Sample Multidisciplinary Trauma Committee Minutes Confidential ...

Sample Multidisciplinary Trauma Committee Minutes Confidential – Do Not Circulate

Confidential - Peer Review ADULT Multidisciplinary Trauma Performance Improvement and Patient Safety Meeting Minutes August 1, 2000 (0730-0830) Conference Room X 01-01 02-01 03-01 04-01 05-01 06-01 07-01 08-01 09-01 10-01 11-01

Name TRAUMA SERVICE SURGEONS: Adult TMD B MD C MD D MD E MD F MD G MD (Non-core) H MD (Non-core) I MD EMERGENCY MEDICINE J RN K MD (Liaison) L RN M RN N RN ORTHOPEDICS O MD (Liaison) NEUROSURGERY P MD (Liaison) Q MD ANESTHESIA R MD (Liaison) S RN

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Minutes

Minutes July 1, 2000 meeting.

Cases discussed outside of committee, at M&M meetings or within the trauma PI program

Patient AAA MR#0000000 DOB 1-01-1900 Readmission This is a 39 year old female who arrived as a TTA on Day 0 after a single vehicle MVC. Per reports, the patient was found ejected with an initial GCS of 5. She was intubated and transported to Hospital. She was evaluated in the ED and admitted to the SICU with the following injuries; TBI, scalp injury, FB left globe, C7 TP fracture, and multiple right sided rib fractures, right AC joint separation, and left finger fractures. The patient progressed well and was transferred to the floor on Day 5 and continued to work with therapies. She was deemed ready for discharge on Day 6 with outpatient PT. Her D/C meds were; Tylenol, flexeril, valium, neurontin, and oxycodone. She represented back to the ED on Day 8 with complaints of uncontrolled pain. She was re-admitted to the trauma service and a pain regimen was established. While unfortunate that this patient had persistent pain requiring a readmission, there were no missed injuries identified. Once medications were adjusted, she was again d/c’d. Patient BBB MR#0000000 DOB 1-01-1900 Laparotomy > 4 hrs This is a 20 year old male who arrived as a TTA on Day 0 @ 0934 after a high speed head-on MVC. The patient arrived with a GCS of 15 complaining of abdominal and pelvis pain. Initial CT abdomen was suspicious for mesenteric/bowel injury. He was taken to the OR for an ex/lap on Day 1 with an incision time of 0254; > 4 hours after ED arrival. This patient apparently had subtle findings initially, and was placed in the hospital for serial abdominal exams. Discussion surrounded the difficulty in diagnosing mesenteric and bowel injuries by any one modality alone: physical exam, FAST, CT, etc. In retrospect, there was moderate fluid in the pelvis, mesenteric stranding, a seatbelt mark, and abdominal tenderness. In systems such as ours where 24-hour coverage allows for serial exams, it is reasonable to observe patients with equivocal findings in order to avoid negative laparotomies. However in those patients with clinical decompensation or in whom a high suspicion for a hollow viscous injury is present, prompt exploration and repair can expedite hospital LOS, and reduce morbidity. Discussed with residents/faculty importance of documentation of serial exams, as

Approved, TMD No concerns were raised regarding the cases reviewed

well as signs/findings for bowel/mesenteric injuries. Patient CCC MR#0000000 DOB 1-01-1900 Readmission / liver abscess This 41 y/o man was admitted as a trauma patient following a motorcycle crash Day 0. He sustained multiple fractures, hemopneumothorax managed with chest tube, and a high-grade liver laceration. This was embolized. He was managed on the solid organ protocol and ultimately discharged Day 23. He returned Day 26 with fever, chills, and RUQ pain. CT scan demonstrated a large right hepatic lobe fluid collection with air bubbles, concerning for abscess. CT guided drainage was performed and returned purulent fluid. He improved post-drainage and discharged Day 39. The patient was appropriately managed on the solid organ protocol at initial admission, and because of the embolization procedure he was expected to have some devascularized liver that would have placed him at risk for abscess development. No changes in management suggested. Patient DDD MR#0000000 DOB 1-01-1900 ED Death This 58 y/o man arrived as a TTA following MVC. He was found in a burning car which had left the road and collided with a tree. He was unresponsive and pulseless when found by passersby, and bystander CPR was performed until EMS arrival. EMS coded the patient and transiently got a pulse back; he arrived in the ED with CPR in progress and asystole on the monitor. Ultrasound showed no pneumathoraces and no cardiac activity. Administration of epinephrine produced pulseless electrical activity. Given blunt arrest mechanism, at least 20 minutes of resuscitation, and absence of cardiac activity, resuscitative efforts were terminated and the patient died at 1306. No changes to management suggested; blunt cardiac arrest is generally accepted as non-survivable. Patient EEE MR#0000000 DOB 1-01-1900 Hospital Death This 27 y/o man arrived as a TTA with a self-inflicted gunshot wound to the head. He was stabilized in the usual manner and CT scan showed a trans-cerebral gunshot wound crossing the midline and involving the brainstem. He died in the SICU within a few hours of arrival. This was a non-survivable injury and no changes to management were suggested Patient FFF MR#0000000 DOB 1-01-1900 Hospital Death This 34 y/o man arrived as a TTA on Day 0 by air from a rural area. He was found

pinned under a riding mower. He was asystolic when EMS arrived about 20 minutes after being called. He regained and lost pulses at least one more time during transport. He arrived in the trauma bay with perfusing rhythm and GCS 3. CT of the head showed global effacement consistent with severe anoxic brain injury. CT A/P showed hemoperitoneum with blush in the left colon; he was taken to the OR and at laparotomy a left hemicolectomy and damage control closure were performed. He went to IR for evaluation of significant zone 2 retroperitoneal hematoma, and a lacerated lumbar artery at T12 was identified and embolized. An EVD was placed. Neurology was consulted by Neurosurgery, and both services felt the patient’s injuries were non-survivable. On Day 1, the patient’s family elected to withdraw cares, and he died shortly thereafter. No changes to cares were suggested. Patient GGG MR#0000000 DOB 1-01-1900 Hospital Death This 49 y/o man was the unhelmeted driver of a motorcycle that crashed on Day 0. He was GCS 3 on arrival as a TTA with fixed pupils and no pulses. CPR undertaken in ED with return of circulation. FAST was positive and also showed a pericardial effusion. The patient was taken to the CT scanner where SAH/SDH and skull/facial fractures were found. He was hemodynamically labile during scanning and coded in the CT scanner. Once pulses were regained, he was taken to the OR. A laparotomy was performed which identified significant hemoperitoneum. His abdomen was packed and preparations made for median sternotomy given pericardial effusion on ultrasound; the sternal saw reportedly didn’t work and a pericardial window was therefore made instead. This returned serous fluid. The spleen was found to be lacerated and was removed. The abdomen was packed in damage control fashion, and an EVD was placed by Neurosurgery. The patient was packaged for transport to IR for pelvic angiogram, but sustained another cardiac arrest before he could be transported. Again, he regained pulses with CPR, but given his deteriorating condition his injury burden was felt to be non-survivable. He was taken to the SICU where he died. No changes to management were suggested – his head injuries were not obviously nonsurvivable on CT, and given positive FAST and cardiac instability the pericardial window and laparotomy were indicated. Patient HHH MR#0000000 DOB 1-01-1900 Hospital Death This 79 y/o woman was the passenger on a motorcycle that crashed. She was helmeted and arrived as a TTA on Day 0. She had multiple comorbid conditions and was on warfarin. She was initially GCS 15 on arrival and complained of dyspnea and chest pain. Initial workup with CXR, PXR, and FAST was negative. She was administered FFP because of her warfarin use and mechanism, and was taken to CT. The trauma team was instructed to take the patient to main CT instead of ED CT; on arrival there were no imaging personnel available. The patient’s O2 saturations were deteriorating, and the trauma team made the decision to take the patient back to the ED for intubation. This was accomplished, but the patient was given intubation drugs before blood pressures could be obtained, and she sustained

cardiac arrest. She regained pulses with ACLS resuscitation. FAST was repeated and negative. She was then taken to the CT scanner where head and C-spine CTs were completed before she coded again. Perfusing rhythm was restored with further resuscitation, and given the finding of an effusion on the right from the available CT images, a right chest tube was placed with ~300 mL initial output. The head CT was negative and there were right 1st rib and clavicle fractures. She was taken to the SICU where she coded a third time. Despite ongoing massive transfusion with 1:1:1 resuscitation, she appeared to be developing a coagulopathy with brisk, ongoing bleeding from the chest tube. She regained pulses, and the family asked that she be transitioned to comfort cares. She again sustained cardiac arrest, and further resuscitative efforts were stopped Patient III MR#0000000 DOB 1-01-1900 Hospital Death This 76 y/o woman had a prolonged hospital stay. She had multiple comorbidities, including chronic steroid use for rheumatoid arthritis. She arrived as a transfer on Day 0 after undergoing laparotomy at Red Wing for perforated viscus. She was found at that time to have a stercoral perforation of the colon and was treated with segmental resection, long Hartmann, and colostomy. She developed postoperative bleeding and was taken back to the OR where an avulsed mesenteric vessel was identified. This was packed and she was sent to Hospital for ongoing care. In the OR at Hospital on Day 1, she was found to have a perforation of the splenic flexure and an exposed, large mesenteric vein in the right lower quadrant. A completion extended right colectomy was performed and she was left with an ileostomy. Her abdomen was closed. Her remaining hospital course was difficult, and notable for difficulty with liberation from the ventilator (requiring intubation 3 times), C difficile colitis, PE for which she was started on warfarin, and adrenal insufficiency which required burst doses of steroids. She had issues with her wound which were managed conservatively. Her mental status and ability to participate in therapies waxed and waned. Ultimately, though, she was able to discharge to a skilled nursing facility back in Red Wing on Day 40. The facility reported to Hospital the next day that the patient had died overnight – she was found dead at vital sign checks on the morning of Day 41. The cause of her death was unclear; no changes were suggested in her management. Patient JJJ MR#0000000 DOB 1-01-1900 Hospital Death Patient was a 71 year old male admitted to SICU on Day 0 as a non-TTA. He was found down in a parking lot. Initial GCS was 14 but the patient progressively declined. He underwent tracheostomy and PEG. Serial imaging of the abdomen revealed development of pneumotosis. As the patient deteriorated, care was withdrawn and the patient was placed on comfort status. When pneumotosis was identified and widespread, surgical intervention was not recommended in light of any evidence of neurologic recovery.

Patient KKK MR#0000000 DOB 1-01-1900 Hospital Death This patient was a 65 year old male admitted on Day 0 as a restrained driver involved in a rollover motor vehicle crash. There was widespread CNS injury and EVD was placed by Neurosurgery. The patient was also known to have hepatocellular cancer. He remained on support with no improvement in neurologic status. Withdrawal of care was recommended. An Ethics consultation was required because of division within the family on this decision. Ultimately, the patient went into PEA arrest and expired having been made DNAR. [Code-0; Trauma Service] Patient LLL MR#0000000 DOB 1-01-1900 Hospital Death This is an 88 year old male that was arrived as a TTA on Day 0 after crashing his motorized bike. The patient arrived with a GCS of 15 complaining of back pain. Initial evaluation found the following injuries; TBI, sternal fracture, multiple bilateral rib fractures, left PTX (CT placed in the ED), pulmonary contusions, and multiple spine fractures. He was admitted to the SICU with a Neurosurgery consult. He was started on Neo to maintain MAP>85. The patient was increasingly agitated with increased O2 requirements and was intubated on Day 2. The patient was taken to the OR with Neurosurgery for a spinal fusion on Day 4. His respiratory status improved and he was weaned and extubated on Day 8. The patient continued to require BiPAP and a family care conference was held with Palliative Care. The patient and family decided against re-intubation and the code status was changed to DNAR. The patient became more obtunded on Day 15 and per DNR/DNI he was not re-intubated and passed away at 0526 on Day 16. This patient had significant injury load, especially for his age. While he was appropriately weaned and extubated in the SICU, his wishes were to not go back on the ventilator should he develop respiratory failure. His fusion was a major operation (T3 – T11), including thoracotomy. He had multiple bilateral rib fractures. Despite maximal measures to optimize his respiratory status postextubation, he ultimately developed respiratory compromise requiring BiPAP. Reviewed identification of significant injury load in the elderly, and involvement of Palliative Care team early on, in order to optimize goals of care. Patient MMM MR#0000000 DOB 1-01-1900 Hospital Death This is an 89 year old male that arrived as a TTA on Day 0 after a ground level fall witnessed by his son. Initial GCS 7 and he was intubated upon arrival. Initial imaging showed a large intracranial bleed, parenchymal contusions, and facial fractures. He was admitted to the SICU, Neurosurgery was consulted, and discussed

with family the non-survivable head injury. Palliative Care was consulted and the patient was placed on comfort cares and extubated. He expired at 1846 on Day 32. Repeat HCT was significantly worse, and the family was involved in shared decision making. Palliative Care was involved early on. The patient avoided major neurosurgical or ICU procedures, and was made comfortable. Discussed importance of early Neurosurgical, ICU and Palliative Care input to assist families and patients articulate appropriate goals of care. Patient NNN MR#0000000 DOB 1-01-1900 Unexpected transfer to SICU This is a 55 year old male who presents to the ED on Day 0 @ 1415 via EMS as a non-TTA after a witnessed fall while at work. He arrived with a GCS of 15 complaining of a headache. Initial imaging showed a SDH, right temporal bone fracture, and scalp hematomas. He was admitted to TRAUMA UNIT @ 2115. The patient was taken for his repeat HCT at 2232 where an acute EDH was noted. Neurosurgery was notified requested the patient be transferred to SICU for closer monitoring. This was an appropriate admission to the SICU. While the patient was admitted initially to TRAUMA UNIT, he was placed on close monitoring and when his follow-up CT changed, he was moved to a higher level of care, per our practice guidelines. Discussed criteria for initial SICU admission, including depressed GCS, intracranial hemorrhage on anticoagulation, HD instability, post-procedure, and localizing signs. Patient OOO MR#0000000 DOB 1-01-1900 Hospital Death This is a 55yo male admitted to SICU on Day 0@ 2134 as a TTA. Pt was an unhelmeted motorcycle driver who crashed into a pole. Pt was intubated on scene & was hypotensive en route. Initial injuries were a deformity to RUE & large open skull fx. On arrival to ED GCS=4 (E1V1M3). MTP was initiated, R needle thorocostomy performed & subsequent chest tube placed. Multiple injuries including cerebral edema, multiple areas of IPH, Right skull base fracture, Right occipital condyle fracture & multiple facial fractures. Consultants included Neurosurgery, Ortho & Palliative Care. Family discussed findings & minimal chance of meaningful recovery with Neurosurgery. Patient was made comfort cares on Day 1. Pt expired on Day 2 @1649. Patient was hypotensive en route, and upon arrival. Tx with fluids and blood, as well as right PTX were beneficial in promptly improving BP. HCT had evidence of hypoxic encephalopathy. Very significant injury load in the patient. Early

involvement of Neurosurgery, Palliative Care, and ICU. Discussed strategies to reduce hypotension in polytrauma patients. Patient PPP MR#0000000 DOB 1-01-1900 Unexpected transfer to SICU This is a 46 yo male admitted on Day 0 as a non TTA after fall from standing. + LOC. Initial HCT @1939 showed L SDH & small R SAH. Patient was admitted to TRAUMA UNIT. Repeat HCT on Day 1 @0615 showed enlargement of SDH, new small amount of hemorrhage layering R tentorium & 6mm L to R midline shift compared to 3mm on prior exam. Remained awake, alert & oriented. Transferred to SICU at 1600 on Day 1. 3rd HCT on Day 2 @ 0453 showed decreased in L SDH & midline shift now 3mm.

CASE REVIEWS

CASE REVIEWS: Name: AAA Admit Date: 2/2/1902 MR # 00000000 This case involves a 53 year old who was injured while pulling down a branch with a tractor. The branch struck him and he woke up on the ground with excruciating back pain. He was initially evaluated at Outside Hospital where T1 and T3-7 transverse process fractures and T12-L1 3 column compression fractures were diagnosed. He was transferred to Our Hospital for definitive management of his injuries. He arrived at 2105 and was evaluated as a non-trauma activation. His GCS was 15 and he was neurologically intact. He was admitted to the trauma service with the spine service consulting. The spine consultant agreed with admission to TRAUMA UNIT with a surgery likely planned for the next 1-2 days if the condition remained unchanged. In addition, an MRI was obtained at 2222 on the evening of arrival. The patient remained stable without neurologic deficit and went to the OR on Day 2 at 1310. He went for a T1-L4 fusion initially percutaneous but converted to open. Per Operating Neurosurgeon’s note and the intraoperative neuro monitoring note, there was a “loss of sensory potentials intraoperatively which did not correct with BP

AA MD – Emergency Medicine TMD – Trauma Surgery BB MD – Neurosurgery / Spine CC MD – Anesthesia DD RN – OR Nursing

manipulation”. Following the surgery, the patient was admitted to the SICU. He sustained an incomplete SCI with loss of motor function due to subluxation intra-operatively per the neurosurgery progress note. He had an anterior corpectomy performed on Day 10. By his discharge date, he continued to have lower extremity paraplegia which improved minimally post-operatively. He had 2/5 strength plantar flexion and dorsiflexion on the right and 1/5 strength plantar flexion and dorsiflexion on the left. He fires hip and knee flexors and extensors but 0/5 strength bilaterally. He was transferred to inpatient rehabilitation on Day 19. Discussion Points: 1. Please review the medical record and identify any opportunities in patient care in relation to the intraoperative neurologic deficits that occurred. The operative report, intraoperative monitoring report, and anesthesia record are included in this packet. This case was tabled until the next meeting so that Neurosurgery and Anesthesia are present for the discussion. The TMD summarized the case. Per Dr. AA, there were no ED issues to present. Dr. BB from Neurosurgery commented that this patient had a large body habitus and that positioning is difficult. When he was positioned prone, the body habitus and position started to affect the fractures. Dr. CC from anesthesia agreed. He said that the case was initially started as a percutaneus case with monitoring. Nitrous was the anesthetic agent initially used which can affect potentials. The neuromonitoring technician noted that no potentials were obtained and the nitrous was then turned off at 1545. The case started at 1430 per Dr. CC. Also, he commented that only sensory potentials were being monitored, not motor. Dr. CC noted that the concentration and type of anesthesia (Nitrous) would affect the reading of potentials however it wouldn’t have caused them to be zero. Dr. CC indicated that anesthesia in these cases can be challenging. Dr. BB added that this was a very challenging case because the patients ankylosing spondylosis which makes positioning more

The case will be discussed and a protocol/practice guideline created to standardize anesthesia management in cases like this one. Documentation both by anesthesia and the monitoring technicians will be discussed as there was not a good timeline of events that could be created.

Dr. CC Dr. CC

Dr. CC Discuss with

difficult even despite the patients large body habitus. Dr. BB felt that the combination of this patient’s body habitus, comorbidities, and positioning resulting in fracture instability were the cause of the deficits, not the level or type of anesthesia used. The group did note that the MAP levels were lower than ideal in this case. Ideally, they would be 70-80 mmhg; however this patient had lower levels at times during the case. Dr. CC commented that the anesthesia department has a meeting set up to discuss and create a protocol or practice guideline that would standardize anesthesia for higher risk patients such as this. There were some issues with the documentation of times that made the case more difficult to assess a timeline; this will also be addressed with the anesthesia group. The committee discussed what could have been done better in this case. The three things highlighted were: 1) BP, closer BP monitoring to ensure MAP stays within range of 70-80 mmhg. 2) Anesthesia agents. It is best not to use Nitrous in these cases. A protocol or guideline will be developed or discussed at the Anesthesia meeting. 3) Imaging intra operatively. The fractures could be reimaged during the case to see if the fracture position was changing. Dr. BB commented that in this case however, with the open technique being used, the neurosurgeon could visualize the fracture changing thus didn’t need imaging to show this. 4) Better documentation – will be discussed with anesthesia groups 5) Better evoked potential reporting record – again, with the times. 6) Standard approach to anesthesia in these cases – meeting occurring. 7) During these high risk cases (patients with ankylosing spondylosis) would it be beneficial to have the neurophysiologist in the room during the case? Committee members felt it would. Dr. EE asked if there could be a standard checklist created that would be followed if a patient experiences fracture changes and loss of potentials like this one. The checklist would include 1) stop the

neurophysiology staff whether a physician should remain in the operating room during high risk cases such as this one. The minutes will be sent to the Neurosurgery M&M meeting for review and comment.

Dr. BB / Hospital Quality rep

Nitrous; 2) ensure the BP is within range;3) re-image. He felt this may help with the timing of these items, so they occur immediately. The meeting minutes will be also sent to Neurosurgery M&M/PI for their review and discussion. Name: BBB Admit Date: 2/2/1902 MR # 00000000 This case involves a 75 year old male who was injured after a tree he was cutting fell and struck him in his left shoulder. He then fell on the stump striking his chest. Reportedly, he had difficulty breathing and could move all extremities but could not walk initially. He was evaluated and admitted to an outstate hospital. Upon arrival at that hospital, he became hypotensive and unresponsive. He was evaluated by Neurosurgery and was moving his extremities. On hospital day #2 at Outstate Hospital, he reportedly was not able to move his extremities. An MRI could not be performed as he had a pacemaker. The decision was to transfer him to Our Hospital for definitive management of his injuries. He was transferred to Our Hospital and admitted to the SICU on the trauma service. His injuries included: Multiple left-sided rib fractures (4-10) with a flail segment. A left-sided pneumothorax with a chest tube Open book pelvis fracture T10 vertebral body fracture ? L knee injury *** an estimation of his ISS score is 29 – this could change however Neurosurgery and orthopedics were consulted. He was placed on strict spine precautions and flat bed rest. A myelogram was performed on Day 1 showing spinal canal effacement without canal narrowing. The patient did not regain movement of his lower extremities. Dr. FF from Neurosurgery consulted Dr. CC from the Spine Service for stabilization of the T10 fracture.

AA MD – Emergency Medicine TMD – Trauma Surgery BB MD – Neurosurgery CC MD – Spine Surgery DD MD- Orthopedic Surgery EE RN – SICU Nursing

In addition, orthopedics placed a traction pin planning operative intervention for the pelvis on Day 4. The patient remained on bed rest and in spine precautions, and he developed a worsening respiratory status. Initially he refused CPAP and BIPAP however even when this was used, his respiratory status declined. On Day 3 an elective intubation was planned with anesthesia. The patient suffered a PEA arrest during this process and had CPR for 5 minutes. He was hypoxic during this time. He was stabilized and intubated. The operative procedure for his pelvis was delayed from Day 4 to Day 5. The spine surgery is pending as of this report. . Discussion Points: 1. Please review the medical record and identify any opportunities for improvement in his overall care. He remained on flat bed rest with strict spine precautions for 3 days prior to intubation with significant injuries and co morbidities. Were there any other options for improving his respiratory status that would not have compromised his spine and pelvic injuries? The case was discussed at the July meeting, however, Neurosurgery and Anesthesia were not present. In addition, the patient continued to experience complications and ultimately died. The discussion / minutes from the July meeting are as follows: The TMD summarized the case. Dr. CC from the spine program was present for the discussion. He indicated that the patient sustained an extension injury to his thoracic spine. He was hypotensive while at the previous facility and could have sustained a cord infarct at that time. The positioning that was required to repair his complex open book pelvic fracture was a concern related to his spine fracture. Dr. CC commented that he would have preferred to repair the spine fracture however the pelvis needed to be definitively repaired first.

Another concern raised was that the IVC filter that was recommended by Dr. CC was not placed in a timely fashion. It took 6 days to get the IVC filter in place. The committee recommended this also be reviewed at the SICU M&M meeting. Committee members recommended that this case be discussed at the August MDPI meeting to understand the issues surrounding the timing to OR with orthopedics, delay in placement of the IVC filter, and other complications that the patient was experiencing. Discussion Points for August meeting: 1. 1. Please review the medical record and identify any opportunities for improvement in his overall care. He remained on flat bed rest with strict spine precautions for 3 days prior to intubation with significant injuries and co morbidities. Were there any other options for improving his respiratory status that would not have compromised his spine and pelvic injuries? 2. Please address the delay to IVC filter placement, whether it has been discussed at the SICU M&M or any additional information. 3. Please address the complications of bowel ischemia, renal failure, GI bleed in this patient. 4. Please discuss the preventability of death. The TMD commented that the case was reviewed at the previous meeting but all of the key specialists were not present and further questions were raised so the case is being discussed again with the additional discussion points above. Dr. DD (Orthopedics) summarized the patient case. He indicated that the patient was at the outside hospital for >1 day prior to transfer. Per Dr. DD the team was waiting for ICU clearance. The case was scheduled for Monday but was further delayed due to the patient sustaining the complication of an arrest. Dr GG (ICU) commented that an earlier operative procedure could have prevented the complication of arrest because the patient would not have been able to refuse bipap treatments as he would have been intubated.

In this case, the spine surgeon was waiting for ortho to repair the pelvis before the spine could be repaired, and ortho was waiting for ICU clearance. Dr. DD commented that the attendings need to communicate on these cases, to ensure that the plan is clear among all of the attending providers. The spine surgeon and orthopedic surgeons did speak about the plan, but this wasn’t clear to the SICU/Trauma attending at the time. Again, communication was discussed as an opportunity in this case. The TMD commented that it is the attending trauma surgeon’s (which on the SICU is the SICU/Trauma surgeon) responsibility to get all the specialists together to communicate about the plan of care on a daily basis. The case was reviewed in the SICU M&M and they recommended anesthesia review in their M&M to see if there were any opportunities around the difficult intubation that occurred on the SICU. Per Dr. GG there were multiple attempts to intubate by the CRNA; however the MDA was not present. Dr. GG asked that any SICU intubation by anesthesia/CRNA needs to also have a staff to staff conversation. Dr. HH commented that the time spent at Outstate Hospital led to many of the complications this patient suffered. Hypotension in the first 24 hours significantly increases the risk of multiorgan system issues. A discussion about the delay to IVC filter occurred. The surgeons commented that although it is not documented, there must have been a reason why the patient did not have the filter placed sooner – whether that was worsening respiratory distress or a similar issue. They commented that they are quite aggressive in getting the filters placed in patients who need them. The preventability of death was discussed. The patient failed to progress, then suffered the bowel ischemia resulting in additional surgical procedures. As he became more acidotic, his daughter felt that he would not want to live like this and she make him comfort cares. He expired shortly afterwards. The committee members felt

The TPM will follow up with the referring hospital to ask that the case be reviewed. The TMD will draft a policy for multiservice attending communication when more than one service is involved. The policy will be presented at the trauma committee meeting. Hospital Quality will bring the case for review at the anesthesia M&M meeting.

TPM RN TMD MD Hospital Quality rep

that the death would be categorized as anticipated with opportunities for improvement. The patient had comorbidities and spent >1 day at the outside facility ultimately missing the window of preventing end organ injury processes. 1) The PI program will follow up with the outside hospital to have the case reviewed for the care provided while the patient was at that facility. 2) The delay to IVC filter is inclear. On a daily basis, VTE prophylaxis is part of the discussion process on SICU rounds. 3) Communication issues – attending to attending in patients having multiple services involved. A policy will be drafted and reviewed at the Trauma Committee. 4) Anesthesia will review the intubation on the SICU at the Anesthesia M&M meeting. Dr. GG indicated he would create a list of criteria that would require the MDA to be present at the intubation.

Open Agenda

No open agenda items were discussed.

Next Meeting

September 1, 2000 in the Conference Room