Wednesday, December 29, 2010

The Discharge Summary that Duke Hospital gave me (and the oddities)

I did receive a Discharge Summary from Duke University Hospital on Saturday September 18 in the morning.  Actually, Matthew Peter Gunn, PA provided me with a Discharge Summary indicating that I was to be discharged Friday September 17 morning.  


In fact, when I mentioned the error to PA Gunn (after I found him alone in my hospital room near my personal belongings as I entered - a story I will save for later).  The PA yelled at me and stormed out of my hospital room.  


I calmly asked Matthew Peter Gunn, PA why the Discharge Summary stated that I was diabetic when I was not. And in fact I have never been diagnosed as diagnosed as diabetic or even pre-diabetic.   


I also calmly asked why the Discharge Summary did not state that I was treated for osteomyelitis.  PA Matthew Peter Gunn's response was to throw a piece of paper on the hospital bed with my diagnosis and retort "what part of preliminary don't you understand"?  Huh? About two hours later the first Discharge Summary was off the Duke Healthview (but I saved a copy).  


Of course, the final report was identical to the report Matthew Peter Gunn PA gave me on Friday September 17, 2010.











Duke University Hospital
DUKE UNIVERSITY HEALTH SYSTEM
UNIVERSAL PATIENT DISCHARGE INSTRUCTIONS
Corrected
Facility:DUMC, Medical Record # R542xx
Patient: HANDY, CHERYL ANN
Admission Date: 09/10/2010 11:54:00 PM 
Encounter: 3836NF
Discharged: 09/18/2010
10:30:20 AM
DOB: 09/10/19xx Age: Gender: F
Language: English 
Completed By: MATTHEW PETER GUNN,PA
Reason for admission:
Incision and drainage of left proximal tibia
Discharge status:
To home under care of health service
     Allergies
Reaction
Severity
Reported by
     Neupogen     
Rash
Moderate
Self
     STERI STRIPS     
itching and rash
Moderate
Self
      Medications                                                                  
      Take these medications:


1.
Metoprolol {LOPRESSOR}
100 MGBy mouthEvery 8 Hours


2.
Pravastatin {PRAVACHOL}
40 MGBy mouthBefore bedtime


3.
Tamoxifen {NOLVADEX}
20 MGBy mouthDaily


4.
Zolpidem {AMBIEN}
10 MGBy mouthEvery Bedtime As Needed


5.
Topiramate {TOPAMAX}
100 MGBy mouthBefore bedtime


6.
Duloxetine {CYMBALTA}
60 MGBy mouthBefore bedtime
(New)

7.
Sennosides - Docusate {SENOKOT-S}
2 TABBy mouthTwice a day
(New)

8.
Laxative/Enema of Choice
1 DOSEMiscelaneousAs needed
(New)

9.
Multivitamin {ONE-A-DAY}
1 TABBy mouthDaily
(New)

10.
Hydrocodone-Acetaminophen 10/400 mg {ZYDONE}
1 TABBy mouthEvery 4 Hours As Neededfor pain#60
(New)

11.
Acetaminophen {TYLENOL}
650 MGBy mouthEvery 4 Hours As Needed
(New)

12.
Oxacillin Inj
12gIntravenousEvery 24 Hourscontinuous infusion x 6 wks
This medication list was created on:2010-09-15 10:35 and last    updated: 2010-09-18 08:25
The above list was verified against your home and hospital medications prior to discharge
Follow pharmacist's instructions on medication labels. Please consult with your doctor before resuming any medications that are not listed above. Please take this form with you to your pharmacy and health care provider.
 Diet
l
High Fiber.
l
Diabetic. 
Activity
l
Light.
l
May drive inwhen off all narcotics and cleared by your doctorday(s).
Special Instructions
l
May shower in 1-2day(s).
l
Waterproof cover over dressing when showering.
l
No tub bathing or soaking.
l
Change dressing in 1-2day(s) per instructions.
l
Sutures/staples out in 10-12day(s) (by healthcare provider).
l
Full Weight Bearing (WB) Status of:left leg.
l
If you smoke (or have smoked within the last year), we strongly recommend that you do not smoke.
l
Keep your legs elevated.
l
Wear your white TED hose on both legs for 8-10 hours a day for 4-6 weeks.
Report any of the following
l
Bladder or bowel symptoms.
l
Temperature is greater than101.5 F (38.1 C) degrees.
l
Numbness or weakness.
l
Severe pain.
l
Nausea, vomiting, chills.
l
Redness, swelling, or draining from incision.
Report issues to:
Orthopaedic Resident on call (919) 684-8111.
If life threatening emergency call 911.
Follow up
The following appointments have been scheduled for you:
l
10/21/2010 08:30 AM - Dr.TIMOTHY A COLLINS - Pain and Pallative Care
l
11/30/2010 04:00 PM - Dr.MICHAEL A BLAZING - Primary Care Fayetteville Road
Additional follow up appointments:                                          
l
Patient to call appointment hub at (919)613-7797 or (800)851-5811 on the first business day after discharge and make appointment in7 days for suture removal in Dr. Bolognesi's office(indicate value for days or weeks).
l
Medication Refills: Call your orthopaedic physician's office during office hours. Refills will not be filled after hours.
f/u 10/8/10 Dr. Maziarz Clinic 2J Duke South with Infectious Disease 930am, weekly CBC/ESR/CRP faxed to 919 6817494
Remember to make healthcare providers aware that you were diagnosed with and/or treated for the following conditions during this Hospital stay:
l
Asthma
l
High Cholesterol
l
Migraines
Breast cancer
KARL M SCHWEITZER, MD   
Department of Orthopaedics
       
ELECTRONICALLY SIGNED ON  

MD/PA/MP Signature and ID
PDIV04



But there is even more interesting stuff associated with the discharge.  Physicians and surgeons are very busy people at Duke Medical.  After I surprised Matthew Peter Gunn, PA in my hospital room on Friday evening September 17, 2010, Gunn told me what the cultures determined caused the osteomyelitis and what the IV antibiotic would be.  


I asked Gunn PA to write the diagnosis and treatment plan down.  Gunn, PA was very busy too.  He write two words:  staph coag negativeNafcillin 


According to my medical records, it was Matthew Peter Gunn, PA and the Home Health Nurse and Pharmacist that decided on my treatment plan.  There is no indication that any board certified physician participated in the treatment plan.  (Remember, they are very busy and no one would look at my open wound.)  This might explain why Dr. Karl Schweitzer was "sensitive" about the antibiotic treatment issue.  I did not even know it was an issue at the time of discharge.


Again, I was just concerned about the open wound.








ROI - Browser Chart - ROI Request #: 278702
09/17/2010     09:31 PM    Arcus,     Joyce     RN,     PRM     ID consult     still waiting culture results today.     Final culture results received after 5pm.     Received Rx from Peter Gunn, PA for Nafcillin 12 grams IV Q24H by continuous infusion.     Spoke     with     Vicky,     on-call pharmacist     from Mid-Carolina Homecare Specialists on her cell phone 919-632-39xx and faxed Rx to their office at 919-465-93xx.     
They do not have enough Nafcillin in stock and suggest Oxycillin as an alternative; discussed with Dr. Eileen Maziarz (RTL) and then Peter Gunn, PA after hours and facilitated a phone call between Vicky and Peter with the outcome that Oxycillin can be substituted.     Vicky is now working on finding an on-cail Mid-Carolina Homecare Specialists RH who can open the referral/case this weekend. Waiting call back from Vicky.     Will discuss with patient if Mid-Carolina Homecare can accept start of care this weekend.     Charge nurse aware.

NOTE BY AUTHOR ***RTL-“resident training license” Dr. Maziarz does not have a full North Carolina medical license and, to my recollection, Dr. Maziarz never met or examined me.  So, Dr. Maziarz probably did not know about my open surgical wound

No one ever told me that there was any issue with the Nafcillin that Matthew Peter Gunn, PA scribbled on the paper and threw on my hospital bed (without any explanation) on Friday September 17, 2010.  I did not know about an issue with the IV antibiotic until last week when I received the medical records.  



John Hopkins has an opinion about how to treat Staphylococci, coagulase negative.  Of course that opinion might have been written by a PA or RN.  I can not be certain - but it does differ from Matthew Peter Gunn PA's recommendation.




Staphylococci, coagulase negative 

John G. Bartlett, M.D.
09-01-2010 


MICROBIOLOGY

  • Coagulase negative staphylococci (CNS) are aerobic, gram positive coccus, occuring in clusters. Frequently found on skin and mucous membranes.
  • Catalase positive, coagulase negative. Major pathogen is S. epidermidis, colonies typically small, white-beige (about 1-2 mm in diameter).
  • Over forty recognized species of CNS, with other major entities including S. lugdunensis, S. haemolyticus. 
  • Many strains with propensity to produce biofilm, allowing for adherence to medical devices.
  • Usually resistant of penicillin and methicillin.

CLINICAL

  • Nearly always a nosocomial pathogen. The usual source is skin flora. Pathogen primarily associated with foreign bodies and biofilm.
  • Staphylococcus epidermis--the major pathogen of the coagulase negative staphylococcus category.
  • #1 cause of nosocomial bacteremia, but also #1 contaminant.
  • #1 infection of plastic/metal: lines, artificial valves, joints, pacemakers and central nervous system shunts, etc.
  • Diagnosis by cultures: need at least 2 positive blood cultures, or heavy growth in presence of e.g., foreign body.
  • Outbreaks in hospitals, ICUs, oncology centers may represent clonal spread.
  • S. lugdunensis infections more similar in type to S. aureus than other coagulase-negative staphylococci. After S. epidermidis, second leading cause of CNS endocarditis. May be cause of aggressive infection. Organism often susceptible to methicillin, only ~25% of strains produce beta-lactamase.
  • S. haemolyticus is second leading cause of CNS neonatal bloodstream infections. Often has reduced susceptibility to glycopeptide abxs (teicoplanin > vancomycin).
  • S. saprophyticus: often listed as second leading cause of UTI (after E. coli) in young, sexually active women.

SITES OF INFECTION

  • Bacteremia: most often due to IV lines, vascular grafts, cardiac valves (30-40% of all coag-neg staph infections)
  • CSF shunt: meningitis
  • Peritoneal dialysis catheter:  peritonitis
  • Prosthetic joint: septic arthritis
  • Prosthetic or natural cardiac valve: endocarditis
  • Post sternotomy: osteomyelitis
  • Implants (breast, penile, pacemaker) and other prosthetic devices: local infection
  • Post ocular surgery: endophthalmitis
  • Surgical site infections

TREATMENT

General principles

  • Most common cause of infection with any foreign material. Pathophysiology is based on biofilm on plastic or metal by relatively avirulent bacterium. Treat bacteremia only if > 2 positive blood cultures (preferably from peripheral sources) or heavy/repeated growth from device.
  • Abx: >80% are beta-lactamase positive and methicillin-resistant. Most active: vancomycintelavancinlinezoliddaptomycin; often addrifampin due to biofilm penetration, but need second agent to prevent resistance.
  • Standard for deep infection: vancomycin 15mg/kg IV q 12 h +/-rifampin 300 mg q8h IV/PO.  Gentamicin 3 mg/kg/d IV divided q8h added to vancomycin + rifampin for prosthetic valve IE.
  • Alt (MRSE): linezolid 600 mg IV/PO twice daily, daptomycin IV 6 mg/kg/d, telavancin 10 mg/kg IV once-daily (infuse over 1 hr). Each +/- rifampin.
  • Alt (methicillin-sensitive): oxacillin/nafcillin 1.5-3 gm IV q6h,cefazolin 1-2 gm IV q8h, ciprofloxacin 400 mg IV q12h,clindamycin 600 mg IV q8h, TMP-SMX. Use sensitivities to guide choice. Note, only assume methicillin susceptible if multiple isolates are so identified.
Site specific recommendations

  • Prosthetic valve: consider valve replacement, abx x 6 wks. Seeprosthetic valve endocarditis module.
  • Peripheral line: remove line, abx x 5-7 days.
  • Central line: may often keep line & systemic abx x 2 wks + abx lock.
  • Prosthetic joint: typically remove joint (two stage more common than single stage replacement), abx x 6 wks. If very early infection (less than 3 wks post-op, debridement and retention an option).
  • Dialysis catheter: keep catheter (at least for first effort) and IVvancomycin (usually 2g IV/week and redose when level <15 mcg/mL) + Abx lock x 10-14 days.
  • Vascular graft: remove graft, abx x 6 wks.
  • CSF shunt: shunt removal usually recommended but variable. IVvancomycin 22.5 mg/kg q12h and PO/IV rifampin plus possible intraventricular antibiotics: vancomycin 20 mg/d +/- gentamicin 4-8 mg/d.
S. saprophyticus UTI

  • When occuring in males, suggestive of anatomic abnormality or recent or present catheterization.
  • High incidence of failure with single dose antibiotic regimens.
  • Variably susceptible to vancomycin.
  • See "Bacterial Cystitis, Acute, Uncomplicated" module for details on multiple regimens.

OTHER INFORMATION

  • Most common cause of bacteremia, but also the most common contaminant in all specimens.
  • CDC: "Never treat a single positive blood culture for Staphylococcus epidermidis."
  • Major cause of all foreign body infections: lines, joints, implants, shunts, valves, etc.
  • Usually need foreign body plus 2 positive cultures or heavy growth to implicate as causative pathogen.

Basis for Recommendations

  • McCann MT, Gilmore BF, Gorman SP; Staphylococcus epidermidis device-related infections: pathogenesis and clinical management.; J Pharm Pharmacol; 2008; Vol. 60; pp. 1551-71;
    ISSN: 0022-3573;
    PUBMED: 19000360
    Rating: Basis for recommendation
    Comments:Source document for most recommendations. Note that S. epidermidis as the cause of implanted medical devices is due to its ability to establish a multilayered highly structured biofilm. These are easier to prevent than to treat so the device often needs to be removed once the biofilm is established.
  • No authors listed ; Choice of antibacterial drugs.; Treat Guidel Med Lett; 2007; Vol. 5; pp. 33-50;
    ISSN: 1541-2784;
    PUBMED: 17450114
    Rating: Basis for recommendation
    Comments:Basis for recommendations in this module.
  • Archer G ; Staphylococcus epidermidis and other coagulase-negativestaphylococci; ; Chapter 184 in Principles & Practice of Infectious Disease, Mandell JL, Bennett JE & Dolin R (Editors) Churchill Livingston Phil 5th Ed ; 2000 ; Vol. 2092-2100 ;
    Rating: Basis for recommendation
    Comments:Coagulase neg. staph include 32 species with 15 indigenous to humans. The value for routine speciation is unclear. Most pathogenic in humans are S. epidermidis (foreign bodies) and S. saprophyticus (UTI's). Other less common pathogens- S. haemolyticusS. lugdunensis, and S. scheiferi. Nearly all S. epidermidisinfections are nosocomial and come from patient or HCW indigenous flora. 



http://goo.gl/X1Li1

With my sincere thanks to John Hopkins for the use of the information in this informational blog.

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