What Improves Patient Outcomes the Most?

Objectives:

1. Demonstrate that when resolving problems involving professionals from different disciplines, it is essential to respectfully involve individuals from each discipline if the conclusion is to be unbiased, have lasting positive impact and be viewed as fair and equitable.
2. Demonstrate that attitudes to professionalism, leadership, communication, shared values, and ethical decision making that are formed in school impact professional behavior following licensure.

Description:

Students will be grouped by discipline to evaluate and recommend a course of action following an adverse patient event involving a middle aged man with a hypertensive crisis who is admitted to the ER.  Subsequently, the students will be divided into interdisciplinary teams before reconsidering the same case.  Faculty will facilitate a discussion among the students addressing the difference in their recommendation under each group composition.  The reasons for the differences will be explored.

Case:

Mitchel Clark, 48 yo, is admitted through the ER to a monitor bed unit of First Memorial Hospital in Baltimore. He was driven their by his wife, Ilene, who had nowhere to leave their 2 kids, Sarah (8yo) and Matt (11yo). Mitchel is diagnosed by a 2^nd year Resident, Sam Coolidge, MD, in the ER with a hypertensive crisis. His SBP ranges from 200-210 mmHg and DBP from 150-160 mmHg. The patient has flash pulmonary edema and is also in atrial fibrillation with a rapid ventricular response (resting heart rate of 142 beats per minute). Dr. Coolidge prescribes metoprolol, 100mg, PO but Mr. Clark’s heart rate when first examined by Morgan Flemming RN, an experienced  nurse in the Cardiac unit remains high (132 bpm). The patient is also administered 20 mg IV furosemide, however, he is becoming more tachypneic and his breathing appears increasingly labored. The nurse is worried that the patient will need to be intubated.  Morgan has seen many residents come and go over the years and is pretty sure she knows as much as they do, so she calls the attending, Jane Crawford, MD, to point out the high heart rate and difficulty breathing and throws in a few disparaging comments about the resident. Dr. Fleming is busy, but grants permission over the phone for administration of additional therapies. These include IV nitroglycerin, digoxin 500 mcg PO, an esmolol gtt and furosemide 80 mg daily. Morgan orders these from the pharmacy and administers to Mr. Clark before leaving the bedside. The Clark family sees and hears all the interactions, but are largely ignored.

A couple of hours later, Malinda Bollings, a just graduated RN conducts a routine physical and exclaims, “Oh my gosh, his heart rate’s 40 but at least his BP is finally normal!” before rushing from the room to seek advice. Mitchel is lethargic and his speech is slurred; he has left-sided facial drooping. His wife is terrified and both kids are crying. Dr. Fleming quickly arrives, immediately realizes the combination of furosemide, esmolol and nitroglyercin was too much. She chews out the nurse for not telling her that the BP dropped so fast and then calls a neurology consult STAT! Meanwhile, the clinical pharmacist, Hipin Li, PharmD openly speculates in front of the family that both physicians “are dopes for just worrying about getting the BP and HR back to normal and never worrying about the problem with fixing things so fast”. Dr. Li is accompanied by her resident, who whips out his iPhone, Googles “too abrupt lowering BP” and tell Dr. Li “That it was a lot of medications to start at once but that he is only having a mental status change or only slightly worse, a stroke. It is not like he is circling the drain or anything”.

A social worker, Sian Hamilton, MSW, speaks with the kids who are worried about their dad. They think “PO” means “probably over”. He explains, “It means you take a medicine by swallowing it. Doc’s say a lot of funny words like that, don’t worry”. Mrs. Clark, relieved that someone is finally telling her and her family what’s going on, feels able for the first time to ask a question. “Should I have told the doctor Mitchel was taking these? They were all so busy and abrupt I was afraid to say anything”. Sian takes the tablets, promising to let Dr. Crawford know. Sian knows very well the reaction he’ll get if he interrupts her now (last time they spoke, the end of the conversation was “We’re done. Just call the patient a cab – it’s the most useful thing you do around here”) so he decides to wait until rounds.

The patient is diagnosed with an acute ischemic stroke secondary to abrupt lowering of his blood pressure. Two days following the stroke the patient has not yet recovered. He has hemiparalysis, and aphasia.

The family sues, believing Mitchel received sub-standard care based on the interactions they observed.

The hospital convenes a group to investigate the case and make recommendations to avoid a recurrence.

Sample Questions

What is the health professional’s role in making sure that a patient completely understands what is going on around him or her?  Which professional is responsible for providing clear information to the patient?