Mortality Audit power point Presentation.pptx

Mort

1. Mortality Audit Dr. Bukenya Ali 16 TH /Jan/2025

2. OUTLINE CASE PRESENTATION DISCUSSION TAKE HOME MESSAGE

3. CASE PRESENTATION NAME; H.H AGE; 50 SEX; FEMALE RESIDENCE; BUWAMBO RELIGION; PROTESTANT OCCUPATION; BUSINESS N.O.K; P.M (DAUGHTER) DOA; 17 TH /NOV/2025 16:00HRS…? DOD;19 TH /NOV/2025 23:02HRS

4. Received a 50Y/F patient with known ISS, Ca Stomach, on medication. Pt presented with c/o: Refusal to eat x 3/7. Progressive General body Weakness x 4/7 P/C: Chronic body itching over 5/12 and yellow coloration of the eyes for over 5/12. HPC 50Y/F background h/o ISS, and Ca Stomach. Presented with hx of refusal to eat x 3/7. Reports total reduction of appetite for food, mainly solid foods, however has been depending on little sips of fluids. No nausea or vomiting Pt reports passing stool well, of normal colour. HPC Continued; No abdominal pain and no distension. Pt. Also reported marked progressive general body weakness, with easy fatigability and also awareness of her heart beats. NB: Pt claims to have had a review x 1/52 ago by surgical oncologist and had a plan tp insert a feeding Jejunostomy tube, however procedure was postponed for some time.

5. Encourage Oral intake. IV maintenance fluids i.e 500mls bd 12 (N/S) For Surgical Oncologist review Plan; Admit patient to St. Betty. Do CBC, Blood grouping & X-matching, PT/INR, LFTs, RFTs. Mg’t at EMD: -IV N/S &D 5 1L (1:1) Stat - Pass Urinary Catheter On Ward - Booked blood (04 units) of packed cells to be transfused on ward.

6. PSH X : Pt with known malignant neoplasm of the stomach, on haemostatic radiation therapy. Underwent 05 cycles (20 days in 5 fractions) PMH: She is also a known ISS on medication. No known allergies to food or drugs, never used Herbals. FSH: Stays with a fully supportive family. There is Hx of cancers, however does not drink alcohol or smoke. O/E: - Sick looking, severely wasted pt , mildly dehydrated with grade II bilateral pitting edema. No Jaundice ROS: MSK - Has had bilateral lower limb swelling for x 2/52, which was being managed conservatively on pt diet. GUS: - Reports to have not passed urine x1/7, but had no dysuria. CNS: - Caretaker reports on & off episodes of confusion x 1/7, where she usually had uncoordinated speech. No convulsions, no loss of consciousness. R/S: - No h/o Cough, No DIB, no chest pain

7. P/A: Normal fullness, no tenderness, palpable suprapubic non-tender mass, smooth (suspected full bladder). Normal bowel sounds. No other palpable masses. R/S: Bilateral chest expansion with equal air entry. No doled sounds. Breath sounds are vesicular. N.B: - Pt was to do IHCs (Pan Ck. Ckit , Vimentin, K167, CD4s). Imp: - 50Y/F known ISS & Ca stomach with; Severe anaemia Delirium (due to the on & off confusion). Vitals: BP - 101/75 mmHg. PR = ~ 150 Bpm SPO 2 : 97% Temp: 36.7 C RBS: 4.0 mmol/L CVS: - Tachycardic, with a regular pulse rate, normal fulness. Heart sounds 1&2 heard with hemic mummer. CNS: - Not fully conscious with GCS of 14/15, V 4 M 6 E 4 PEARL, NO FND

8. P/A: Normal fullness, Moving with respiration. Soft & non-tender. There is a palpable mass around the umbilicus ~ 14 x 8 cm. Hard, Fixed & non-tender. Plan: R/v by Oncology team. IV D 50 50mls Stat IV D 50 Follow up on LABs Transfused with 250mls of whole blood Allow feeds Monitor vitals IV Kabiev 1440 mls in 24Hrs IV Fluids N/S, R/L 1.5 h, 1:2 in 24 Hrs Palliative care consult to review & counsel pt 18 TH /Nov/2024: R/V a 50Y/F with a background of ISS and Ca stomach on HAART and Haemostatic radiotherapy. Admitted due to failure to feed. Pt reports difficulty in swallowing and is anaemic. Currently has F1BW O/E: Sick looking, wasted (Cachexic) with severe pallor, no jaundice, severe dehydration and bilateral lower limb edema. Vitals: BP - 100/70 mmHg. PR = ~ 143 Bpm SPO 2 : 98% RBS: 3.0 mmol/L

9. 18 TH /Nov/2024: R/S: Mild distress, with RK – 26Bpm. SPO 2 : 98% Chest is symmetrical with equal air entry. No doled sounds. Other symptoms: Statusquo. Breath sounds are vesicular. Dx: A 50Y/F with a background of ISS/HTN with: ? Electrolyte imbalance. Hypoglycemia Anaemia

10. Vitals: 04:00pm BP - 92/62 mmHg, PR = ~ 127 Bpm SPO 2 : 97%, RBS: 7.9 mmol/L Plan: Continue with Oral morphine for pain management. Ongoing Counselling. Continue Medical mg’t as per chart Awaits Oncology review. Palliative Care Team: 18 TH /Nov/2024: Pt. reviewed today, reports abdominal pain rating it at 2/5, has general body weakness & poor appetite, is severely emaciated, and has difficulty in swallowing. Psychologically depressed about the disease prognosis. Vitals: 12:30pm BP - 100/60 mmHg, PR = ~ 124 Bpm SPO 2 : 98%, RBS: 9.9 mmol/L 02:30pm BP - 90/60 mmHg, PR = ~ 130 Bpm SPO 2 : 98%, RBS: 6.9 mmol/L

11. CNS: - E 4 V 3 M 6 13/15 Plan: IV N/S 1L over 02 Hrs Transfuse 01 unit of whole blood Continue current Rx plan. 19 TH /Nov/2024: R/V a 50Y/F ISS with Ca stomach on HAART and radiotherapy. Currently attendant reports worsening GBW. Currently has F1BW O/E: Sick looking, Cachexic A+ D++. Vitals: BP - 86/64 mmHg. PR = ~ 120 Bpm (low volume) SPO 2 : 98% RR: 26 Bpm Central line in situ R/S: Mild distress, Equal air entry bilaterally, normal percussion.

12. P/A: - A huge palpable peri-umbilical mass, firm ?? Omental cake. Other systems are status quo. Plan: Best supportive care Continue with IV Kabiven 1440mls in 24Hrs Do CBC Continue with Palliative and end-of-life care. IV fluids NS:RL 1L in 24Hrs 19 TH /Nov/2024: MWR R/V a 50Y/F with ISS, Ca stomach on HAART, and haemostatic radiotherapy. Disease is not yet staged. Awaiting IHC. O/E: Very sick, Cachexic A+ D++. Vitals: Temp – 37.3 o C BP - 90/60 mmHg. PR = ~ 128 Bpm very thin and thready SPO 2 : 97% Palechiae on her Rt. UL R/S: RR: 26 Bpm No respiratory distress. No air entry in the lower lung zones bilaterally

13. P/A: - A huge palpable peri-umbilical mass, firm. Other systems are status quo. Plan: Continue Palliative care Reinstate IV Kabiven 1440mls in 24Hrs at 8:00pm Continue above management. 19 TH /Nov/2024: MWR R/V a 50Y/F ISS, on HAART, with Ca stomach on hemostatic radiotherapy. (not yet staged) also on Palliative care. Concerns: No new concerns O/E: Cachexic, Sick looking with severe pallor and moderate dehydration. Vitals: BP - 88/60 mmHg. PR = ~ 128 Bpm - thin and thready SPO 2 : 97% on RA R/S: In obvious respiratory distress. RR: 30 Bpm , reduced to no air entry in the lower lung zones bilaterally

14. Re-examined Pt on reaching HDU and found dilated fixed pupils with no corneal reflexes. She had no pulse with a silent precordium with no heart sounds, and no breath sounds as well. Pt was confirmed dead at around 23:02Hrs. Possible cause of death? ? Cardiac arrest 2 o to MODs. Condolences were passed on to the family and last office performed. 19 TH /Nov/2024: Called at 10:55pm to review a 50Y/F ISS, on HAART, with Ca stomach on hemostatic radiotherapy and on Palliative care, who was reported to be gasping. On arrival, found pt lying supine, eyes wide open mouth agape and noted no chest movements. Palpated for both central and peripheral pulses and found weak thready collapsed carotid pulse. Connected pulse oximeter SPO 2 : 48% BP – machine connected but BP was unrecordable. PR = ~ 40 Bpm - thin and thready. Rushed Pt to HDU however, lost vital readings on the way.

15. Discussion ( swiss cheese model) Patient factors; Systemic factors; Policies, Checklist, Training Personnel factors; Education - Communication –Intervention Patient factors Patient was a known ISS / HTN with Ca stomach. Pts was so cachexic and vitals kept dropping. Failure to feed.

16. Discussion Cont . . . Systemic factors Policies are in place at emergency Check list is there at emergency. What is the criteria for HDU admission And what was the goal of care ? Is it palliative Factors pertaining to us Diagnosis & intervention was it right?? Communication; Lack of timely communication for the surgical Oncology team to review. Delayed staging of the disease. No radiology CT results mentioned/recorded.

17. Was the death preventable? Possibly NO. Good Points Doctors on duty including the SHO and nurse team attended to the pt. At least, timely medical interventions were done Take Home Points:

18. Conclusion Stomach cancer is a disease of complex etiology involving multiple risk factors and multiple genetic and epigenetic alterations. Control of H. pylori infection by means of eradication or immunization is likely to have immense potential in stomach cancer prevention. In addition, changes in dietary habits and lifestyle could reduce the incidence of stomach cancer especially in high prevalence areas. There is now evidence that mutations in a number of genes as well as genetic polymorphisms are associated with an increased risk for stomach cancer. Despite the availability of new drugs and association regimens, the therapeutic outcome for gastric cancer is still dismal. Knowledge of the diverse risk factors together with current genomic and proteomic technologies would help in identification of high-risk individuals, targeting precursor lesions, improving preventive strategies, and providing appropriate personalized therapy

19. References Goral V. Etiopathogenesis of Gastric Cancer. Asian Pac J Cancer Prev. 2016;17(6):2745-50. PMID: 27356684. Guan, WL., He, Y. & Xu, RH. Gastric cancer treatment: recent progress and future perspectives. J Hematol Oncol 16, 57 (2023). https://doi.org/10.1186/s13045-023-01451-3 Nagini S. Carcinoma of the stomach: A review of epidemiology, pathogenesis, molecular genetics and chemoprevention. World J Gastrointest Oncol. 2012 Jul 15;4(7):156-69. doi : 10.4251/wjgo.v4.i7.156. PMID: 22844547; PMCID: PMC3406280. Zali H, Rezaei- Tavirani M, Azodi M. Gastric cancer: prevention, risk factors and treatment. Gastroenterol Hepatol Bed Bench. 2011 Fall;4(4):175-85. PMID: 24834180; PMCID: PMC4017429.