COMMENTARY

My Top Six Easily Preventable Causes of Patient Death and Morbidity

Melissa Walton-Shirley, MD

Disclosures

March 15, 2016

Within seconds of the code-blue announcement a rapid-response team crams the patient's door, congesting the room with militarylike efficiency. Adrenalin and angst interface over an endotracheal tube, defibrillator, and compressions. CPR buys time while the well-choreographed team begins its dance. The steely ER nurse shakes her head "no" at the absence of a femoral pulse in the face of a mocking QRS complex. Her hand is locked in position, buried deeply in a silent groin as the patient's lifeless body gently rocks to the rhythm of chest compressions.

The intubator positions himself at the head of the bed then efficiently slides the #7 past the vocal cords. The other troop members open and deliver medications with clocklike precision, duly recording each move, changing with the barrage of arrhythmias. Simultaneous to the administration of a second epi, then a shock, the undulating baseline of what is now ventricular fibrillation coalesces into a recognizable QRS complex. The patient's cheeks transform from pale to pink as systole and diastole reestablish their relationship with electricity. A few seconds later the ER nurse shakes her head "yes" as a nimble pulse finds her index finger. CPR is halted, and there is a collective sigh of relief. The team, having reestablished a lifeline, disappears as efficiently as they converged. The floor nurse stands among strewn syringes, plastic, and paper while prepping the patient for transfer to the ICU.

This scenario proves we've become most proficient at the "whats" of hospital medicine, but unfortunately, we have little time to examine the "whys." Every code blue deserves a figurative autopsy to bolster prevention of the next. We are pretty good at the prevention of deep vein thrombosis [DVT], pulmonary embolism [PE], and line infections. We do some things well like faithfully reciting our "time-outs"; maybe that keeps us from operating on the wrong limb or the wrong patient, but there are old complications emerging that can spell as big a disaster for some. Here are my top six easily preventable causes of patient death and demise in 2016.

1. Disrespecting Hypokalemia

Among the barrage of useless phone calls for the ever-detectable but nondiagnostic troponin of 0.0000000infinity, I rarely hear about electrolyte imbalance anymore.

Potassium is a fickle element. A level of 3.2 mEq/L, though well tolerated by many, can produce an assortment of cardiac arrhythmias including ventricular tachycardia, torsades de point, and paroxysmal atrial fibrillation. Before we mapped the human genome, we knew there are many modifiers of the QT interval, and lack of potassium is one of them. Let us all agree from this day forward to replace potassium as soon as its deficiency is discovered. If there is any reluctance to bother the provider with a low potassium level, please bother us with something that could kill a patient and instead apply that same reluctance to calling about the already-elevated troponin level.

2. Not Minding Our IV Fluids

What is it about a hospital setting that blinds us to common sense when it comes to hydration or the lack of it? Once, in the same week, I was asked to see a patient who was dyspneic and another patient, three floors underneath her, who was on a ventilator receiving Neo-Synephrine and dopamine for unexplained hypotension.

The breathless patient had big legs, pulmonary edema, an LV systolic ejection fraction of 65%, mild mitral regurgitation, and the expected diastology. She avoided an ET tube by sitting straight up at the bedside and panting like a lizard to keep her head above the 9 L of intravenous fluids (IVF) she'd received since surgery 4 days earlier. I had no idea about her output because no one was recording it. She survived by swimming the backstroke, the butterfly, and the 200-meter until someone could stop her IVF and give her 40 mg of IV Lasix.

The ventilated patient with mysterious hypotension required tons of pressors in the face of an increasing creatinine and sinus tachycardia. When his mouth was pried open, if one had flicked his tongue it would have been dust. There was a veritable jungle of IV fluids hanging at the bedside but each bag was dripping only a µcc per minute. When we added all of that up, the team of specialists was allotting him a whopping 40 ccs per hour at best. A few liters of crystalloid later, he was off all pressor agents. He hadn't received a calorie of real nourishment in a week. I could see him figuratively trudging over desert sand for days, falling to his knees in gratitude for his first real bag of fluids and total parenteral nutrition (TPN).

3. Discharging the Patient on All the Same Drugs That Weren't Working When They Were Admitted

I saw a case where the hospitalist did a brilliant job of diagnosing a PE and absolutely saved the patient. The admitting blood pressure on a boatload of beta-blockers, a little diuretic, and amlodipine was 100/60 mm Hg. It dropped like an anvil within 2 minutes of standing a couple of days into the admission. Despite what is known about RV stretch and preload reduction with PE, his wife reported that he had been dizzy for months. His beta-blockers were decreased, the amlodipine and the diuretic were discontinued, and he felt remarkably improved. A few days later he stood at home and went boom. He had been discharged on the same medications he came in on. Although it's far easier to click "continue home meds" than click "reconcile medications" at discharge, when we do that, we win the battle but we lose the war.

4. Global Neurologist Deficiency (GND)

We've tried to compensate for our global neurologist deficiency but we've failed miserably. We've piped them in through talking mobile devices and Star Trek–like big screens. We've engaged in phone consultations ad nauseam, and America keeps the interstates hot with transfers, yet we hear incessant stories about how pinched-nerve diagnoses result in permanent nursing home stays. We've watched patients languish in midstroke while families are told, "They can't do anything more there than we can do here."

As long as there are intracranial stents and coils, Neo-Synephrine drips, and folks who know how to push intracranial perfusion, tertiary centers will always have the market cornered on many forms of stroke care, but a good neurologist is best to answer the question, "Should I stay or should I go?" to one of those tertiary centers. They are best at protecting our neurologically challenged patients until a decision can be made.

(If today's politicians were really medically savvy, they would run on the platform of "A neurologist for every town" and if the American public could understand just how that would translate into fewer nursing-home patients, that candidate would win.)

5. Focusing on Length of Stay Instead of Quality of Stay

The worst first question to ask a consultant is, "When can they go home?" The best question is, "Do you think they are ready to go home?" Yes, patients can stay too long in the hospital, but that's absolutely not the trend these days. We discharge straight from the ICU more than ever, sometimes without the patient having walked or gotten up on their own or despite low-grade fevers or heart rates bouncing up to 150 bpm in afib. Sometimes we don't review the telemetry for important clues of how they might return to us with strokes or falls. Up-front savings from early discharge can translate into bonuses for hospitals, but shortsighted discharge planning results in long-term costly sequelae.

6. Not Looking at Telemetry

Telemetry is a ready-made treasure trove of prevention, but complacency abounds. With what has become rampant monitor fatigue we should not trust that a patient's telemetry is clean. If the discharging provider's last move just included a click on the patient's telemetry to review it, every single minute of every day we would find enough ammunition to make any serial killer proud. Those six tiny beats of paroxysmal AF could spell disaster if not quantitated with long-term outpatient monitoring. A decrease in beta-blocker dose may have unleashed a barrage of supraventricular tachycardia (SVT) for later. "Mama" might have fallen because her "inappropriate sinus arrhythmia for age" hints at asystoles to come. "Dad's" LVEF is 38%. No one called about the seven-beat run of ventricular tachycardia (VT) he had last night, and he's on his way out the door. We must assume that no one called because no one saw it. All telemetries must be labeled guilty until proven innocent.

As our screen addiction, lack of staffing, declining verbal communication skills, and reluctance to spend money where money needs to be spent increases, we are cutting some very inexpensive inpatient corners. A simple phone call, the occasional hallway conversation, a new neurology recruitment strategy, more monitor techs, and a daily review of telemetry by every nurse and care provider of every patient would go a long way in preventing the next readmission or worse. Every code deserves a figurative autopsy to find whether there was a preventable cause or if telemetry hints at things to come. A detailed checkout to the oncoming team is paramount to success.

As a nation of providers, we are capable but not connected. If we are vigilant regarding prevention of these complications in inpatient care, we can save a lot of heartache, decrease morbidity, and avoid unnecessary death. Perhaps now, more important to many CEOs around the nation, we could save a lot of money, too. Prevention equals dollars. Now that should get some much-needed attention.

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