Cardiopulmonary Resuscitation Committee Meeting Minutes Summary

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

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

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

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 5 of 9 Topic Discussions/Conclusions Recommend ations/Action Responsibl e Person Follow- up Date Case #3 – Ms. Kristine Schuster (2/11/22) Case Discussion : Medical Emergency was paged at 1428 to west side of BLDG 25 outside. Upon arrival of the NOD, VA Police, VA Fire, Maintenance staff, and transportation staff were present and working on extrication. MOD was present. Woman was pinned under the front left tire of her vehicle (Blue Dodge Van). Prior events leading to accident are not known. After extrication patient was placed on long board, oxygen applied via BVM and IV obtained 18ga left AC (1438). At this time Tomah Ambulance arrived and took control of the scene. Patient was loaded into ambulance was transported to landing for possible transport by Med flight due to the mechanism of injury (1442). Due to weather condition Med flight was not flying. Patient was transported to GHS-Lacrosse. Patient's husband (Patrick Schuster-Veteran) was in the facility and given an update regarding his spouse. VA Transportation gave husband a ride to GHS- Lacrosse and if needed will ensure transportation home to Adams. Incident was cleared at 1510. Tomah Leadership was notified directly after (1514). Heads up written and sent to Tomah Quadrad at 1715. Recommendations from response team : NA Items that went well : Everything, Tomah Health gave kudos to the response team for handling it great. I tems that did not go well: NA Equipment not available or not functioning properly: NA NA NA NA Case #4 – Ms. Elizabeth Cutler (2/12/22) Group Discussion : Rapid Response paged at 1815. Veteran had gone outside and slipped on patch of ice landing on right knee. Veteran was assisted inside by VA Fire due to weather. VS- 123/83, 97%RA, 76, 18, 98.4, and BG-227. After evaluation by the MOD Veteran was taken to TMH via Tomah ambulance for further evaluation. Distal femur fracture post fall. RCA chartered for this case as it is a sentinel event as a sentinel event. Documentation was all entered very well. Good decision to send Veteran out for care as Radiology services most likely would not have been on site. Suggestion to document if the appropriate winter footwear was worn Items that went well: Staff response times NA NA NA

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 6 of 9 Topic Discussions/Conclusions Recommend ations/Action Responsibl e Person Follow- up Date Items that did not go well: NA Equipment not available or not functioning properly: NA Case #5 – Mr. Randy Worke (2/16/22) Group Discussion : Veteran was being seen on a routine Primary Care Provider check when he became dizzy, diaphoretic, and lightheaded. VS= R=16, 94% on RA, EKG= NSR, BP=58/39, and Pulse=60. BG=101. Veteran could have been seen by Urgent Care (UC) and monitored for his blood pressure instead of calling an Emergent transport. The was a cap in documentation about the timing of the ambulance arrival on scene, if it may have occurred prior to the blood pressure coming back down. Recommend that Dr. Simon review the VA Policy with the Laboratory Department Service Line Manager for fasting blood draws. Dr. Simon to inquire with lab on what lab orders must remain fasting and if patients can be given an hour range for their specific lab work ordered. No Nursing documentation of the event. No set times for lab appointments are scheduled, maybe lab could educate the patient if they will be arriving later in the day if they need to fast for the labs to be drawn. Items that went well: NA Items that did not go well: NA Equipment not available or not functioning properly : NA 1. Reminder to staff what cases can be seen thru UC vs 911. 2. Review with lab what lab work must remain fasting and for hour long to avoid patients’ arrival to facility feeling weak. Dr. Simon Dr. Simon 4/21/22 4/21/22 Case #6 – Mr. Gordon Boe (2/18/22) Medical Emergency paged at 1035. Scene cleared at 1041. Veteran displaying seizure like activity. Veteran does have history of pseudo seizures and carries a bottle of his prescribed Clonazepam (did not have with him today). Veteran was assisted back to his wheelchair, vital signs obtained. PCP-Dr. Damstra order a lx dose of his clonazepam for which Veteran picked up in Outpatient pharmacy. Veteran was then taken home by his driver. VS: 139/82, 18, 95%RA 108, BG 117. Committee discussed various options to assist the patient with these recurrent episodes, final result was the need for input from other resources to see what options are available for the veteran and VA to prevent future episodes. This case has never been brought forward to the Disruptive Behavioral committee (DBC), as it has always been called as a medical emergency. Follow up with PACT Team to try and look for options for Veteran to not have an episode every time he comes to the VAMC. Dr. Simon 4/21/22

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

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 7 of 9 Topic Discussions/Conclusions Recommend ations/Action Responsibl e Person Follow- up Date Items that went well: Response of team Items that did not go well: NA Equipment not available or not functioning properly: NA Case #7 – Mr. Patrick Robertson (2/24/22) Group Discussion: Food Cart was in front of drink fountain, against wall, and wheels locked. Veteran standing by cart facing away. Veteran fell backwards striking head on corner of cart. Rapid Response was paged at 1333. MOD arrived at 1335. Veteran was evaluated and c-spine cleared by MOD. Veteran was helped to a seated position and back of head assessed. Wound cleaned and wrapped-no stitches necessary. VS 123/58, HR104, 95(70RA, 18, BG 189. Head CT was obtained. All responders wore the proper PPE. All documentation appeared to be accurate and timely. Items that went well: Response of team Items that did not go well: There is confusion on how much information to give dispatch when calling an emergency. At a minimum dial 911 and state what type of emergency Medical or Rapid and a location-with enough details of location to get the Emergency to the general vicinity. Equipment not available or not functioning properly: NA NA NA NA Case #8 – Mr. Nicholas Schmitz (3/8/22) Group Discussion: Upon NOD arrival, MOD was on scene assessing Veteran. Staff was checking a blood sugar: 80. Vitals – BP: 94/62, HR: 62, SpO2: 97%, and RR: 16. VA Police arrived, and sufficient staff was called. Veteran was alert, oriented and mildly diaphoretic. MOD spoke with Veteran about a possible vasovagal episode causing his brief loss of consciousness and encouraged Veteran to be seen in UC. Veteran declined advice as he had an appointment to see his PCP this Friday. Veteran was given 1 juice and a granola bar due to lower blood sugar. 1 of 4 responders did not wear proper PPE. MOD did proper documentation. Audiology appointment note did not mention the event. NA NA NA

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 8 of 9 Topic Discussions/Conclusions Recommend ations/Action Responsibl e Person Follow- up Date Items that went well: Quick response, lots of staff. Items that did not go well: NA Equipment not available or not functioning properly: NA Case #9 – Mr. Gordon Boe (3/9/22) Group Discussion: Before NOD arrived, Veteran was in wheelchair. 1124 VA police and Fire arrived and informed their assistance was not needed. Veteran was known to NOD and asked if he had his medications on him. Veteran responded with “yes” and was given cup of water to tak e medication for pseudo seizure. UC RN took one set of vitals; BP: 134/79, HR: 90, SpO2: 96%, T: 97.7. MOD did brief assessment. Veteran asked to call for a ride, as he stated that he drove himself today. UC RN stayed with Veteran until ride arrived. Veteran took prescribed medications and called for a ride home. 2 of the 6 responders did not wear proper PPE. Only vital signs were charted, no notes by any responders. Items that went well: Everything. Items that did not go well: NA Equipment not available or not functioning properly: NA NA NA NA 6. Next Meeting: April 14th, 2022, 9:00am – 10:00am ------------------------------------------------------------------------------------------------------------------- Tina Williams Recorder

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 9 of 9 __________________________________________________________________ Nancy Delzer, DNP, MBA, FNP-BC, ACHPN, AOCN Co-Chair Committee Chair APPROVED/DISAPPROVED __________________________________________________________________ Melissa Simon, DO Chair - COS APPROVED/DISAPPROVED ___________________________________________________________________ Dr. Gregg Meekins, MD, FAAN Chief of Staff Attachments: NA

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

CRC minutes - 3.10.22

Related Documents