Grand Rounds Recap 5.18.22

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Leadership Curriculum: Performance Improvement WITH DR. ERIN MCDONOUGH

Important for real time feedback, initiating behavior change, for team members struggling with potential and those for whom you have concerns about not being able to do the job.

  • Pathway to Performance Improvement

    • Step 1: Define the problem

      • Avoid judgemental wording, unintentional determination of motivations

    • Step 2: Is this a pattern of behavior? Is it a perception or a reality?

    • Step 3: Determine the why behind the behavior or issue; seek first to understand

    • Step 4: Give the feedback

      • Tell the person ahead of time what the meeting is about; “a shot across the bow”

      • Should have a relatively rapid timeline in order to make this timely and effective

      • Focus only a few actionable items, don’t overwhelm

      • Convey your empathy and belief in their ability to change

      • A framework:

        • Ask before telling → clarify non-negotiables → connect to employee’s goals → describe specific behaviors → craft a plan together

  • The role of the leader → Should be both as coaches and mentors

    • Be supportive, involved in the change process, believe that improvement is possible and convey that to the person

    • Maintain accountability

      • Check in, provide positive feedback when able

      • If no movement towards improvement:

        • Is there a competing commitment? This could be subconscious or unconscious

    • Be transparent and disclose all information, concerns and possible consequences

    • Before initial feedback is conveyed, have a bird’s eye view of what the next steps, measurements and escalations could look like.

  • What if no change is occurring? Time for a Performance Improvement Plan (PIP)

    • Is formalized, goes into your work/training record, HR can be involved

      • HR is not the supportive party usually in these situations. They often leans towards legal protection for the organization as a whole and their language can make situation sound more severe or aggressive

    • Can lead to a remediation plan and potentially termination

Alternatives to Admission WITH DR. ARTHUR PANCIOLI

In the current conditions of extensive boarding and frequent staffing changes, using hospital admission may not be the best use of resources.

  • Especially true for patients whom we admit for social issues/concerns, SNF/NH placement, hospice or home health arrangements, obtaining DME, etc. 

  • Often alternatives are set up through medical social workers–please call them and they can either assist or direct you to the appropriate party

  • Consider respite center placement for undomiciled patients with medical needs but who do not necessarily require direct oversight and management by a physician

    • Most centers require some baseline level of physical abilities (climb certain number of stairs, etc)

    • Potentially can have PT/OT evaluation and recommendation requirements

    • Patients must bring a 30-day supply of all medications and wound care supplies with them

  • Call the PCP or referring provider – rapid follow up via telephone, telehealth or office visit is often able to be arranged and can prevent admissions

    • Data suggests improved rate of bounce-backs for these patients

  • Other local resources:

    • Community Health Workers – can set up new PCP appointments for patients with access to a telephone within 2 weeks of their ED visit

    • Cincinnati Health Network “Healthcare for the Homeless” Services – provide physical exams, blood tests, mental health medications and short term counseling, substance abuse counseling and treatment, basic dental care, STI testing, pregnancy testing, disability paperwork and some access to and prescribing of medications, insurance enrollment.

R4 Case Follow Up: Mental Health in Pregnancy WITH DR. SARAH WOLOCHATIUK

The Case(s):

  • Case 1: A young pregnant female currently at 18wks GA presents to the ED with suicidal ideations. She reportedly took a handful of 30mg XR nifedipine 30-60mins prior to arrival. 

    • Physical exam overall unremarkable, fetal heart tones 190

    • Received activated charcoal and whole bowel irrigation, empiric calcium

    • Admitted to MICU although stable in ED due to high potential for rapid decompensation, no complications during hospital stay

    • Chart review notes an uncomplicated remainder of her pregnancy with healthy delivery, has since been lost to follow up.

  • Case 2: A young pregnant female in her second trimester with a PMHx of anxiety and depression on buspar and zoloft who presents with lightheadedness.

    • Recent trauma admission for jump vs fall from moving vehicle and two brief admission for hypoglycemia and hypokalemia; all within the past 4 weeks.

    • Exam notes a drowsy young woman with slurred speech but otherwise nonfocal neurologic exam and no other abnormalities

    • POC glucose on arrival 43 – given dextrose with some improvement. 

    • Found to be hypoglycemic and hypokalemic, labs notable undetectable C-peptide and very supratherapeutic insulin level but these did not result until after she was discharged. Provider attempts to reach patient but is unable to; subsequently calls patient’s OB to discuss the results and concern for intentional self harm vs secondary gain.

Calcium Channel Blocker Overdose:

  • Management overall based on low quality evidence but is standard of care

  • GI Decontamination if timing of ingestion supports it

    • Activated charcoal 1g/kg up to 50g

    • Whole bowel irrigation 

  • Aim for mild hypercalcemia (~12-15)

  • IV Fluids - bolus, especially consider while mixing pressors or if shock is undifferentiated

  • Pressors - norepinephrine first line

  • Atropine and/or pacing for bradycardia

  • High dose insulin and dextrose therapy

    • Insulin has a positive inotropic effect on the heart → under stressed conditions, cardiac tissues will use glucose metabolism as their primary energy source. 

      • Possibly also induces endothelial NO synthase activity to cause vasodilation in the cardiac and pulmonary vasculature

    • 1u/kg bolus then continuous infusion at 1u/kg/hr

    • Watch your patient’s potassium!

    • D50 drip to maintain euglycemia

  • Intralipid - 1.5mL/kg bolus of 20% then 0.25mL/kg/min infusion

  • Glucagon 5mg IV q10mins x2

    • Will cause emesis

  • ECMO

Exogenous Insulin Use and Factitious Hypoglycemia:

  • Secondary to surreptitious use of insulin or insulin secretagogues

    • Often intentional but can be secondary to medical error

    • Not seen with SGLT2 inhibitors

  • More prevalent in women than men, often seen in healthcare workers, 30-40s

  • Diagnostic workup initiated only in event of high clinical suspicion

    • Check insulin, C-peptide, Proinsulin, and insulin secretagogue levels

      • C-peptide is  an endogenous cleavage product from insulin synthesis → should be high in the event of insulinoma or similar pathologies

    • Can also measure insulin antibodies (do not have to be while hypoglycemic)

Self Harm and Suicide in Pregnancy:

  • Female sex is thought of as a protective factor for completion of suicide attempts, with pregnancy/being a parent is often thought of similarly

    • A large retrospective cohort study in the UK evaluating self harm rates in women, both pregnant and not, from 1990-2017 showed:

      • Risk for self harm decreased by 50% during pregnancy (2.07 vs 4.01 events/1000 person-years) in the whole cohort of ages 15-45

      • Risk for self-harm was about the same in pregnant and non-pregnant 15-19 year olds

      • After delivery, self-harm risk increases peaking at 6-12 months postpartum

  • 4-5% of women experience suicidal ideations during their pregnancy

    • Risk factors include lower SES, pre existing depression, domestic or intimate partner violence, history of childhood abuse, age <20, history of psychiatric hospitalization, substance use disorders, anticipated single parenting, unplanned pregnancy

  • Mandated perinatal depression screening tools are not sensitive

  • Long term effects

    • Mounting evidence suggesting a link between parental self-harm and a wide range of adverse outcomes for the child later in life, in addition to potential detrimental effects in utero from self harm activities

    • Most studies investigating the prevalence of perinatal self-harm use population administrative datasets based on hospital discharge coding. 

      • Furthers stigmatization of self-harm

      • Carries a high risk of misclassification bias, often not effectively capturing those who self harm but do not present to the hospital. 

    • Perinatal self-harm could therefore be a substantial public health issue that is overlooked by the research community and health services

R3 Taming the SRU: Disorientation WITH DR. CHRIS ZALESKY

Case 1: Cyanide Toxicity

  • Patient brought in by EMS for altered mental status, possible stroke alert. 

    • Nonfocal neuro exam, GCS 5.

    • Hypoxic, tachycardic on arrival. Glucose WNL.

    • Additional history provided by EMS that the patient was pulled from a burning building. No burns or soot seen on physical exam.

    • VBG 6.89/104/66/-16, carboxyhemoglobin 3.1, lactate 13.2 

    • Got bipap and cyanokit, following commands by time they  left the ED

  • Clinical Features

    • History often notes access to cyanide via industrial manufacturing or exposure from high risk event (structure fire, proximity to burning of items containing significant nitrogenous products)

    • Initial symptoms are nonspecific and include headache, anxiety, confusion, abdominal pain

    • Multiple abnormalities are seen on physical exam including:

      • Hypertension

      • Tachycardia

      • Tachypnea

      • “Cherry red” or flushed skin

      • Seizure activity

      • Obtundation

  • Pathophysiology: Cyanide halts ATP generation by blocking cytochrome oxidase in the electron transport chain → “histotoxic hypoxia” and lactic acidosis

    • Also causes pulmonary and coronary vasoconstriction via secondary mechanism

    • Triggers NMDA release in CNS

  • Diagnosis most often made by clinical suspicion and appropriate risk of exposure

    • Lactate trends nearly identically with CN levels

    • Given correct clinical context, Lactate >8 is highly predictive of CN toxicity

  • Treatment of cyanide toxicity = hydroxocobalamin (Cyanokit) 70mg/kg (typical adult dose is 5g) + sodium nitrite + sodium thiosulfate 

    • Half-life is 2-3 hours

    • Cyanide is metabolized by the liver

    • Sodium thiosulfate can induce methemoglobinemia so check carboxyhemoglobin levels prior to administration

Case 2: Neuroleptic Malignant Syndrome vs. Serotonin Syndrome

  • Patient presentation: Transferred from outside hospital for stroke alert.

    • Initially noted global aphasia, 2x versed en route due to “rigidity”

    • On exam has increased tonicity

    • No medical records or history available

    • Glucose 487 on arrival to ED, vitals notable for profound, increasing pyrexia

    • Starting differential for AMS + hyperthermia + Seizures = sepsis, sympathomimetic toxidrome, anticholinergic toxidrome, serotonin syndrome, neuroleptic malignant syndrome, malignant hyperthermia

  • NMS

    • Pathophysiology is functionally acute dopamine withdrawal

      • Via taking antipsychotics or abrupt cessation of parkinsonian meds

    • Presentation

      • Lead Pipe rigidity

      • Decreased reflexes on exam

      • Diaphoretic, hyperthermic

      • Often develops over 1-3 days

    • Treat with bromocriptine

  • Serotonin syndrome

    • Pathophysiology is increase of synaptic serotonin; severity exists on a spectrum

      • Causative Agents:

        • MOAIs

        • SSRI/SNRIs → can be seen with therapeutic levels and appropriate use, not just overdose

        • Ecstasy, cocaine, MDMA, methamphetamines]

        • Triptans

        • Trazodone

        • Fentanyl, tramadol

        • Linezolid

        • Ondansetron, metoclopramide

        • Lithium, valproic acid

        • Ginseng, nutmeg, St. John’s Wort

    • Presentation

      • Can be variable as disease exists on a spectrum

      • Hyperreflexia and clonus (ankle and ocular)

      • Increased tone in lower extremities more than upper extremities

      • Diaphoretic, hyperthermic

      • Hyperactive bowel sounds

      • CNS agitation (mental status and autonomics)

        • More prominent in SS than NMS

    • Diagnosis requires clinical suspicion primarily

      • Can use Hunter Serotonin Toxicity Criteria, 84% sensitive and 97% specific compared to medical toxicologists

    • Treat with cyproheptadine

      • ONLY available for oral administration

      • Poor efficacy overall so often not recommended

      • Discuss on case by case basis with your local toxicologist