CRC minutes - 3.10.22.pdf

Confidentiality Note: The information contained in these minutes is privileged and confidential information intended for quality management purposes and is protected from disclosure. Dissemination, distribution, or copying of this information is prohibited. This document and related records (or information contained herein) are deemed CONFIDENTIAL AND PRIVILEGED under the provisions of 38 U.S.C. § 5705. The statute provides for fines up to $20,000 for unauthorized disclosures. Page 1 of 9 Cardiopulmonary Resuscitation Committee (CRC) Veterans Affairs Medical Center (VAMC) – Tomah, Wisconsin ATTENDANCE: P = Present A = Absent E = Excused X = Alternate N=Not Required MEMBERS DEC 16 DEC 30 JAN 13 FEB 2 FEB 10 MAR APR MAY JUNE JULY AUG SEP OCT NOV DEC Chair – Acute Care Provider or Designee A P P P P P Co-Chair – Deputy Associate Chief of Staff-MS P P P P P P Committee Administrative Support – MS E P P P P P Fire Department Chief or Designee A A P P P P Urgent Care Nurse Manager or Designee A P P A P P Performance Improvement Representative P P P P P P Education Instructor P P P P P P Respiratory Therapist P P P P E P Police Department Representative A P P P P P Nurse of the Day (NOD) or Designee P P P P P P AdHoc Members - - - - - - Associate Chief of Staff-MS P - - - - P Topic Discussions/Conclusions Recommend ations/Action Responsibl e Person Follow- up Date 1. Date, Time, and place of Meeting March 10th, 2022, 9:00am – 10:00am via TEAMS

Confidentiality Note: The information contained in these minutes is privileged and confidential information intended for quality management purposes and is protected from disclosure. Dissemination, distribution, or copying of this information is prohibited. This document and related records (or information contained herein) are deemed CONFIDENTIAL AND PRIVILEGED under the provisions of 38 U.S.C. § 5705. The statute provides for fines up to $20,000 for unauthorized disclosures. Page 2 of 9 Topic Discussions/Conclusions Recommend ations/Action Responsibl e Person Follow- up Date 2. Review/ Acceptance of Previous Minutes: Minutes for 2/10/22 are in process, all prior CRC minutes have been completed. 3. Old Business: None 4. Agenda Items AGENDA Cardiopulmonary Resuscitation Committee (CRC) 1. Date and Time of Meeting: March 10th, 2022, 9a-10a 2. Place of Meeting: TEAMS : 1 872-701-0185, ID - 857 612 207# 3. Review Previous Minutes: all complete except the 2/10/22 minutes 5. Agenda Items: 5.1. Review Emergency Response Reports – TEAM to discuss all Emergency Responses to give reports to the group. type of emergency Patient info date of emergency assigned reviewer 1 RR Gary Peterson - emp 1/17/2022 Yaniel Pabon 2 ME Jeffrey Rose 2/10/2022 Marissa Hoffman 3 ME Kristine Schuster 2/11/2022 Adam Reinart 4 RR Elizabeth Cutler 2/12/2022 Kate Achman

Confidentiality Note: The information contained in these minutes is privileged and confidential information intended for quality management purposes and is protected from disclosure. Dissemination, distribution, or copying of this information is prohibited. This document and related records (or information contained herein) are deemed CONFIDENTIAL AND PRIVILEGED under the provisions of 38 U.S.C. § 5705. The statute provides for fines up to $20,000 for unauthorized disclosures. Page 3 of 9 Topic Discussions/Conclusions Recommend ations/Action Responsibl e Person Follow- up Date 5 ME Randy Worke 2/16/2022 Marcie Fulford 3/10/2022 yes 6 ME Gordon Boe 2/18/2022 LeAnne Arne 3/10/2022 No 7 RR Patrick Robertson 2/24/2022 Elizabeth Wood 3/10/2022 No 8 ME Nicholas Schmitz 3/8/2022 Nancy Delzer 3/10/2022 No 9 RR Gordon Boe 3/9/2022 Nancy Delzer 3/10/2022 No 6. Next Meeting: April 14th, 2022, via TEAMS 4.1 reports Case #1 – Mr. Gary Peterson (1/17/22) Group Discussion: Rapid response called. Veteran was approached by staff for morning medications and BG check. Veteran was unresponsive to voice, was immobile, and was not responsive to pain. Staff called rapid response. After arriving on scene, NOD called police dispatch requesting 911 ambulance. Veteran transferred via ambulance to Tomah Health. VS = 158/90, O2=95%, R=18, P=90. Blood glucose = 138. 2 of the 6 responders wore proper PPE. Stroke protocol is located on each crash cart as well. Possible re-education of the NOD staff to wait for the MOD to decide on transport options. Items that went well : Everything, team arrived quickly, staff was monitoring employee. Items that did not go well: NA Equipment not available or not functioning properly : NA Reminder for MOD staff to follow the policy to send stroke cases to GHS not thru the 911 ambulance. NOD reminder to go out as well. Dr. Simon 3/10/2022

Confidentiality Note: The information contained in these minutes is privileged and confidential information intended for quality management purposes and is protected from disclosure. Dissemination, distribution, or copying of this information is prohibited. This document and related records (or information contained herein) are deemed CONFIDENTIAL AND PRIVILEGED under the provisions of 38 U.S.C. § 5705. The statute provides for fines up to $20,000 for unauthorized disclosures. Page 4 of 9 Topic Discussions/Conclusions Recommend ations/Action Responsibl e Person Follow- up Date Case #2 – Mr. Jeffery Rose (2/10/22) Case Discussion : RN on 406B called for a medical emergency with the assumption that the patient had a low blood sugar as he was not responsive, could not follow commands, and had a change in LOC. Blood Glucose level was checked with the value of 190, and a repeat check of 126. Per NA, the patient was his normal self at 06:00HRS, and when he was approached in his room around 07:10 HRS he was slumped in his wheelchair in the door threshold going into his private bathroom and was not responsive. Per MOD, he wanted to R/O a possible CVA, so an emergency ambulance was called. VS= BP=111/73, T=97.3, P=94, 02=96% on RA, and R=16. NIH stroke scale completed by MOD. NIH stroke scale score = 24. 3 of the 7 responders did not wear proper PPE. Inconsistences noted in charting and NOD documentation of events. Better hand off communication is needed by ward staff. No documentation from the Nursing staff in the medical record. No Nursing discharge note even though Veteran was sent off site, then brought back after event. MOD did the appropriate documentation. Items that went well : Quick responsiveness for medical emergency team, NOD, MOD, Fire Dept. VA Police, and 911 ambulance crew. Items that did not go well : Immediate re-education of staff regarding how to call for an emergency. Staff RN was unaware/unsure how to call an emergency. Upon arrival to Medical Emergency, it was relayed that he had a low blood sugar and that objective data had not been retrieved yet (was not hypoglycemic). Education given as to not state the reason as such until Objective data is retrieved "blood glucose checked, with lab value". Increase closed loop communication (information presented was chaotic and it was advised to have the RN assigned to the patient at bedside to answer questions to NOD and MOD (as to how the patient was found and who found him, DNR status, medication recently received). Have computer with CPRS chart of patient up at bedside at all emergencies so that information is readily available. Equipment not available or not functioning properly : NA Follow up with the individual Nurse on scene for the documentation items that were missed thru the Nurse Manager. Dr. Simon 3/10/2022

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