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________________________________________________________________________ The Unfortunate Admission Page 1 of 8 This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means-electronic, mechanical, photocopying, recording or otherwise without the permission of the University of Minnesota. �2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity employer and educator. This document is available in alternate formats. For information, contact Barbara Blalock 612-626-7379

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CLARION

An Interprofessional Student Committee of the Center for Health Interprofessional Programs (CHIP)

UNIVERSITY OF MINNESOTA

The Unfortunate Admission

The details contained in this case were written as a team by (listed alphabetically)

Karyn Baum, MD, MSEd

Associate Professor of Medicine Special Assistant to the Dean

School of Medicine University of Minnesota

Andra Fjone, MN, CPNP Clinical Associate Professor

School of Nursing University of Minnesota

Sandra Potthoff, Ph.D. Associate Professor and Director

Program in Healthcare Administration School of Public Health

Division of Health Policy and Management University of Minnesota

William Riley, Ph.D. Associate Professor

Associate Division Head School of Public Health University of Minnesota

Don Uden, Pharm.D. Professor

Pharmaceutical Care and Health Systems College of Pharmacy

University of Minnesota

________________________________________________________________________ The Unfortunate Admission Page 2 of 8 This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means-electronic, mechanical, photocopying, recording or otherwise without the permission of the University of Minnesota. �2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity employer and educator. This document is available in alternate formats. For information, contact Barbara Blalock 612-626-7379

Sentinel Event Day One Jane Nagel is an 18-year-old woman who presented to the emergency department (ED) at 5 p.m. complaining that she was “not feeling well.” She told the admitting staff she had nasal congestion, stuffiness, sore throat and a cough for the last couple weeks. She also had achy joints and chest discomfort on the right side. In fact, her cough led her to quit smoking for two weeks. She had not been drinking or eating much during the last few days, and she said her urine was darker than usual. Mary Wood, RN obtained her vital signs in the ED. Her temperature was 95.4°F and pulse was 83 beats per minute. Her blood pressure was 102/59 mmHg, respirations were 16 breaths per minute and oxygen saturation was 100 percent on room air. James Hall, M.D., saw her in the emergency room. He obtained the above history and learned she had stopped her Plaquenil about two months ago (the physicians complete the medicine reconciliation process in the Emergency Department). Jane told the doctor that it had not helped control her lupus, so she had decided to quit taking it without consulting her physician. Jane’s SLE (lupus) was diagnosed two years ago when she presented with an array of symptoms and findings that included joint pain, blood in her urine, chest discomfort and a positive double-stranded DNA and ANA. A rheumatologist saw her initially and has followed her care intermittently since the initial diagnosis. However Jane often is unable to go to her appointments because of her lack of transportation. Because the hospital and clinic have recently converted to an electronic health record (EHR), only the last nine months’ worth of appointments are available (the rest are in the paper clinic chart, which is located in the clinic). Jane’s physical examination was essentially normal, although James Hall, M.D., thought she appeared mildly dehydrated. He ordered some intravenous normal saline. Her chest x-ray was read by James Hall, M.D., as clear and was unchanged compared to one done at the same hospital just three weeks ago. This x-ray had been done in the ED when Jane had presented for chest pain, which was ultimately attributed to her lupus. She had been advised to see her rheumatologist but had not made the appointment. To assist with diagnosing her chief complaints, multiple blood and urine laboratory tests were ordered during this visit to the ED.

________________________________________________________________________ The Unfortunate Admission Page 3 of 8 This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means-electronic, mechanical, photocopying, recording or otherwise without the permission of the University of Minnesota. �2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity employer and educator. This document is available in alternate formats. For information, contact Barbara Blalock 612-626-7379

James Hall, M.D., planned to discharge Ms. Nagel after the IV fluids were administered, but he decided to admit her to the hospital when she told him that her pain was very similar to the pain that lead to her lupus diagnosis two years ago. He agreed with Jane’s suggestion that she might be having a flare of her disease because she stopped taking her medication. James Hall, M.D., told the attending general medicine physician he recommended she be admitted. Upon admission to the General Medicine Unit, Grant Thompson, M.D., the intern on call, obtained some additional history. Jane was also diagnosed as bipolar disorder and had been admitted nine months ago to a psychiatric unit in a hospital in the same system for a suicide attempt. Jane lives in a sober house after completed treatment for drug abuse. She has some biological family but was placed in the foster-care system for six years after being removed from her mother’s house because of her mother’s drug addiction. Her older sister also suffers from drug and alcohol addiction. Jane denied using any street drugs or alcohol. The complete physical examination done by Grant Thompson, M.D., was normal. Her white blood count, hemoglobin and electrolytes were all within normal ranges. Grant ordered multiple other laboratory tests, a urine toxicology screen and a pregnancy test. He also ordered a psychiatry consult because Jane had told him that she had not been seeing a therapist or psychiatrist nor taking any medications for her bipolar disorder. About 9 p.m., Jane’s laboratory work was completed. Her erythrocyte sedimentation rate was 73 mm/h (normal 0-20 mm/h). The nasal swab for influenza, rapid streptococcal screen and urine pregnancy test were negative. Grant Thompson, M.D., briefly discussed the case over the phone with the attending physician Marc Cash, M.D. They agreed that the likely diagnosis was a flare of her lupus with a complicating systemic viral or urinary track infection. They decided to restart her Plaquenil, start prednisone at 20mg per day and consult rheumatology the next day. Grant wrote this order on his way home at 9:30 p.m. At 10 p.m. the pharmacy received the orders, and James Miller, Pharm.D., reviewed the orders. He wrote a note to ask when Jane had her last eye exam. Because he wanted to follow-up on the patient’s history, James decided not to fill the Plaquenil that night, since it was written as “qday.” He sent up the prednisone dose.

________________________________________________________________________ The Unfortunate Admission Page 4 of 8 This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means-electronic, mechanical, photocopying, recording or otherwise without the permission of the University of Minnesota. �2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity employer and educator. This document is available in alternate formats. For information, contact Barbara Blalock 612-626-7379

Day Two Jane had a restless night and did not sleep well. The night nurse found a sleeper chair for her boyfriend, who had spent the night in her room. When Grant Thompson, M.D., arrived at 7:30 a.m. the next morning, he reviewed her vital signs and the morning laboratory work prior to seeing her. Jane had received a total of 1.5 liters of normal saline since admission. Her urinalysis showed 10mg/dl ketones, 3 squamous epithelial cells/high power field, trace leukocyte esterase, 11 WBC/ high power field and mucous. Consistent with a lupus flare, Jane’s complement concentrations were a C3 of 51mg/dl (90-200), a C4 of 4mg/dl (15-50) and a CH50 of 22mg/dl (60-144). The sputum gram stain showed mixed gram- positive and gram-negative organisms with less than10 squamous epithelial cells/low power field. Her blood culture was negative at less than 24 hours. Her urine toxicology screen was positive for acetaminophen, caffeine and opiates. Grant Thompson checked the ED note and did not see any note that they had given her opiates for pain. Grant Thompson, M.D., saw Jane on patient rounds. She was lying in her hospital bed with her boyfriend. Grant believed Jane looked better than the previous day. The rheumatologist who saw her later that day also felt that she had a lupus flare with a concomitant viral infection. Grant and the attending physician discussed Jane’s case. Both believed she should be ready for discharge by the next day. They agreed she should be started on levofloxacin for a urinary tract infection. Thompson noted the need for the antibiotic in his daily documentation. About 10 a.m. Jo Forsyth, Pharm.D., the pharmacist for the day, called Grant Thompson, M.D., to ask about Jane’s last eye exam. Grant didn’t know when the appointment was. After talking with Jo, they decided to start the medication but wrote an order for an ophthalmologist exam before Jane was discharged. Grant noted the order on the sheets that he carries in his pocket for each patient to remind himself to order an exam. At 4 p.m., Grant Thompson, M.D., noticed that no psychiatry note was on the chart. He asked the nurse, Jackie Billings, RN, if someone from the consult team had seen Jane. Jackie did not think so. Grant double-checked to ensure the order had been removed by the Health Unit Coordinator the day before. His check showed the order was removed. He was certain he had called the psychiatry department and left a message requesting the consult. Psychiatry staff do not give out a pager number or name of a physician. Instead,

________________________________________________________________________ The Unfortunate Admission Page 5 of 8 This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means-electronic, mechanical, photocopying, recording or otherwise without the permission of the University of Minnesota. �2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity employer and educator. This document is available in alternate formats. For information, contact Barbara Blalock 612-626-7379

they only have a telephone with an answering machine. This is how all consult requests must be made. Frustrated by the lack of response by the psychiatry department, Grant Thompson, M.D., called the hospital operator to obtain the name of someone to page. He finally managed to reach the administrative assistant of the psychiatry department. She said the department didn’t have a record of the consult request. She said they’d had some problems with the answering machine. She connected Grant with one of the staff psychiatrists, who recommended that Jane follow-up as an outpatient since she was not actively suicidal. He gave Grant a phone number to give to Jane so she could schedule an appointment. Angry about this lapse in care, Grant left after spending 45 minutes on this issue. In his haste to leave, he forgot to write the order for the levofloxacin. It was Friday, and Tracey Wells, M.D., was covering for the attending physician Marc Cash, M.D., that weekend. Marc discussed the patients over the phone with the Tracey and indicated he thought Jane was improving and she should be discharged tomorrow. At 6 p.m., Beth Mirrow, LPN, noticed that Jane’s vital signs indicated that she had a fever of 101.3°F and a pulse of 118 beats per minute. Beth called the on-call intern who ordered another set of blood cultures and recommended that acetaminophen be given for the fever. Beth ensured the orders were complete, and Jane’s temperature decreased in one hour. The on-call intern did not have a chance to write down this information and her decisions to order the culture and medication and forgot to pass it along to Grant Thompson, M.D., the next morning Day Three Jane felt worse on Saturday morning. After her shift was finished, Kim Franklin, RN, entered Jane’s morning vital signs at 7:19 a.m., which were a temperature of 101.3°F, pulse of 140 beats per minute, blood pressure of 105/46, respirations of 30 breaths per minute, and oxygen saturation of 93 percent on room air. She made a note in the electronic vitals section that “report was given to AM shift for intervention.” Grant Thompson, M.D., came in to work on Saturday at 7 a.m. He was hoping to get finished and leave a little early to enjoy the good weather. Jane was the first person he saw. Her boyfriend was once again in the bed with her. Jane was sleepy but otherwise her exam was noted to be normal. It is not clear whether or not he checked her morning vital

________________________________________________________________________ The Unfortunate Admission Page 6 of 8 This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means-electronic, mechanical, photocopying, recording or otherwise without the permission of the University of Minnesota. �2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity employer and educator. This document is available in alternate formats. For information, contact Barbara Blalock 612-626-7379

signs or those from the evening before. Although that information is on the computer, there is no way to determine who accessed the information. Len Cameron, LPN, learned about Jane’s temperature from Kim Franklin, RN. This was his third shift on the Medical/Surgical ward. He had just been hired after working for three years at a local transitional care facility. Per her standing orders, Len gave Jane some of the “as needed” acetaminophen as well as an oxycodone for the right-sided chest pain about which Jane had started complaining. He rechecked her vital signs at 9:11 a.m. Her temperature decreased to 100.4°F, and her pulse was 123 beats per minute. He saw that she had blood cultures drawn the previous evening so he did not call the intern and discuss Jane’s status. Grant Thompson, M.D., and the covering attending physician, Tracey Wells, M.D., discussed Jane’s case at 9 a.m. Grant mistakenly reported yesterday’s vital signs to Tracey. During their discussion about Jane, Grant realized that he had forgotten to write the antibiotic order. He was afraid to tell Tracey because she had a reputation for being very hard on interns. They decided Jane could be discharged, and Grant wrote the orders. Len Cameron, LPN took the discharge forms and went over them with Jane. She said that she felt poorly, was having some trouble breathing and really did not want to go. Len called Grant Thompson, M.D., and told him that “the patient does not feel ready to go home” but did not convey any other information to Grant or give his opinion. Grant told Len that Jane had already stayed an extra day because of the mix-up with the psychiatry consult. Len was unsure when to call an attending physician and didn’t want to get the intern in trouble. He told Jane that the medical staff felt that she could go home. She was discharged at 10 a.m. and then took the bus home. At 11 a.m., Grant Thompson, M.D., finished rounding, writing orders for his patients and went home. Grant double-checked Jane’s initial blood cultures drawn in the ED. Those cultures remained negative. He did not see that blood cultures had been drawn the previous evening. Laboratory tests that do not have reported results (such as the cultures from the previous night) do not show up in the laboratory section on the new EHR unless you click “show pending” next to the tests you want to see. Grant is a new user of the EHR and didn’t know which tab to click. Since it was Saturday, Grant could not make the ophthalmology appointment. Clinic scheduling is open from Monday through Friday. Instead, he wrote the phone number for them on Jane’s discharge orders.

________________________________________________________________________ The Unfortunate Admission Page 7 of 8 This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means-electronic, mechanical, photocopying, recording or otherwise without the permission of the University of Minnesota. �2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity employer and educator. This document is available in alternate formats. For information, contact Barbara Blalock 612-626-7379

At 12:15 p.m., the microbiology laboratory technician paged the on-call intern, Jeff Splaine, M.D. The blood cultures drawn the previous evening were both positive for gram-negative bacteria, indicating Jane had a bacteremia and was potentially sepsis. The intern went to the medical unit and quickly looked through Jane’s records to determine her status at discharge. Concerned for her, at 1 p.m. he called Jane at the Sober House and asked her how she was feeling. She told him that she was exhausted, coughing and felt warm and sweaty. Jeff advised her to immediately come back to the hospital. Jane told him that she had just gotten home and was exhausted. She had no car or ride and did not have enough energy to walk back to the bus stop. Jeff Splaine, M.D., placed her on hold and tried to find out if the hospital could pay for a cab. The charge nurse at the front desk said there was not a mechanism to get that done. Jeff apologized to Jane and said he didn’t think a cab was possible. He emphasized the need for her to come right back and go directly to the Medicine Care Unit. Jane finally arrived at the hospital by bus at 7:15 p.m. and was immediately admitted to the Medicine Care Unit. She was clearly exhausted, flushed and diaphoretic. At 7:23 p.m., her vital signs were a temperature of 104.7°F, pulse of 149 beats per minute, blood pressure of 100/38 mmHg, respirations of 40 breaths per minute, and oxygen saturation of 92 percent. Jeff Splaine, M.D., examined her within a few minutes of her arrival and quickly concluded that she was in septic shock. He and the nursing staff immediately transferred her to the Medical Intensive Care Unit and began multiple intravenous antibiotics including ceftriaxone, vancomycin and levofloxacin. Jane had not taken any of the medications, including the levofloxacin, given upon discharge because she was worn out and slightly nauseated. Jane rapidly decompensated during the next two hours. She progressed into acute respiratory distress, had to be intubated and placed on a ventilator. Her chest x-ray revealed new airspace opacities in both lungs consistent with bilateral pneumonia or acute respiratory distress syndrome. Her blood pressure dropped and multiple vasopressors were started to maintain her blood pressure. Despite heroic measures, her blood pressure could not be stabilized. Jane died at 2:12 p.m. the next day.

________________________________________________________________________ The Unfortunate Admission Page 8 of 8 This case study was prepared for the CLARION Interprofessional Case Competition. It was developed as the basis for discussion in the Case Competition. Information in this case is fabricated/fictitious. Any resemblance to any healthcare provider is purely coincidental. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means-electronic, mechanical, photocopying, recording or otherwise without the permission of the University of Minnesota. �2008 University of Minnesota Board of Regents. The University of Minnesota is an equal-opportunity employer and educator. This document is available in alternate formats. For information, contact Barbara Blalock 612-626-7379

The blood cultures from the evening of the second day of her hospitalization grew Hemophilus influenzae. Her autopsy revealed bilateral gram-negative pneumonia with bacteremia and multi-organ failure, likely from septic shock.