Mortality Audit power point Presentation.pptx

Mort Audit

1. Mortality Audit Dr. Bukenya Ali 08 TH /Sept/2025

2. OUTLINE CASE PRESENTATION DISCUSSION TAKE HOME MESSAGE

3. CASE PRESENTATION NAME; W.G AGE; 74 SEX; MALE RESIDENCE; KANSANGA, MAKINDYE RELIGION; ANGLICAN OCCUPATION; SECURITY OFFICER N.O.K; N.S (DAUGHTER) DOA; 09 TH /MAR/2025 22:30HRS. DOD; 13 TH /MAR/2025 16:00HRS

4. PC Painful left upper limb x 2/7 HPC Received a 74Y/M patient, referral from Bugolobi medical centre for further Mgt, known HTN, for over 08Yrs on unknown medication. Reportedly slid into a ditch while heading to work x 2/7 ago, and fell on his left upper limb, lost consciousness for over 10 mins, no fits, no ENT bleeding, no D.I.B. Was immediately taken to the above referring centre where he received the F/A before being referred. Review of Other Systems; CVS: - Reports no D.I.B while lying flat, no palpitations, and no chest pain. R/S: Reports no chest pain, no D.I.B. on coughing. G.I.T: - Reports no abdominal pain, no abdominal distension, no difficulty passing stool or flatus.

5. PSH X : Pt reports no hx of surgical intervention, and no hx of blood transfusions. PMHx: He is known to have HTN for over 08Yrs on an unknown medication. Reports no known allergies to food or drugs. FSH: Reports smoking occasionally in cold seasons; however, he denies drinking alcohol. He is married with 07 Children. O/E: - Fair general condition, afebrile, no pallor, no jaundice, no cyanosis, no dehydration. Vitals: BP - 124/64 mmHg. SPO 2 : 97% RA PR = ~ 79 Bpm RR = 17b/m ROS: MSK – Reduced power, and tenderness in the left upper limb. CVS: - Warm peripheries, CRT < 3s, S 1 +S 2 +O. Pulse is of normal volume, regularly regular. R/S: - Not in distress, chest is moving with respiration, broncho-vascular breath sounds, equal air entry bilaterally. P/A: - Normal fullness, moving with respiration, no surgical or therapeutic scars, soft, non-tender, and no palpable organs. CNS: - GCS:15/15, PEARL, no FNDs, neck is soft

6. Note: X-ray done from peripheral clinic shows # Lt. humeral neck. Impression: 74Y/M with HTN and # of the lt. humeral neck. At that moment, a plan was made to admit the pt , at St. Patrick, given IV paracetamol, do Lab work-up, including CBC, Blood grouping & X-matching, PT/INR, HIV, ECG Recommended for Orthopeadic review. Review - 10/03/2025 unknown time, orthopeadic r/v was done, who noted the above h/o 74Y/M known HTN, on unknown regiment admitted as a referral with Lt neck humeral #, who by then, reported that the pain was being controlled. And O/E , it was noted that the pt had no pallor, and no jaundice. Vitals: BP - 145/75 mmHg. SPO 2 : 99% R/A PR = ~ 69 Bpm Temp. = 36.2 o Locally: Lt. upper limb deformity with tender shoulder, and limited range of motion. Distal neurovasculature intact.

7. A plan by the Orthopeadic surgeon was made as shown bellow: Plan; For ORIF today. Fasting instructions observed. Lets do ECG and ECHO urgently Blood grouping & X-matching and book 2 units of blood. Do RFTs and LFTs Install shoulder immobilizer. Noted r/v ROS were stable by then. They noted investigations from the referring centre, with CBC results in normal ranges as shown. Serology was also Positive (but pt not yet aware), and an x-ray of the # left humeral neck. Noted referral: 1- WBC:8.81 (N), Neut : 7.23 (N), Hb: 12.2g/dl (N), PLT: 199 (N)

8. Intra-Op findings: Under aseptic conditions, through a Deltoid pectoral approach findings were of severe osteoporotic bone and comminution in the surgical neck. Did Harvested iliac crest bone graft and inserted it into the surgical neck # Temporary reduction was done with K. wires and fixed with a four-hole philous plate. Pt was put on antibiotics and Analgesics including IV cephazolin 2gm, IV Dynapar 75Mg, IV morphin 5mg.

9. A plan was made to inform the homecare, start oral Rivaroxaban, oral calci -vita, p.o Aldrin 75mg weekly, encourage ambulation and continue with post-op Rx. Pt was r/v by evening team on the same day, with no significant concerns then. Only noted vitals to be BP - 110/60 mmHg. PR = ~ 80 Bpm Plan was to continue with the Rx 11/03/2025 – Review by Orthopeadic Team Who noted the h/o the pt , a day-1 post-ORIF, and bone graft following # humeral neck. Only concern by then was pain at the surgical site. O/E: - FGC, afebrile, no pallor, no jaundice, and no dehydration. Vitals were noted recorded (however, they also noted a posite HV rapid test result). L/E: Noted a clean dressing, dry and intact. Neural vasculature was not examined that time.

10. Homecare / counsellor r/v pt , found him in deep sleep, woke him up and managed to discuss pt serostatus and found it to be unknown to him. Counsellor planed to draw two purple tops of blood samples for serology check-up and CD4 count. Do a TB urine LAM and to keep the RCT in NHC Plan: Continue Rx and keep limb in sling. 12/03/2025 – 7:40am Orthopaedic r/v Pt was r/v by the Orthopaedic team, and noted a 74Y/M known HTN and ISS, day-2 post ORIF, and bone graft following # neck of Lt. proximal humerus. No major concern as pain was by then well controlled O/E: - FGC, afebrile, no pallor, no jaundice. Vitals were note to be: BP - 121/70 mmHg. L/E: Lt. limb in arm sling, dressing clean, dry with intact NVB. PR = ~ 78 Bpm

11. A plan was made by then, to change dressing, repeat x-ray of the arm, and to continue with the Rx and follow up on counsellors requested investigations. On the same day, at 17:46Hrs EWR team , r/v pt and the concerns by then were Productive cough, vomiting (about 3 episodes), following a wound dressing in OPD theatre. O/E: - FGC, afebrile. L/E: Dressing clean and dry with no local tissue swelling. R/S – Not in distress and chest was clear. Vitals: BP - 117/81 mmHg. PR = ~ 91 Bpm A plan was made to give pt Ascoril , continue with the rest of the Rx, and add I.V Ondansetarone , I.V RL and to do CBC and B/S

12. 13/03/2025 – 8:50am Orthopaedic r/v R/v the Pt who was now day – 3 post ORIF, and bone graft, and the concern by then was one episode of vomiting and but the pain is well controlled. O/E: - FGC, no pallor, no jaundice. Vitals were noted recorded and systemic examination was also not done. However, L/E: showed soiled dressing. A plan was made to continue with previous management, change dressing in OPD theatre, and follow up on requested investigations. On the same day, 13/03/2025 – 09:00am , a major ward was done (Surgeon, SHO and JHO), who r/v pt who had just returned from dressing in the OPD theatre, with concerns of Mild respiratory distress and desaturating at 68-70% on R/A. Also Reported mild left upper chest pain and cough that he reported to have started immediately post- ORIF (Caretaker reports thick yellow sputum, no hemoptysis).

13. Also note a long standing h/o smoking. O/E: - Elderly, afebrile, not pale. Vitals: BP - 130/74 mmHg. PR = ~ 114 Bpm SPO 2 : 68-70% RA RR = 30bpm R/S – Mild respiratory distress, equal air entry bilaterally with basal crackles L>R L/E: dressing is clean and intact. No examination of the neaurovasculature was done. An impression was made of an Elderly male, 3 days post-ORIF with pneumonia. ?? PE Also note a long standing h/o smoking.

14. A plan was made as shown below: Oxygen therapy-15L/min NRM, SC Clexane 80IU O.D Do D-Dimers CBC. Hold Rivaroxaban I.V D50% 30mls tds Continue the rest of the Mgt I.V Fluids: 3L (NS 2 : 1 D5) in 24 Hrs Physician review Transfer patient to HDU 10) Do CT Angiogram Noted that the physician was informed and the D-Dimers results were high as shown below: 3.89 (0-0.5mg/ml).

15. On the same day, 13/03/2025 – at 12:36 pm , SHO was called to r/v the pt who noted the Hx and found the Pt restless, with a BP - 111/64 mmHg, PR = ~ 120 Bpm, SPO 2 : 72-74% at 15L / min NRM R/S – had dyspnea and in Distress with crackles all over the lung fields CNS – Confused and delirious A plan was made to invite the physician to review, book ICU, continue Rx, follow up the Labs, gve I.V 50% Dextrose and catheterize pt. At 01:08 PM SHO reported to have tried to secure a space in ICU but in vain It was planned to refer the Pt

16. Noted: Continued excessive oral secretions. No return of spontaneous circulation. Patient confirmed dead at 4:00 pm . Condolences were passed on to the family, and the last office was performed. Cause of death: 62/u post-ORIF with suspected pulmonary embolism. Newly diagnosed RVI Key Note: Patient died during the final stages of processing referral to Mengo ICU for further management. 13/03/2025 – 03:30 Pm surgical team was called to r/v the pt who was then at St. Betty HDU, having been transferred from St. Patrick with concerns of unresponsiveness. On assessment; Airway: with coffee brown secretions, started suctioning the airway. Breathing: Absent chest movements and absent breath sounds. Circulation: Warm peripheries. Absent carotid, radial, and femoral pulses. Disability RBS – 10.1 mmol/L. Intervention: Chest compressions and bag mask ventilation initiated. Did 5 cycles.

17. Discussion ( swiss cheese model) Patient factors; Systemic factors: e.g , policies and procedures Personnel factors: Communication –Intervention Patient factors Patient was a newly diagnosed ISS. Pt vitals kept dropping. .

18. Discussion Cont . . . Systemic factors Unsatisfactory history taking and Recording Policies are in place at emergency What is the criteria for ICU admission And what was the goal of care? Factors about us Diagnosis & intervention was it right?? Communication; Lack of timely communication for booking a space in ICU. Delayed diagnosis of the condition. No radiology CT results mentioned/recorded.

19. Was the death preventable? Possibly Yes. Good Points Doctors on duty including the SHO and nurse team inadequately attended to the pt. At least, timely surgical interventions were done Take Home Points:

20. Conclusion Fat Embolism Syndrome (FES) is a rare but severe and potentially fatal complication, most frequently associated with long bone and pelvic fractures. It occurs when fat globules enter the circulation, triggering a systemic inflammatory response that manifests as the classic triad of respiratory distress, neurological abnormalities, and petechial rash. The transition from asymptomatic fat embolism to life-threatening FES is unpredictable and can occur rapidly, even in young, healthy patients with an initially stable presentation. Diagnosis is challenging due to the lack of a definitive test and relies on clinical criteria and supportive imaging findings, such as characteristic patterns on brain MRI. The key to mitigating FES mortality is prevention through early surgical stabilization of major fractures, which is considered the cornerstone of management.

21. Conclusion Cont. . . : Fat Embolism Syndrome (FES) and ORIF While ORIF is the procedure often required for this stabilization, the timing and strategy must be balanced against the patient’s physiological state to avoid exacerbating the risk. There is a critical need for heightened clinical vigilance, early recognition of symptoms, and aggressive supportive care. Current evidence suggests that standardized predictive criteria for identifying high-risk patients are lacking, underscoring the importance of further research to develop protocols for risk stratification and preemptive management in trauma patients undergoing fracture fixation.

22. Conclusion ORIF is a common and generally successful procedure for managing fractures of the ankle, proximal humerus, distal humerus, and olecranon. However, it carries a significant risk of postoperative complications, which are highly dependent on the fracture location, patient demographics, and surgical technique. Common complications include surgical site infection, nonunion, malunion, nerve injury, residual pain, post-traumatic osteoarthritis, and hardware-related issues. Complication rates can be substantial, reported from 7.2% in the short term for olecranon fractures up to 36% for ankle fractures, often necessitating reoperation.

23. Article References Author Year of Publication Study Topic Findings Conclusion Barlow et al. 2020 Locking Plate Fixation of Proximal Humerus Fractures in Older Patients The study found that this procedure continues to be associated with a high complication rate in patients older than 60 years. Despite advances in implant technology (locking plates), the treatment of proximal humerus fractures in the elderly remains challenging with a high frequency of complications. Han et al. 2022 Complications of ORIF for Adult Distal Humerus Fractures Common complications included elbow stiffness (46.5%), osteoarthritis (24.1%), heterotrophic ossification (21.8%), and postoperative ulnar nerve symptoms (15.3%). The reoperation rate for major complications was 12.9%. ORIF with plate fixation is a reasonable treatment for distal humeral fractures with acceptable severe complication rates. Surgeons must be vigilant about ulnar nerve complications, as prophylactic transposition did not reduce symptoms. Shaikh et al. 2018 Correlation of Clinical and Imaging Findings for FES Diagnosis The article discusses how clinical parameters (e.g., respiratory distress, neurological decline, petechiae) can be correlated with specific imaging findings (e.g., brain MRI changes) to confirm a diagnosis of FES. Diagnosis of FES relies on a combination of clinical criteria and supportive imaging findings due to the lack of a definitive diagnostic test.

24. References Barlow, J. D., Logli , A. L., Steinmann, S. P., Sems, S. A., & Cross, A. G. (2020). Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate. Journal of Shoulder and Elbow Surgery, 29 (8), 1689–1694. https://doi.org/10.1016/j.jse.2020.01.095 . Han, S.-H., Park, J. S., Baek , J. H., Kim, S., & Ku, K. H. (2022). Complications associated with open reduction and internal fixation for adult distal humerus fractures: A multicenter retrospective study. Journal of Orthopaedic Surgery and Research, 17 (1), 399. https://doi.org/10.1186/s13018-022-03292-1 Shaikh, N., Mahmood, Z., Ghuori , S. I., Chanda, A., Ganaw , A., Zeeshan, Q., Ehfeda , M., Mohamed Belkhair , A. O., Zubair, M., Kazi , S. T., & Momin, U. (2018). Correlation of clinical parameters with imaging findings to confirm the diagnosis of fat embolism syndrome. International Journal of Burns and Trauma, 8 (5), 135–144.