Critical Values: To Alert or Not to Alert? PDF

Critical Values: To Alert or Not to Alert? The 911 of EEG Leisha Osburn, MS, MHA, MPH-HPM, R.EEG/EPT, NA-CLTM, CNIM, DABNM, FASET, FACNS ONDS Annual Conference July 2022 Author Relevant Disclosures  Founding Member and CEO of Next Gen Neuro, a company t...

Critical Values: To Alert or Not to Alert? The 911 of EEG Leisha Osburn, MS, MHA, MPH-HPM, R.EEG/EPT, NA-CLTM, CNIM, DABNM, FASET, FACNS ONDS Annual Conference July 2022 Author Relevant Disclosures  Founding Member and CEO of Next Gen Neuro, a company that provides remote EEG/cEEG monitoring and staffing solutions.  No other disclosures.  Why EEG Critical Values? It’s All About Time RECAP and Is There Really Q&A Legal Risk? Test Your Gut- Writing a P&P for Critical Value EEG Critical Values Pattern Leisha Recognition Care Settings and EEG Care Settings and EEG Critical Values Critical Values So...What are Critical Values in Health Care? In the early 2000s, a group of Massachusetts Hospitals began talking about effective communication of critical patient test results Joint Commission took interest in this and published the Safe Practice Recommendations of this hospital Coalition as part of their February 2005 Joint Commission Journal on Quality and Patient Safety. In fact, TJC dedicated that entire Journal issue to the subject of Communicating Critical Test Results. “While at first it may appear deceptively simple, health care clinicians need to see [Critical Test Results] CTRs in the “Big Picture” – and understand that ordering tests, reporting results and values, and then acting on those results are steps in a complex process of medical care.”, from Risk Review, Nov. 2006 The Massachusetts Coalition defined CTRs as values/interpretations for which delays in reporting can result in serious adverse outcomes for patients.  Safe Practice Recommendations Massachusetts Coalition Identify Identify who should receive the results Identify Identify who should receive the results when the ordering provider is not available Define Define what test results require timely and reliable communication Identify when test results should be actively respoted to the oredering provider and establish Identify explicit time frames for this process Identify Identify how to notify the responsible providers Establish a shared policy for uniform communication of all types of test results (laboratory, Establish cardiology, radiology and other diagnostic tests) to all recipients Design Design reliability into the system Support and maintain Support and maintain systems Support Support infrastructure development In the years immediately following these publications, multiple studies conclude… Failure to act on abnormal test results is a common medical error, with potentially serious consequences For patients it can mean a loss of opportunity to begin treatment For providers and health systems the outcome can be legal liability, loss of patient trust, and unnecessary costs Goal 2 Improve the effectiveness of communication among caregivers. Report critical results of tests and diagnostic procedures on a timely basis. Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life-threatening situation. The objective is to provide the responsible licensed caregiver these results within an established time frame so that the patient can be promptly treated. Why Should We Create Critical Values for EEG/cEEG?  Why EEG Critical Values? It’s All About Time RECAP and Is There Really Q&A Legal Risk? Test Your Gut- Writing a P&P for Critical Value EEG Critical Values Pattern Leisha Recognition Care Settings and EEG Care Settings and EEG Critical Values Critical Values Why Treat Seizures and Status? Payne, et al1 showed a significant difference in neurologic decline (per Seizure Burden vs. Neurologic Peds Cerebral Performance measure) Decline for increasing lengths of “Seizure 200 15.70% 18.00% Burden” 180 160 16.00% 14.00%  Seizure Burden=% time/hour pt 140 174 12.00% 120 having electrographic seizure 100 10.00%  At ~2% no decline; by ~16% (9 min) 80 60 8.00% decline in 174/259 (67%) patients 40 6.00% 4.00% At 20% (12 min.) Seizure Burden/hr, 20 0 0 2.00% Odds of neurologic decline increased 1 2 by 1.13 for every 1% increase in Sz Patients with Neurologic Decline Burden across all diagnoses Mean Seizure Burden (p=0.0016) 1Payne, E. T., et al, (2014). Seizure burden is independently associated with short term outcome in critically ill children. Brain, 137(Pt 5), 1429-1438.  (2017) Time to EEG is independently associated with outcome in critically ill neonates and children.  2017 Study out of Boston Children’s Hospital  Retrospective observational study in patients from birth to 21 years of age who underwent clinically indicated cEEG in the ICU  Main outcome measure was in-hospital mortality  625 patients total; 211 neonates (24% premature) and 414 pediatric patients  Electrographic seizure occurred in 176 patients (28%) SE occurred in 20 (11%) Sanchez Fernandez, I., Sansevere, A. J., Guerriero, R. M., Buraniqi, E., Pearl, P. L., Tasker, R. C., & Loddenkemper, T. (2017). Time to electroencephalography is independently associated with outcome in critically ill neonates and children. Epilepsia, 58(3), 420-428.  (2017) Time to EEG is independently associated with outcome in critically ill neonates and children. TIME IS BRAIN for RESULTS  In neonates -after controlling for gender and SEIZURES TOO! prematurity, independent factors associated with mortality were  prematurity  presence of status epilepticus (SE)  the time from ICU admission to initiation of cEEG  In pediatric patients -after controlling for gender and age, independent factors associated with mortality were:  the presence of SE  the time from ICU admission to initiation of cEEG Sanchez Fernandez, I., Sansevere, A. J., Guerriero, R. M., Buraniqi, E., Pearl, P. L., Tasker, R. C., & Loddenkemper, T. (2017). Time to electroencephalography is independently associated with outcome in critically ill neonates and children. Epilepsia, 58(3), 420-428  Langhan ML, Stanton B. Seizures in neonates: diagnosis and management in the emergency department. Pediatr Emerg Med Pract. 2020;17(6):1-20. Relevant Key Points Early seizure cessation is important for improved outcomes Studies have shown that high seizure burden and status epilepticus are independently associated with worse outcomes EEG is often key to making a definitive diagnosis, as subclinical seizures and benign mimics are common in this age group https://www.ebmedicine.net/topics/neurologic/neonatal-seizures  Why EEG Critical Values? It’s All About Time RECAP and Is There Really Q&A Legal Risk? Test Your Gut- Writing a P&P for Critical Value EEG Critical Values Pattern Leisha Recognition Care Settings and EEG Care Settings and EEG Critical Values Critical Values Are There Legal Consequences to Unreported and/or Undetected EEG Critical Values? http://www.outsidethebeltway.com/who-should-pay-child-porn-victims-and-how-much/law-money-gavel/  Legal Consequences?  Seizures following a reaction to angiogram dye were monitored with serial EEGs and treated unsuccessfully  Patient was eventually transferred to Mayo where they were successfully treated for status epilepticus, but suffered permanent brain injury  Patient (a physician) received 4 million dollars from suit claiming negligent failure to properly treat status epilepticus at first hospital http://getcashmaker.com/get-cash-online/lost- Minnesota Association for Justice (2010) Minnesota Case Report, Volume 29, Number 2. money/ http://www.robinskaplan.com/resources/news/medical-malpractice-case-report-4-million-for-failure-to-treat-status- epilepticus-following-angiogram Legal Consequences?  64 y.o. Charles Gray entered an EMU and was taken off nearly all his meds to be evaluated for surgery  The EEG Tech left Gray unattended for about an hour to take a break and tend to other patients on day 4  He had a recorded seizure, then respiratory and cardiac arrest and was found dead when the tech Charles Gray (credit: CBS) returned  The hospital accepted responsibility http://denver.cbslocal.com/2008/07/11/monitoring-mistake-leads-to-hospital-death/  Legal Consequences? 6-year-old Christian Padilla  2005 had successful cardiac surgery but was slow to wake up afterwards  Caregivers failed to recognize that the patient was having seizures, describing him as “ acting fidgety” in the medical notes (NBC News, 2008)  Christian was having seizures as a result This Children’s of the brain swelling that killed him hospital  After Christian’s death his parents were now has a awarded $1.25 million in liability Neurotelemetry Program compensation Aleccia, J. (2008). Before code blue: Who’s minding the patient? Retrieved from http://www.nbcnews.com/id/24002334/ns/health-health_care/t/code-blue-whos-minding-patient#.VQDSr_nF8jw  Why EEG Critical Values? It’s All About Time RECAP and Is There Really Q&A Legal Risk? Test Your Gut- Writing a P&P for Critical Value EEG Critical Values Pattern Leisha Recognition Care Settings and EEG Care Settings and EEG Critical Values Critical Values Critical Values for Remote cEEG Monitoring in the ICU  Call Reading Neurologist if:  New onset of seizure  Significant change from baseline EEG Once the initial threshold is met (Patient has now had the first seizure), ARE THERE NEW CRITICAL VALUES? Call if Seizure lasting > 5 minutes New type of seizure is seen X number of seizures in 1 hour, etc.  Call Bedside Care Provider anytime patient may be at risk for physical injury  Could STAT reporting of results help this patient? Result in potential harm if withheld? Patient admitted with a subdural hematoma. Patient had mental status changes and right upper extremity twitching when Propofol was turned off. Patient was on anti- seizure medication. (Osburn & Wolfe, 2012)  Could STAT reporting of results help this patient? Result in potential harm if withheld? Patient admitted with cardio- pulmonary arrest. Patient unresponsive with lip twitching. R/O seizure vs. Myoclonus. Patient was on no anti- seizure medication. (Osburn & Wolfe, 2012)  Could STAT reporting of results help this patient? Result in potential harm if withheld? Patient post-op from a thoracic abdominal aneurysm repair. Postoperatively, patient was noted to have right sided weakness. Patient somnolent and ventilated. MRI revealed an acute left hemispheric infarction. Patient was not on anti- seizure medication. (Osburn & Wolfe, 2012)  Could STAT reporting of results help this patient? Result in potential harm if withheld? Patient with hypoxic encephalopathy from near drowning. Comatose, unresponsive, no outward presentation of seizures. Subclinical seizures noted (Several episodic events with build up to this activity seen). (Osburn & Wolfe, 2012)  Why EEG Critical Values? It’s All About Time RECAP and Is There Really Q&A Legal Risk? Test Your Gut- Writing a P&P for Critical Value EEG Critical Values Pattern Leisha Recognition Care Settings and EEG Care Settings and EEG Critical Values Critical Values   Call Reading Neurologist if:  New onset of seizure  Significant change from baseline EEG Critical Values Once the initial threshold is met (Patient has now had the first seizure), for Remote ARE THERE NEW CRITICAL VALUES? Call if Monitoring of Seizure lasting > 5 minutes cEEG in the New type of seizure is seen X number of seizures in 1 hour, etc. EMU  Call Bedside Care Provider anytime patient may be at risk for physical injury Call Bedside Care Provider to assess patient during new onset event. Case Presentation- -History  17-year-old admitted to hospital after new onset of episodes of speech arrest  Patient is sitting quietly in the bed. Modified from Osburn & Lau, WSET 2009 What Initial Action, if any, Should the Remote Tech Take? (Patient is still sitting quietly in bed. Appears to be watching TV.) Modified from Osburn & Lau, WSET 2009 Other Actions the Remote Technologist Should Take? End of episode— Lasted 3 minutes Modified from Osburn & Lau, WSET 2009  WHAT IS THE CORRECT ACTION TO TAKE?  19-year-old patient admitted for possible new onset seizures. Initially on no AEDs.  On Day 1, patient had first generalized tonic/clonic seizure. Care Providers notified and seizure meds started.  Day 2 of EMU monitoring, THIS second generalized tonic/clonic seizure is seen. It lasts 2 minutes. Modified from (Osburn & Wolfe, 2012)  Critical Values for Remote RT Intermittent Monitoring of In-Home cEEG/AEEG  Call Designated In-Home Companion if:  Patient may be at risk for physical injury  Call Designated Physician OR In-Home Companion Per Protocol, if:  Any time patient has a seizure lasting greater than X minutes  Any time patient has X number of seizures in 1 hour  Discuss options for event follow-up: Call 911 Call 911 for wellness check DesignatedCompanion will take patient to the Emergency Room Designated Companion will observe patient in-home and escalate care if indicated  WHAT IS THE CORRECT ACTION TO TAKE?  Patient has a history of fairly well controlled generalized tonic/clonic seizures and a past history of non-epileptigenic events.  Pt was seen for a complaint of recent increase in seizure frequency.  AEEG is ordered to determine if recent events are GTC seizures or non-epileptic events.  On Night 1 of AEEG In-Home monitoring, this generalized tonic/clonic seizure is seen during an Interval Check. The event lasts 2 minutes.  Future Scenarios: Critical Values for Remote EEG Testing at Point of Acute Injury  Why EEG Critical Values? It’s All About Time RECAP and Is There Really Q&A Legal Risk? Test Your Gut- Writing a P&P for Critical Value EEG Critical Values Pattern Leisha Recognition Care Settings and EEG Care Settings and EEG Critical Values Critical Values “ Recommendations for Setting Up a Critical Value Policy  Terms Should Be Clearly Defined (i.e., What does "critical" ” mean?)  Responsibilities for All Staff Should be Clear (Techs, Reading MDs)  Should be written by Key Stakeholders Involved (Techs, Reading MD, etc)  Should Specify the Procedures for communicating abnormalities (phone vs fax vs EMR)  Should Specify Time Between Detection and Notification  Should Establish Monitoring Activities and Evaluation Procedures (The Joint Commission, 2010) Mission Health Critical Values Reporting Policy https://missionhealth.org/wp- content/uploads/2018/04/Critical- Value-Reporting-Policy.pdf CHMC Care Pathways: A User’s Guide https://www.childrensomaha.org/wp-content/uploads/2018/06/users-guide_clinical-pathways.pdf Use Order Sets to Establish and Document EEG Critical Values  Utilize technology to set values between Physician and Technologist:  EEG Equipment- custom tabs for reports  EMR Orders  Secure Messaging Templates Courtesy of Gillette Children's Specialty Hospital Seattle Children’s Hospital Clinical Standards Work Seizure Pathway  https://www.seattlechildrens.org/pdf/seizure-pathway.pdf  Critical Values for Can You Build This One? “the Outpatient EEG  Terms Should Be Clearly Defined (i.e. What does "critical" mean?) Responsibilities for All Staff Should be ”  Clear (Techs, Reading MDs)  Should be written by Key Stakeholders Involved (Techs, Reading MD, etc)  Should Specify the Procedures for communicating abnormalities (phone vs fax vs EMR)  Should Specify Time Between Detection and Notification  Should Establish Monitoring Activities and Evaluation Procedures (The Joint Commission, 2010)  Why EEG Critical Values? It’s All About Time RECAP and Is There Really Q&A Legal Risk? Test Your Gut- Writing a P&P for Critical Value EEG Critical Values Pattern Leisha Recognition Care Settings and EEG Care Settings and EEG Critical Values Critical Values  Q&A THANK YOU FOR JOINING! More questions? Contact me at: Leisha Osburn [email protected] 317 372-5716  References  Introduction: Communication critical test results. Jt Comm J Qual Patient Safety 2005, Vol 31, Issue 2.  11.2006_communicating.critical.test.results2.pdf http://www.pinsco.com/downloads/Risk_Review_D ownloads/11.2006/11.2006_communicating.critical.test.results2.pdf  Critical-and-Unexpected-Findings-Reporting-Policy.pdf https://xray.ufl.edu/files/2008/06/Critical-and- Unexpected-Findings-Reporting-Policy.pdf  Direct Communication of TCMI Between Practitioners guideline 2021- 01.pdf https://wmc.wa.gov/sites/default/files/public/Direct%20Communication%20of%20T CMI%20Between%20Practitioners%20guideline%202021-01.pdf  The Healthcare Manager: Critical test results in laboratory – Policy and process for identification and communication https://expresshealthcaremanagement.blogspot.com/2018/09/critical-test- results-in-laboratory.html  Communicating About Critical Test Results: Risk Management Tip https://www.mlmic.com/blog/physicians/communicating-about-critical-test-results  Failure to Perform/Communicate Critical Test Results | Healthcare Insurance Reciprocal of Canada https://www.hiroc.com/resources/risk-reference-sheets/failure- performcommunicate-critical-test-results  CDC_ReportingCriticalValuesSummary.pdf https://www.cdc.gov/labbestpractices/pdfs/CDC_ReportingCri ticalValuesSummary.pdf  Communicating critical test results: safe practice recommendations. | PSNet https://psnet.ahrq.gov/issue/communicating-critical-test-results-safe-practice- recommendations References and Other Resources  History of critical values http://www.captodayonline.com/Archives/0808/0808_critical_values_4.html  Reducing Diagnostic Errors through Effective Communication https://link.springer.com/article/10.1007%2Fs11606-007-0393-z  Massachusetts Coalition for the Prevention of Medical Errors- Communicating Critical Test Results http://www.macoalition.org/communicating-critical-test-results.shtml  CHOP Clinical Pathways https://www.chop.edu/clinical-pathway/unprovoked-seizure-clinical-pathway  Poor communication risks https://www.hipaajournal.com/effects-of-poor-communication-in-healthcare/  Monitoring mistake leads to hospital death https://denver.cbslocal.com/2008/07/11/monitoring-mistake-leads-to-hospital-death/