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Death audit

1. Morbidity and mortality Audit report JJU SHY REFERRAL HOSPITAL College of Medicine & Health Sciences may 2024 Dr Mahamud A. Internal Medicine R2

2. Outline Objectives Mortality @ emergency and wards for 2 weeks Gaps adentified Source of data Challenges of finding data Suggestions

3. Objectives To review emergency and ward activities To identify strengths, weaknesses, limitations and opportunities To improve performance and clinical outcome To encourage for research in quality improvement To deliver optimal care

4. Introduction Intermal medicine has ► emergency department including emergency ICU-unit ► wards( ward A( 33 beds), B(32 beds) and C( 17 beds) ► centeral ICU

5. IM-department staffing There are a total of 14 seniors in internal medicine including nephrologist, hematologist, cardiologist and Emergency and critical care specialists. There are a total of 31 medical residents( R2,R2 and R3). There are a total of 15 medical interns. There are 51 nurse at medical ward

6. Activities Dialy round at emergency and ward including CICU. Progress notes, investigation updates Pt monitoring ( regular vital signs taken) Vasopressor management In both emergency and wards Fluid management and blood transfusions Routine drug administrations as per order Defibrillator and cardioversion ---@ emergency Patient transport ( dialysis, imaging)

7. POCUS ( point of care ultrasound)--@emergency Bedside 12 lead ECG CPR Patient admission, transfer and discharge

8. Emergency department MRN Dx of admission Cause of death Duration of stay 15377 P1. Knewly Dx stage 4 RVI + SCAP + ?PCP + septic shock of chest focus P2. AKI with uremic encepahalopathy P3.HCV positive P4: ?CNS toxo P5. oral candiasis Multi-organ organ failure 2ry to refractory septic shock. 1 day 15367 P1. Killip class 4 MI + s.bradycardia P2. Known HTN+ known Type 2 Dm P3? Type 1 cardiorenal syndrome refractory cardiogenic shock 1 days

9. EOPD MRN Admission diagnosis Cause of death Duration of stay 17110… P1.Nyha class 4 stage c Chf 2ry to ? IDCP + known PTE on enoxaparine ppted by SCAP with prapneumonic effusion P2. supratherapeuric INR + P3. Rt sided hemiparesis 2ry to ? Ischemic stroke P4.known hypertension Multi-organ failure 2ry to cardiogenic shock 1 day 17226 P1. Known type 2 DM with DKA( corrected) P2.ARDS 2ry to septic shock of chest focus r/o meningitis/ ischemic stroke P3. AKI 2ry to septic ATN + mild hypokalemia + mod.hyponatremia ( water deficit=1.7l) Respiratory failure 2ry to ARDS 2ry to sepsis of chest focus 2 days

10. Mortality case discussion,,15377 This is a 35 yrs old knewly Dx RVI presented with severe global type of headache for the 2months, and HGIF, altered in mentation followed by 2 episodes of abnormal left upper extremity movement for the last 4 days . P/E. GA ASL V/S: BP:70/40 PR. UR RR.28 SPO2. 77% atm . R/S, criptation over lower 2/3 posteriorly CVS. S1 and s2 well heard no murmur or gallop CNS. GCS. 10/15 pupil, Reactive bilaterally Power difficult to asses,,,, DTR +2

11. Kept with the assessment of P1. Knewly Dx stage 4 RVI + SCAP + ?PCP + septic shock of chest focus P2. AKI with uremic encepahalopathy P3.HCV positive P4: ?CNS toxo P5. oral candiasis

12. Inves summary CBC LFT CXR and CT not done WBC 12.1 Hbsag negative ALP 459.9 Multifocal pneumonia NEUt 84.2 ESR 82mm/ hr ALT 84 cT : not done Lymph 9.1 Creatine 10.74 AST 97 Hgb 10.1 Urea 338 HCT 33.5 PLT 192 ECG: normal Anti HCV.. POSITIVE

13. Managed with Vancomycine 1gm iv q72hrd hydrocortisone 50mg iv qid Ampicilline 2gm iv q4hrs carbamezapine 200mg po bid Cotrimoxazole 1920mg po bid Fluconazole 200mg po daily Prednisole 40mg po bid for 5 days----D/C Diazepam 1omg iv prn Phenytoin 1gm loaded then 100mg po tid Cefipime 1gm iv dialy Put on noradrenaline 4vials in 1L of ns after 2 bags of NS resuscitation

14. Death circumstance A 35yrs old female pt kept with Asst P1. Knewly Dx stage 4 RVI + SCAP + ?PCP + ? CNS toxo P2. AKI with uremic encepahalopathy P3. HCV positive P4. oral candidiasis ON: MANAGEMENT Immediate cause of death … Multiorgan organ failure 2ry to refractory septic shock.

15. Pitfalls Family couldn’t afford 2 nd line vasopressors..dopamine Difficult in getting the results in time….like CT scan

16. Next case MRN.15367… 60yrs old male known cardiac pt for 8 yrs , known DM for 5 years on unspecified medication currently presented with epigastric pain, easy fatigubility , palpitation, diaphoresis and PND of 5 days. He is an active smoker P/E, GA, ASL V/s: BP. 70/50 PR, UR RR. 28 deep breathing Spo2:88% facemask HEENT, PC NIS Chest, bilateral fine creptations

17. CVS: jvp raised , heart sounds are distent . Msk : grade 2 pitting edema CNS: GCS: 14/15 confused. kept with the assessment of: P1 . killip class 4 MI(cardiogenic shock)+ severe bradycardia P2 . known hypertension P3 . known DM P4. type 2 cardiorenal syndrom

18. Investigation Pt had investigations at hand Not found at the system

19. managed with 300ml of NS given bollus ASA 81mg po dialy after loading Clopedigrol 75mg po dialy after loading UFH 4000 iv then 12500 iu sc bid cimetidine 200mg iv Bid Catheterized

20. Atrovastatine 80mg po dialy Noradrenaline 4 vials in 500ml of NS ,,, starting 5d/m Lasix 20mg iv stat Atropine 0.5 ng iv stat see response then according every 5 minutes till maximum 3mg. Ceftriaxone 1gr iv bid

21. Death circumstance Despite on vasopressor, the patient couldn’t maintain MAP>65 and started to deteriorate and ICU was communicated but the family refused. ► immediate cause of death: refractory cardiogenic shock

22. Pitfalls Patient refused to be admitted in the ICU Difficult to copy outside investigation into hospital’s system

23. Next case…17110 A 95 yrs old female known hypertension and PTE on treatment presented with Rt sided body weakness for 3 days, SOB for 2days and dry intermittent cough of 2 wks. P/E: GA: ASL V/S: Bp : 150/90 PR: 72 RR: 28 Spo2: 91%atm Chest: bibasilar fine crackles Cvs : s1 and s2 well heard no murmur or gallop

24. CNS: GCS: 7/15,, pupil small in size and bilaterally reactive to light Kept with the assessment of: ► Nyha class 4 stage c Chf 2ry to ? IDCP + known PTE on enoxaparine ppted by SCAP with prapneumonic effusion ► supratherapeuric INR (8.55) ► Rt sided hemiparesis 2ry to Ischemic stroke ► known hypertension

25. Investigated with CBC COAGULATION PROFILE ELECTROLYTES CHOLESTEROL WBC: 8.4 PT: 88.7…….H K: 6.8……..H CHOL: 75.6 HGB: 9.9 INR: 8.55……H Na: 135.1 TRIG: 135 HCT: 34.1 aPTT : 36.9….H CHL: 106.1 HDL”: 36.3 MCV: 83.2 RENAL FUNCTION LDL: 66.2 PLT: 162 CREA: 3.41…..H URE: 135.1…..H LEFT VENOUS DOPPLER: NORMAL VENOUS EXAM BRAIN CT SCAN:left MCA teritor infracton with mass effect

26. Managed with Put on INO2 Challenge with 250ml of NS Catheterized and Ngtube inserted Omeprazole 40mg iv dialy Cefepime 1gm Iv tid manitol 300ml iv loaded then D/C Vancomycine 1gm iv bid Hydrocortisone 100mg iv then 50mg iv qid Dopamine 5mcg/kg/ mnt add 4vials with 500ml of NS, start 5drops every 30mnts double until BP > 90/60mmhg

27. Death circumstance This is a 95yrs old female known hypertension and known PTE on medication presented with Rt sided body wkness of 3 days, SOB and dry intermittent dry cough. P/E: GA: asl , v/s: 70/50, PR: 52 RR:28 CNS: GCS: 7/15,, deteriorating. ON: cefipime, vancomycine and vasopressors Immediate cause of death: Respiratory failure 2ry to ? Raised ICP/ sepsis of chest focus CPR: done but was not successful. ICU – comunicated but there were no bed available

28. Next case,,, 17226 This is a 50yrs old female known type 2 dm on medication for 5yrs, presented with mental change of 2 days, nausea and vomiting of ingested matter of multiple episodes of same duration. Also she has SOB, cough and severe global type of headache of 3 days For the last 2 days she had behavioral changes and decreases urine amount.

29. P/E: GA: ASL,, In cardiorespiratory distress V/S: Bp : 100/50 PR: 110 RR: 29 T: 37.9 Spo2: 90%atm HEENT: pc, nis LGS : no lap detected Chest: bilateral lower 2/3 course criptations over posterior chest Cvs : JVP flat, s1 and s2 well heard no murmur or gallop Abd / gus / msk / int : no abnormalities detected. CNS: GCS: 4/15 ( E: 2 M: 1 V; 1), power: difficult to assess.

30. Kept with the assessment of P1: coma 2ry to ?stroke r/o complicated p. meningitis P2. ARDS + septic shock of chest focus P3: AKI 2ry to? Septic ATN +hyperkalemia + hypernatremia P4: known Type 2 DM with DKA ( corrected) investigated with CBC ELECTROLYTES RENAL FUNC Chest x-ray Brain ct scan WBC: 13.6 K: 5.8 CRE:2.7----4.8 ESR: 36 xxx Xxxxx HGB: 12.5 Na : 149 UR: 59.3---115.5 HCT: 39 CHOL: 122.3 URINE ANALYSIS MCV: 90.7 NON-REVEALING PLT: 140

31. Managed with Put on facemask Cefepime 1gm iv loading then 1gm iv dialy Vancomycine 1gm iv loading then 1gm iv q72hrs Ampicilline 2gm iv q4hrs ► ICU was communicated &family refused Ufh 5000iu sc bid NPH 22/10 with premeal 2iu Omeprazole 40mg iv dialy Salt free diet

32. Death circumstance A 50yrs old female known type 2 dm on medication presented with change in mentation, nausea and vomiting, dry intermittent cough and severe global type of headach . P/E: GA: ASL v/s: bp : 90/50 PR: 115 RR: 27 Spo2: 68% on 10L of facemask o2. R/S: diffuse criptations ► ICU- planed but no available bed. CNS: GCS: 8/15 ( E: 2 V: 2 M: 4) Immediate cause of death : respiratory failure 2ty ARDS

33. Ward deaths for 2 weeks( 24/8----7/9/16E.C) MRN Dx at admission Cause of death Duration of stay 16872.. 30yr/f Nyha class 4 stage c Chf 2ry to CRVHD +cardiogenic shock 2ry to acute decompensated HF + Atrial fib + severe symptomatic hyponatremia Refractory Cardiogenic shock 6 days 15183.. Nyha class 4 stage c chf 2ry to ?IHD ppted by CAP with grade 2 pulm edema + newly Dxed type 2 DM + AKI 2ry to ? Septic ATN + urosepsis + uremic encephalopathy + known asthma + pituitary macroadenomia + mod. Hypernatrmia ( deficit=4.5l) Cardioge nic shock 3 days

34. MRN Admission diagnosis Cause of death Duration of stay 14124 ?meningoencephalitis + ?brain abscess( early cerebritis ) + incisional hernia + Nyha class 4 stage c Chf 2ry to ?IHD + r/o cardiogenic shock + AKI 2ry to ?contrast induced nephropathy Cardiogenic shock 2 days 7679 Paraplegia 2ry to disc prolapse + 19 th post partal day+ sepsis of wound focus + severe anemia 2ry to IDA + grade 4 bedsore Multiorgan failure 2ry to refractory septic shock 16days

35. MRN Admission diagnosis Cause of death Duration of stay 14859 P1:Known type 1 DM with severe DKA P2: sepsis of chest focus P3: ?pyogenic meningitis P4: moderate hypernatremia(1.9L) P5: Bicytopenia (severe thrombocytopenia)

36. Case discussion.. 16872.. This is a 30yrs old female pt who is known hypertensive for the 10yrs and was on unspecified medications and known cardiac pt for last 7months on unspecified medications, currently presented with generalized body swelling started from lower extrimities and progress to upward to involve the abdomen for 1 month duration, in association with she had yellowish discoloration of eyes and itching sensation of the body for 1week duration.

37. P/E GA: ASL V/S: bp : 90/50 PR: 112 RR:24 Spo2: 92% ATM HEENT: PC NIS Chest: fine criptation over the lower 2/3 of the chest posteriorly CVS: s1 and s2 well heard no murmur or gallop Abd : protuberant abdomen, moves with respiration and no organomegally detected

38. MSK: grade 3 pitting edema CNS: GCS: 15/15, COTPP Admitted with the assessment of: Nyha class 4 stage c Chf 2ry to CRVHD +cardiogenic shock 2ry to acute decompensated HF + Atrial fib + severe symptomatic hyponatremia

39. Investigated with Liver enzyme ALP: 139 ALT: 45.6 AST: 105.3 D bil .. 17.55,,, T-bil:29.6 LDH: 554 Urine analysis Blood +2 Others..none revealing HgA1c= 5.7 Electrolytes K: 4.2 Na: 116 Chl : 77.8 CXR and U?S… not done Renal function Cre : 1.03 BUN: 33.9 CBC WBC: 14.4 HGB: 10.4 HCT: 34.3 MCV: 81.3 PLT: 192

40. Managed with Lasix 40mg iv challenged Catheterized 3% saline given Digoxine 0.125mg po dialy Lasix 40mg iv if BP> 90/60 Noradrenaline 8vials in 500ml of NS … start 5 drops/ mnt

41. Progress note This is a 30yrs old female pt admitted with the asst of P1. nyha class 4 stage c chf ry to crvhd P2. cardiogenic shock ry to acute decompensated heart failure P3. atrial fib P4. severe symptomatic hypernatremai

42. She is on Digoxine .125mg po dialy Lasix 40mg iv if bp >90/60 Ceftrixone 1gm iv bid Noradrenaline drip 32mcq/ kg.mnt Subj: she has bilateral nasal bleeding Obj : GA: ASL v/s: Bp80/50mmhg PR: 87( irir ) RR: 24 Heent : pc nis R/S: fine criptaiton over 1/3 of the chest posteriorly CVS: s1 and s2 well heard no murmur or gallop ABD: flat palpable liver border at right costal margin MSK: grade 3 pitting edema CNS: cotpp Assesment : same + deteroriating

43. Death circumstance Despite that the patient was on vasopressors and diuretics V/S: Bp : 7 0/40 PR: 122 RR: RR: 14 Spo2: 68% on facemask Chest: course criptation on bilateral chest posteriorly CNS: GCS:3/15 and deteroriating Immediate cause of death : cardiorespiratory arrest 2ry to refractory cardiogenic shock pitfalls ► ICU was communicated but family refused

44. Next case..15183.. This is a 80yrs old female known hypertension and cardiac pt for 8 and 4 months respectively, presented with chest pain for 4 days duration associated with GBS, started from lower extrimities and involve to abdomen, also has SOB,cough of whitish frothy sputum more commonly at night,PND and orthopnea of 3 pillows. Has dysuria, frequency and urgency of 1 week duration and she was having change in mentation in between and abnormal behavior of 1 week duration.

45. P/E: GA: ASL V/S: BP: 90/60 PR: 98 RR:24 Spo2: 86% atmosph HEENT: pc nis Chest: right lower 2/3 course criptation CVS: s1 and s2 well heard no murmur or gallop Abd : full abdomen moves with respiration GUS: suprapubic tenderness

46. CNS: GCS:8/15(E:2 v: 2 M:4) Admitted with the assessment of: ► Nyha class 4 stage c chf 2ry to ?IHD ppted by CAP with grade 2 pulm.edema . ► newly Dxed type 2 DM + ► AKI 2ry to ? Septic ATN + urosepsis ► known asthma + pituitary macroadenomia + mod. Hypernatrmia ( deficit=4.5l)

47. Investigated with CBC URINE ANALYSIS ELECTROLYTES RENAL FUNC Brain MRI WBC : 25.8 KETONE:TRACE K: 3.5 CRE: 2.5 Pitutary macroadenoma HGB: 14.7 BLOOD: +4 Na: 158.4 UREA: 112 Echo: moderate calcified Aortic stenosis HCT: 42.8 LEUKOC: +2 CHL: 114.4 PLT: 489 PROT:+1 Abd —U/S: normal TROPONINE: 2X NORMAL HgA1c: 8.6 CXR: cardiomegaly

48. Managed with Lasix 40mg in 50ml of infusion ----D/C 500mL of D5w over 24hrs Cefepine 1gm iv loaded then 1gm iv dialy Vancomycine 1gm loaded then 1gm iv Q72hrs Sulbutamole puff started NG tube inserted Omeprazole 40mg iv dialy ICU COMMUNICATED AND she has been DEFERED Noradrenaline 4vialis in 500ml of NS….. Family refused to have it.

49. Progress note A 80yrs old female known hypertensive and cardiac pt for 8 and 4months presented with chest pain, generalized body swelling, SOB, orthopnea and PND and also she developed bezzare behavior and irritability, also she has decreased PO-intake and developed change in mentation. p/e: GA: asl v/s: BP: 90/60 PR: 90 RR: 26 Spo2: 90% (5L INO2) Chest:Rt lower 2/3 course criptation CNS: GCS: 6/15 ( E:2 V:1 M:3) Asst : same + deteriating .

50. Death circumstance Despite family refusal to have vassopressors , pt was deteriraiting p/e: GA: ASL V/S: Bp : 70/40 Pr : 57 RR: 28 Spo2: 87% ( 5LINO2) Chest: right sided course criptation CVS: jvp flat and s1,s2 well heard CNS: GCS: 6/15 Immediate cause of death: cardiogenic shock Pitfalls…….. ICU refusal

51. Next case..14124 This is a 55yrs old female pt presented with change in mentation of 2 days duration in association she had LGIF , global type of headache. She is a known asthmatic pt for 5 yrs on salbutamol puff prn and she was done cholecystectomy 7 yrs back Otherwise: no sob,orthopnea and pnd no chronic medical illnesses

52. P/E: GA: ASL V/S: bp : 80/50 PR: 105 RR: 22 Spo2:80% atm HEENT: pc nis Chest: bilateral course criptation on posterior 1/3 Cvs : s1 and s2 well heard no murmur or gallop Abd : full abdomen, there is a prodrutting mass aroung umbilicus during coughing. CNS: GCS:14/15 confused

53. Admitted with the assessment ? Meningoencephalitis+ ? Brain abscess( early cerebritis ) incisional hernia Nyha class 4 stage c chf 2ry to ? IHD + r/o cardiogenic shock Aki 2ry to ? Contrast iduced nephropathy

54. Investigated with CBC RENAL FUNC LIPID PROFILE ELECTROLYTE CBC: 12.8 CRE : 1.1 …… 4.3 CHOL: 32.89 K: 3.71 CXR: cardiomegaly with grade 2 pulmonary edema HGB: 10.3 UREA: 20----62 TRIG: 58 Na: 134.99 HCT: 33.2 HDL: 7….L CHL: 114.45 ECHO: not done MCV: 85 TSH: 2.1…NORMAL LDL: 9….L PLT: 156 HCVag : NEGATIVE CT with contrast: early cerebritis HBSag ; NEGATIVE

55. Managed with Lasix 40mg iv tid Ceftriaxone 2gm iv —D/C meropereneum 500mg iv bid Metronidazole 500mg iv tid —D/C plasil 10mg iv bid Vancomycine 1gm iv Q72hrs 4vials of noradrenaline in 200ml Omeprazole 40mg iv dialy of NS , start 5 d/m and scalate Ufh 5000iu sc bid noradrenaline 4vials in 500ml Amitrytylline 25mg po dialy

56. Progress note 55 yrs old female pt transferred from ward B with the assessment of: P1:? Meningoencephalitis+ ? Brain abscess( early cerebritis ) P2: Nyha class 4 stage cchf 2ry to ? IHD + r/o cardiogenic shock P3: Aki 2ry to ? Contrast nephropathy ON: vasopressors, prophylactic UFH, diuretics and antiobiotics

57. Death circumstance Despite the vasopressors 32mcq/kg/ mnt , antibiotics and diuretics, patient was deteriating and ICU was communicated and family refused Immediate cause death : Refractory cardiogenic shock

58. Next case,,,7679 A 35Yrs old para 8 mother presented with the complaint of lower back wound of 3 weeks duration ,has hx of lower extrimity weakness of 3months wiht history urinary retention. she was amenorrhc for the past 8 months and delivered to an a dead male neonate weightinf 9 70gr p/e: GA: CSL V/S: BP: 100/70 PR: 88 RR: 20 Spo2: 95% atm HEENT: pale conjectiva nis LGS: no abnormalities detected.

59. Chest: clear with good air entery Cvs : s1 and s2 well heard no murmur or gallop Abd:28wk sized gravid uterus,, no hepatospleenomegally MSK: there is eschar with pussy drainage involving the gluteal and upper thigh of the both lower extrimties CNS:GCS: 15/15 power: 0/5 on bilateral lower extrimities

60. Admitted with the assessment of Paraplegia 2ry to compressive myelopathy + 3 rd tm px + grade 4 bedsore + severe anemia 2ry to IDA +RH- ve managed with Ceftriaxone 1gm iv bid Metronidazole 500mg iv tid wound care bid Blood was transfused Ufh 5000iu sc bid

61. Prednisole 50mg po dialy Ferous sulphate 325mg po tid Folic acid 5mg po dialy DISCHARGED– RE- ADMITTED WITH SAME DIAGNOSIS + SEPSIS OF WOUND FOCUS antibiotics – re-initiated Vancomycine, meroperium started based on blood culture results.

62. CBC OFT WBC: 4K CRE: 0.9....1.7 INR..1.3 PREPHEREAL MORPH..... Microcytic hypochromic HGB: 6.6 BUN: 20...48 MRI: INDEX: L4/L5 disc protrusion + L5/S1 ANULAR TEAR CSF.ANAYLYS normal PTL: 90 ELECTROLY URINE ANALYSIS CXR: NORMAL CEEL..3 CBC REP K: 3.5...3.7 LEUK +2 URINE CULUTRE: enterococus sensitive to cefipem and cefotoxim WBC : 12 Na: 125..124 DOPLER:Normal HB:G: 4.8 PLT: 159

63. Circumstance of death 35yrs old female pt admited with assessment of Paraplegia 2ry to compressive myelopathy + grade 4 bedsore + sepsis of wound focus with septic shock On: vancomycine, meroperium , noradrenaline 32mcq/kg./ mnt . circumstance of death: multi-organ failure 2ry to refractory septic shock

64. Next case.. 14859 This is a 30yrs old known typr1 DM on NPH presented with change in mentation of 2 days duration, associated with vomiting of ingested matter of multiple episodes of 3 days and has excessive urination, thirst and increased feeling of hunger for the past week. no abnormal body movement, dysuria and frequency P/E: GA: ASL V/S: BP: 90/50 PR:130 RR: 28 Spo2: 94%atm HEENT: pc nis Chest: bilateral fine crackles over the lower 2/3 of chest Cvs : s1 and s2 well heard no murmur or gallop

65. Abd : scaphoid abdomen with mild epigastric tenderness and no HSM GUS: no cva tendernss CNS: GCS: 7/15( E 3 V: 1 M: 3), pupil: bilaterally reactive and mid-sized admitted with the assessment of: P1:Known type 1 DM with severe DKA----corrected P2: sepsis of chest focus P3: ?pyogenic meningitis P4: moderate hypernatremia(1.9L)

66. CBC ELECTROLYTE LIVER ENZYM RENAL FUNC WBC : 32.6 K: 3.86 ALP: 382 CRE: 1.07 HGB: 11.4 Na: 138.26 ALT: 109 URE: 88 Brain CT.. Considered but not done HCT: 36.0 CHOL: 155.26 HBSAG: -VE AST: 302 MCV: 96.3 ANTIHCV: -VE URINE ANALY Abdominal u.s. . Planned PLT: 194 AMYLASE: 44.74 GLU: + 2 HGA1C: 17.3 KET: +3 BLOOD:+2

67. Managed with DKA.. Managed and corrected with IV- kcl . Cefipime 2gm iv tid Vancomcine 1gm iv bid Noradrenaline infusion started 16mg/kg/ mnt Hydrocortisone 50mg iv qid after loaded Ampicilline 2gm iv q4hr ICU—communicated and family refused

68. Circumstance of death A 30yrs old male known type 1dm admitted with the assesment of P1:Known type 1 DM with severe DKA----corrected P2 : sepsis of chest focus P3 : ?pyogenic meningitis ON: antibiotics and vasopressors Immediate cause of death : respirator failure 2ry to sepsis of chest focus

69. Source of data From patient charts Form nurse heads From residents

70. Challenges in retrieving data Difficult in getting death log-book in the system.. Both discharge and death summary are in one place Date and clander : system uses europian clander Discharge death

71. SBFR-reporting system– should be traceable In every case reported, there should be traceable….having MRN, ward and date of death

72. Defibrillator should be available at wards Bedside ultrasound crash-card for emergency drugs should be available Proper ICU- consultation should be implemented and proper patient counsoling .

73. Strengths Timely rounds BID Good start to IPC Proper isolation rooms for active pulmonary TB pts

74. Gaps and weakness Late inter-departmental consultation Incomplete registration

75. Recommendation Patient as well as community education Early inter-departmental and ICU consultations Fulfillment of equipment's

76. Thank you