Author: Linda L. Herman, MD

1. Title: Patient Satisfaction
2. Target Audience: Medical Students, Residents

• Author/Affiliation: Linda L. Herman, M.D. – Department of EM, Kaweah Health Care District

1. Source Material:

May allow learners to read handout on patient satisfaction before participating in the simulation.

1. Environment: ER at a community medical center, with specialty consultants avalilable. 1 dedicated nurse.  Additional personnel as needed.
2. Actors:
   1. 1 nurse
   2. Husband of patient
   3. Teenage daughter of patient
   4. Attending physician
   5. Tech to perform EKG

• Case Narrative: 46 year old female (Mrs. AIDET) with syncope arrived by ambulance.

  Phase 1 – Initial Interview Patient is conversant, awake, comfortable. Lying on the cart.  Husband and teenage daughter are present. 106/78 – 92 – 16- 98.6   History: Patient states that she has had a cold for a couple of days.  Took her temperature but did not have a fever.  Has called off work for 2 days.  Has not been sleeping well because of her stuffy nose.  Was in the shower, began coughing, had syncopal episode and fell and hit head.  Her daughter heard her, called the father who came home and called the ambulance. She complains of scalp pain in the left parietal area.  She has had a slight nonproductive cough. She denies having a headache before the fall.  She denies chest pain, back pain, stomach pain, SOB, risk factors for PE, vomiting, diarrhea, melena, hematachezia, etc.  She denies recent travel, sick contacts, working with animals, camping, etc.  She states that this has never happened to her before.   PMH: Hypothyroidism PSH: appendectomy as a teenager, C-section with her daughter and son Meds: Levothyroxine 125 mcg per day SH: stay at home mother Denies tobacco use Drinks socially Denies drugs of abuse FH: Mother with HTN, father died of cancer about 1 year ago ROS: positive for rhinorrhea, nasal stuffiness, myalgias, nonproductive cough   Phase 1 106/78 – 92 – 16- 98.6 Monitor – Sinus rhythm, rate 92  Pulse ox: 98% RA EKG available after completion The nurse and tech are in the room, had finished obtaining the 12-Lead EKG  when the learner arrives. The resident knocks when entering room, introduces self to all involved.  Tech hands EKG to that learner who looks at it.  Tech says to learner, “I showed it to Dr. Warrington and he said that it was not a cardiac alert. He also told me to give to you since you are going to be taking care of the patient Desired action: The learner looks at the EKG, thanks the tech, and sits down to take history.  Before beginning the history, explains his role and asks if everyone wants to be present for this. (This gives the patient a chance to say whether she would like any family members to leave for the history and physical.)   Asks family members if they have anything to add to the history.  Performs physical.  Explains to family and patient the plan, the results of the EKG, what tests are going to be ordered, estimates time of evaluation and asks if they have any other questions.  If the learner does not perform the desired action, have the husband and daughter ask questions:

• “Who are you?”
• “Do you work alone in the ED?”
• “What do you think caused this?”
• “What tests are going to be ordered?”
• “Was the EKG okay?”
• “How long will we be here?”
• “What’s the plan?”

When the history and physical is complete and all questions and explanations have been performed, the next phase begins. Phase 2 104/72 – 88 – 16- 98.6 Monitor – Sinus rhythm, rate 88    Pulse ox: 98% RA Learner leaves room to present to the Attending Physician. The attending does ask before the presentation starts, “Is this a critical patient?”  To which the learn replies, “No”.  The learner  presents case to attending outside the room.  Attending physician, enters room.  Desired action: Introduces self to patient and family and explains his role.  Repeats the history that he heard from the resident or medical student, performs a physical.  Asks the family if the resident explained the plan.  If not, the attending explains the plan.  If he does not, the family should again ask the questions:

• “Are you the supervisor?”
• “Are you a doctor?”
• “What do you think caused this?”
• “What tests are going to be ordered?”
• “Was the EKG okay?”
• “How long will we be here?”
• “What’s the plan?”

Once the attending physician has completed the history and physical and answered all questions then Phase 3 begins. Phase 3 108/74 – 86 – 16- 98.6 Monitor – Sinus rhythm, rate 86    Pulse ox: 98% RA Learner is given a CBC and renal panel. Desired action: Patient receives update from learner about results of CBC and renal panel.   The learner explains what is still pending.  Patient asks for blanket and needs to go to the restroom.  The learner finds nurse so patient can be assisted to the restroom.  The learner finds blanket for the patient and gives to patient.  If the learner does not meet the paitent and family’s needs, they need to ask the questions:  

• “What are we waiting on?”
• “Have any of the test results returned?”
• “Could we have some help in here? She needs to go to the restroom and it is cold in here.”

  When the patient and family has been updated and the learner takes care of the patient’s needs then Phase 4 begins. Phase 4 108/74 – 86 – 16- 98.6 Monitor – Sinus rhythm, rate 86    Pulse ox: 98% RA All other studies returned.  Desired action: The learner enters the room and reviews the results with the patient and family.  The learner explains the diagnosis and possible reasons for the syncopal episode.  The learner reassures the family that there is no injury to the brain.  Plans follow up with PMD with patient and family.  Assures the patient that she can return if anything changes in her condition.  The learner elicits questions from the family and patient.  The learner thanks the patient and family for using their services.   If the learner does perform the above, the patient and the family ask the following questions:  

• “Why do you think that she passed out?”
• “Are you sure that it is okay for her to go home?”
• “What did the CT show?”
• “Was anything abnormal on her tests?”
• “We can take her home now?”

• Stimuli (Stimuli provided at the end of the case)
• CBC
• POC blood glucose level
• Pregnancy Test
• EKG – Sinus rhythm, rate in 90s, normal otherwise
• CT scan – shows no abnormality
• CXR and metabolic panel is optional

1. Learning Objectives or Assessment Objectives

Recognition

• Recognizes that patient is not critical

Management

• Applies known satisfiers to enhance patient experience
• Orders IV for possible fluid administration
• Orders patient to be placed on the monitor
• Keeps patient and family members up-to-date on progress
• Evaluates patient for etiology of syncope and does not find serious etiology

History

Exact events

• Did you have a headache? r/o subarachnoid
• Did you have chest pain? r/o MI
• Did you find your heart beating fast? r/o dysrhythmia
• Did you have SOB? Any risk factors for PE?  r/o PE
• Did you have abdominal pain or back pain? r/o AAA
• Have you had any vomiting or diarrhea? r/o hypovolemia
• Is your stool black or melanotic? Any bright red blood per rectum? r/o GI hemorrhage
• Have you had a fever? r/o infection
• Any sudden changes in position? r/o orthostatic hypotension
• Any new medications? To identify medications that might cause hypotension or bradycardia
• Have you ever had this before? To identify any tests that might give an etiology for Syncope

Physical

• Note the vital signs
• Check conjunctiva for paleness
• Check heart tones to check for irregularity or abnormal heart tones
• Check breath sounds to check for abnormal breath sounds
• Check abdomen for tenderness, active bowel sounds, pulsating masses

Correctly disposition the patient

• Disposition – discharges patient with adequate instructions Explain the results of the diagnostic tests
• Explain the diagnosis
• Assure the patient that they can use emergency services again
• Arrange follow-up time with the patient
• Ask patient and family if have any questions

Data Gathering

Asks appropriate questions to rule in or out most common causes of syncope – SAH, MI, Cardiac arrhythmia, PE, hypovolemia, anemia, ectopic pregnancy, vascular catastrophe, etc.  (See above)

• Performs complete physical
• Orders CBC, blood glucose level,
• Orders CT scan of head
• Orders pregnancy test

Teamwork

• Introduces nurse and tech
• Manages up: Makes positive comment about them both ( may include both in comment or comment about each one.

Critical Actions

• IV Saline lock
• Calls patient’s name (Ms. or Mrs. AIDET),
• introduces self, nurse & tech to patient and family,
• Sits down when taking history,
• leans forward and does not interrupt for 20 seconds
• Explains plan and how long it takes
• Maintains eye contact.
• Explains to patient the result of the EKG before leaving the room
• Rounds on patient – lets her know when her labs have returned. Asks about her condition.  Will occur during Phase 3.
• Has discussion with patient and family about her results and plan for care.

1. Debriefing
   1. Review how patient experience/patient satisfaction affects reimbursement from Medicare
   2. Review what behaviors lead to positive patient experience
   3. Review the importance of Discharge follow up phone calls.
2. Debriefing Handout

  Simulation Debriefing Patient Satisfaction/Experience Importance of Patient Experience

• Centers for Medicare and Medicaid Services (CMS) – Value Based Purchasing Program
• Value-Based Purchasing means that CMS adjusts Medicare’s payments to reward hospitals based on the quality of care that they provide to patients
• For Fiscal year 2016 - performance attainment & improvement will determine total hospital reimbursement
  • 25% of payment determined by efficiency (has to do with time metrics)
  • 10% of payment determined by process of care (metrics that deal with best practices
  • 40% of payment determined by Outcomes (mortality and morbidity for certain conditions)
  • 25% determined by HCAHPS (Patient experience)
• HCAHPS – Hospital Consumer Assessment of healthcare Providers and Systems – national standardized publically reported survey of patients’ perspectives of hospital care
• HCAHPS designed in 2005, voluntary collection began in 2006, public reporting began 2008 on the website hospitalcompare.hhs.gov
• There are 11 questions that have to do with the patient experience that are posted on this website. There is a slide of four of the questions and it compares to the 2 similar hospitals in the area, the California average and the national average.  All other metrics are posted on this website also.
• The goals of this program are:
  • To produce comparable data on patients’ perspectives of care so that consumers can make objective and meaningful comparisons among hospitals
  • To create incentives for hospitals to improve their quality of care
  • To enhance public accountability in healthcare by increasing the transparency of the quality of hospital care
• Inability to reach national standards will affect the reimbursement to your hospital from CMS in the millions of dollars
• Survey covers 7 areas
  • Communication with doctors
  • Communication with nurses
  • Responsiveness of hospital staff
  • Pain management
  • Communication about medications
  • Cleanliness of hospital
  • Quietness at night of hospital
  • Discharge information – no to yes
  • Willingness to recommend – definitely no to definitely yes
  • Overall hospital rating – 0 to 10 rating scale
    • Only 9 or 10 is considered as the top-box
  • Quality does equal satisfaction – Patient’s first impression sets the stage for HCAHPS success
  • ED role - nationally
    • 50% of all admission
    • 75% of all plain radiographs ordered
    • 50% of CT scans ordered
  • AIDET
  • Knock first, clean your hands
  • Acknowledge
    • The patient
    • The patient’s visitors
    • Be respectful
  • Introduce self, explain role, who supervising
  • Sit down – take history, acknowledge others and ask if need to add anything
  • Duration and explanation
    • Talk to patient and visitors about what it could be
    • Explain what is going to be done and how long will it take
  • Thank the patient – for everything
  • Manage up your teammates
    • Say positive comments about the nurses, techs, registration clerks on the team
  • Hourly rounding
    • Keep your patient and family up-to-date
    • Ask if their pain is controlled
    • Ask if they need to go to the restroom
    • Ask if they are comfortable – position
    • If they ask for something, see that they get it or if they can’t have it, give an explanation
    • Ask if there is anything else they need
    • Tell them when you will be back
    • Put your name on the white board
  • Sign outs
    • Hot sign outs are at the patient’s room
    • Pros
      • Meet the patient
      • Let them know what is going to happen
      • Get an accurate picture of their condition
      • See if they have any questions
    • Hospital perform their own surveys – find out what the questions are, use words that are used in the surveys so that the patients are prepped to answer correctly
    • Post-visit phone calls
      • Allows to re-connect with the patient
      • Learn from these phone calls
      • Usually 24 – 48 hours after discharge
      • Areas to cover
        • Empathy and concern
        • Clinical Outcomes
        • Discharge or Home-care follow-up orders
        • Perception of Service
        • Process Improvement

Syncope Debrief Etiology of Syncope Focal Hypoperfusion of CNS Structures

1. Cerebrovascular disease
2. Hyperventilation
3. Subclavian steal
4. Subarachnoid hemorrhage
5. Basilar artery migraine
6. Cerebral syncope

Systemic Hypoperfusion Resulting in CNS Dysfunction

1. Outflow obstruction
2. Reduced cardiac output
   1. Tachycardia
   2. Bradycardia
3. Other cardiovascular disease
4. Vasomotor—neurally mediated (reflex vasodepressor)
   1. Carotid sinus sensitivity
   2. Miscellaneous reflex – such as coughing, defecation, urination, etc.
5. Other causes of hypoperfusion
   1. Orthostatic hypotension—volume depletion
   2. Anemia
   3. Drug-induced

CNS Dysfunction with Normal Cerebral Perfusion

1. Hypoglycemia
2. Hypoxemia—asphyxiation
3. Seizure
4. Narcolepsy
5. Psychogenic
6. Toxins

History

• Key characteristics
  • Gradual or abrupt
  • Position when began
• Activities prior to syncopal episode
• Associated symptoms
• Tonic clonic movements
• Trauma occurrence
• Medication ingestion

Diagnostic Evaluation

• 12-Lead EKG
• CBC to check for anemia
• Blood glucose check
• Selective use of electrolytes
• HCG or UCG in female of child-bearing age

 Note: CT scan – is only indicated in uncomplicated syncope if intracerebral hemorrhage is suspected, syncope is accompanied by a headache, there are focal neurological deficits or if associated with clinically significant head trauma.  In this case, the patient fell to floor and hit head.  Have to ask self did she just feel lightheaded, fall and have loss of consciousness or did she have loss of consciousness and fall. All other diagnostic testing is guided by history and physical. 

Disposition

• Admitted
  • History of CHF
  • History of valvular disease
  • Prolonged QT interval
  • New Bundle Branch block
  • Associated with chest pain
  • Associated with unexplained shortness of breath
  • Malignant dysrhythmiaa

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