neuro Surgery Intervention Dr.Akhila PG-I
2 Paediatric 3/M 2/1/2019 to 2/13/2019 - Left Bronchial fistula -
3 EMD 45/M 13-02-2019 7.25PM 13-02-19 8.30PM 1 Hr. SDH with Occipital bone fracture for Neurological Intervention Dr.Vivek PG-II
4 General Medicine 53/M 14-02-19 (03.20am) 2/14/2019 - History of SOB for Cardiologist intervention
LAMA DETAILS - FROM DATE: 02-01-2019TO DATE: 13-02-2019 S.No. Age Sex Department Unit DOA DOL Diagnosis Reason Doctor
1 F Orthopaedics IV 1/13/2019 2/2/2019 Right Humurus mid shaft fracture, distal fibula fracture with right foot first metatarsul fractures with right foot 3rd, 4th, 5th. Patient is not willing for further evaluation and treatment Dr.Prudhviraj PG-II
2 70 F General Medicine VI 02-02-19 (01.54 pm) 02-02-19 (04.30pm) Hemorrhagic storke Patient want to leave hospital and go to other hospital Dr.Vamshi PG-I
3 70 M General Medicine 02-02-19 (06.45am) 02-0219 (04.30pm) CVA Patient wants to go to KHL (MRI) Dr.Deepak PG-II
4 New born M Peadiatric - 28-01-19 (04.00pm) 03-02-19 (10.00am) Hypoxic ischemic encephalopathy with RDS Even after explaining risk and conseqence father wants to take baby home Dr.Parvathi PG-I
5 General Medicine 28-01-1- (12.21pm) 03-02-19 (01.20pm) Acute inferior wall MI sub acute inferior central along with hypoglycemic coma Patient has been explained above the risk and prognosis still wants to go home. Dr.Arvind PG-I
6 42 M AMC 2/2/2019 2/3/2019 Viral pyrexia Patient is not willng for further evaluation and treatment Dr.Aditya PG-I
7) 85 M SICU 2/2/2019 04-02-2019 (03.30pm) right lower limb cellulitis Patient is not willing for further evaluation and treatment Dr.Sindhuja PG-I
8 Pulmonology 1/9/2019 04-02-19 (06.30pm) Right broncichietasis with type-II respuratory failure Patient is not willing for further evaluation and treatment Dr.Anusha PG-I
9 Pulmonology 04-02-19 (01.08pm) 2/4/2019 Right sided hydropneumo thorax with cavities Patient is not willing for further evaluation and treatment Dr.Anusha PG-I
10 F Paediatric 03-0219 (06.45pm) 05-02-19 (02.00pm) febrile seizures Patient is not willing for further evaluation and treatment Dr.Mounika PG-I
11 F EMD 11-01-19 (11.44am) 2/6/2019 acute exacerbation of COPD with respiratory failure Dr.Ravi PG-II
12 40 M Pulmonology 06-02-19 (12.59pm) 2/6/2019 Patient is not willing for further evaluation and treatment Dr.Sailendra PG-I
13 55 M General Surgery III 2/6/2019 06-02-19 (07.00pm) Left Cervical lymphadenopathy Patient is not willing for further evaluation and treatment Dr.Vineela PG-I
14 62 M EMD 08-02-19 (08.53am) 08-02-19 (09.10am) Patient is not willing for further evaluation and treatment Dr.Vivek PG-II
15 70 M Pulmonology 08-02-19 (08.13pm) 08-02-19 (08.40pm) Patient is not willing for further evaluation and treatment Dr.Anusha PG-I
16 51 M General Surgery 24-01-2019 (01.25pm) 09-02-19 (11.25am) UTI Patient is not willing for further evaluation and treatment Dr.Meena Reddy PG-II
17 60 M Orthopaedics III 09-02-19 (02.43pm) 09-02-19 (05.00pm) Right leg both bone fracture Patient is not willing for further evaluation and treatment Dr.Vinod PG-II
18 55 M General Medicine II 05-02-19 (03.49pm) 09-02-19 (04.00pm) Uncontrolled DM and oral candidiasis Patient is not willing for further evaluation and treatment Dr.Lakshmareddy PG-I
19 4 months F pediatric 02-02-19 (09.51pm) 10-02-19 (11.00am) sepsis with bronchpneumonia Patient is not willing for further evaluation and treatment Dr.Sujatha PG-I
20 55 F EMD 10-02-19 (7.40pm) 11-02-19 (06.30pm) acute infract in thalamus and cerebrel hemisphere Patient is not willing for further evaluation and treatment Dr.Akhila PG-I
21 70 F General Medicine I
2/12/2019 12-02-19 (12.00pm) acute metabolic encephylopathy Patient is not willing for further evaluation and treatment Dr.Arvind Reddy PG-I
22 72 F General Medicine IV 2/9/2019 2/13/2019 Metabolic encephylopathy Patient is not willing for further evaluation and treatment Dr.Vamshi Krishna PG-I
23 25 M EMD 13-02-19 (12.23am) 13-02-19 (12.50am) snake bite Dr.Akhila PG-I
24 35 M EMD 13-02-19 (01.53pm)
25 37 M Genera Medicine II 12-02-19 (01.30pm) 13-02-19 (06.30pm) liver disease Patient is not willing for further evaluation and treatment Dr.Lakshmareddy PG-I
5th February (Tuesday) 2.00 pm, 2019 Mini Auditorium.
These meetings are solely focused on improving hospital patient care services. For those who read the previous circular please skip to updates highlighted in bold.
This is being done in a step by step manner:
a) by encouraging regular E logs of individual patients presenting to the Institute (taking care to meticulously deidentify the patient data and obtain signed informed consent which will be overseen by a hospital regulatory committee that will also train students and faculty on responsible use of social media).
Update: The first week saw the creation of departmental Elog groups from 5 departments out of 15 in this institution without a single department E logging any single case in their groups. There was significant contribution from faculty of pathology (to the central E log group), who made the clinical audit team log a few cases by asking active queries regarding a few patients with abnormal lab values. The administration GM was intimated about the format of the "Patient Informed consent forms" for E logging and it is hoped that soon it will become a regular feature in OP and IP with dedicated teams to obtain this consent (similar to current video counselling).
b) Some individual patient logs (inputs) actively collected by the clinical audit PG team from face to face discussion with certain departments were processed further for this week's offline mini auditorium presentation to hopefully make a small contribution in identifying our areas of need. This process will hopefully become smoother and easier when all departments encourage each other to start E logging their daily patient related activities.
Once the above activity starts happening on a regular basis, it will help us develop the necessary competencies to tackle the challenges to our hospital workflow on a case by case basis. The Elog exercise is designed so as to not burden the students and faculty with extra load but help them with a better quality of information to manage their patients.
The overall aim is to achieve better healthcare outcomes for our patients and better student and faculty learning outcomes and these collective analysis of our patient data can be archived as journal publications under the authorship of the presenting PGs and faculty.
At the beginning of the last meeting, PGs from our department of Hospital Administration provided a brief overview of the break up of the number of OPD patients needing conversion to IPD and from the coming sessions they will gradually extend this to case sheet audit presenting our various diagnosis made and the diagnostic tools (clinical, lab, radio) utilized along with therapeutic pharmacological and non pharmacological services availed from the hospital. (5 minutes in 1 PPT)
The last meeting had a brief 10 minute presentation of individual E logged cases by selected departments who highlighted their "current patient requirements (diagnostic and therapeutic) and current challenges to fulfilling them were discussed.
The last meeting discussion remained focused on the above two areas alone and some faculty provided enthusiastic inputs on these two areas.
The morbidity meeting scheduled for 29th January 2019 (Tuesday) 2.00 pm, Room No. – 111, 1st floor Hospital (Clinical Lecture Hall).
A 65 year old male presented with complaints of difficulty in swallowing and swelling on right side of face since 3 days .
I.P. No. 201902607 to be presented by Department of ENT.
A 65 year old male presented with complaints of difficulty in swallowing and swelling on right side of face since 3 days ,was taken for surgery ,intraoperative difficulty in intubation
I.P. No. 201902607 to be presented by Department of Anaesthesia.
A 2 month old male baby presented with respiratory distress ,cold and cough with regurgitation of milk
I.P. No. 201901530 to be presented by Department of Pediatrics.
A 38 year old male alcoholic brought to casuality in an unconscious sate,intubnated outside.
I.P. No. 201901855 to be presented by Department of Emergency Medicine.
A 65 year old male presented with pain in left hip region,a known case of CKD with history of falls.
I.P. No. 201902570 to be presented by Department of Orthopeadics.\
6. A 65 year old male came with complaints of exertional dyspnea,low back ache and neck stiffness
k/c/o tuberculosis
I.P. No. 201923987 to be presented by Department of Medicine.
Note: All patient related Histopathology, Microbiology and Radiology to be discussed by the respective Pathology, Microbiology and Radiology departmental faculty and presenting clinical PGs should discuss with PGs of Radiology and Pathology, Microbiology well ahead in advance
The presenting PGs are request to consult Dr. Rakesh Biswas from Monday to Thursday evening to prepare their presentations adequately.
The morbidity meeting scheduled for 2nd November 2018 (Friday) 2.00 pm, Room No. – 111, 1st floor Hospital (Clinical Lecture Hall).
1. A 40yr old man with poison consumption, tachycardia and dilated pupils.
I.P. No. 201837080 to be presented by Dr. Sufia Almas 1st year General Medicine PG, Dr. Rajesh, Asst. Prof, Dept. of General Medicine.
A 24 year old woman G3P2L2 with 2 previous LSCS with 37 weeks 3 days GA with mild anemia
Uncertain history about cough and medication used.
I.P. No. 201836050 to be presented by Dr. Bindu 1st year OBGY PG, Dr. Dedeepya 3rd year OBGY PG and Dr. Rama Rao Asst. Prof of OBGY, Department of Pediatrics, General Medicine, Pulmonary Medicine, EMD, Pathology.
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A 3 month old Baby with severe bronchopneumonia with metabolic acidosis.
I.P. No. – 201835759. To be presented by Dr. Thomas, Prof & HOD of Pediatrics
Note: All patient related Histopathology, Microbiology and Radiology to be discussed by the respective Pathology, Microbiology and Radiology departmental faculty.
The presenting PGs are request to consult Dr. Rakesh Biswas from Monday to Thursday evening to prepare their presentations adequately.
The morbidity meeting scheduled for 19th October 2018 (Friday) 2.00 pm, Room No. – 111, 1st floor Hospital (Clinical Lecture Hall).
A 42yr old man with Fever, cough and rapidly progressive breathlessness.
I.P. No. 201836187 to be presented by Dr. Aditya Samitinjay PGY-1, Dr. M. Manasa Reddy PGY-1, Dr. L. Srujan Reddy PGY-3 and Dr. Varun, Senior Resident, Dept. of General Medicine.
2. An 80 year old man with intermittent breathlessness since 15 years, admitted with sudden progressive breathlessness
I.P. No. 201835306 to be presented by Dr. Anusha, Dr. Mudassir, Dr. Surabhi and Dr. Srikanth, Asst. Prof., Dept. of Pulmonology
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A 28 year old primi gravida with PPH (Postpartum Hemorrhage) and PPCM (Peripartum Cardiomyopathy)
I.P. No. – 201836617. To be presented by Dr. Sriveni, PGY-2, Dept. of OBG, Dr. Vamshi, PGY-3, Dept. of EMD and Dr. Sunita, Assoc. Prof., Dept. of OBG
Note: All patient related Histopathology, Microbiology and Radiology to be discussed by the respective Pathology, Microbiology and Radiology departmental faculty.
The presenting PGs are request to consult Dr. Rakesh Biswas from Monday to Thursday evening to prepare their presentations adequately.
The morbidity meeting scheduled for 12th October 2018 (Friday) 2.00 pm, Room No. – 111, 1st floor Hospital (Clinical Lecture Hall).
1. An 80 year old man with terminal ileal gangrene with proximal transverse colon perforation.
IP number 201831810 to be presented by Dr . Anand PG Surgery and Dr. Ramesh Asst. Prof of General Surgery Unit - IV.
2. A 70 year old man with lower limb cellulitis, with resistant hypertension and acute on chromic kidney injury since 2 months with type-2 diabetes mellitus since 10 years.
IP number 201833765 to be presented by Dr. Vamshi PG Surgery and Dr Manasa, Dr. Aditya,
Dr. Srujan PG Medicine along with Dr. Lakshmi Narsamma Prof of Surgery and Dr. Rakesh Biswas Prof of Medicine.
3. A 3 Months old child with dextrocardia, cardiogenic shock and septicemia: short discussion by faculty pediatrics.
Note: All patient related Histopathology, Microbiology and Radiology to be discussed by the respective Pathology, Microbiology and Radiology departmental faculty.
The presenting PGs are request to consult Dr. Rakesh Biswas from Monday to Thursday evening to prepare their presentations adequately.
Morbidity Meeting
The morbidity meeting scheduled for 5th October 2018 (Friday) 2.00 pm, Room No. – 111, 1st floor Hospital (Clinical Lecture Hall).
1. 63 year old man with diabetes, facial paralysis and ear pain.
IP number 201834584 to be presented by Dr . Soundarya, Intern along with Medicine PG and ENT PG
2. 52 year old woman with lower limb pruritus since 2 years
IP number 201834133 to be presented by Dr Hina, Intern along with Dermatology, Surgery and Medicine PGs.
Note: The presenting PGs are request to consult Dr. Rakesh Biswas from Monday to Thursday evening to prepare their presentations adequately.
