1. Stabilize acid-base status
2. End-of-life discussion
3. Nuclear medicine stress test in woman with recent NSTEMI
4. Cellulitis which followed a traumatic amputation
5. Hyponatremia secondary to psychogenic polydipsia and (perhaps) thiazides, presented as altered mental status
6. Achalasia – needs myotomy
7. Lung cancer with bony metatases – needs biopsy documentation
8. Patient s/p below knee amputation for gangrene – awaiting rehab placement
9. Severe tonsillitis – probably bacteremic – responding to clindamycin

The first patient was very complex. He was in the ICU after an in-hospital arrest. He had multiple medical problems, and develop ATN 2 days later.

The second patient died the next morning. My resident and I spent 30 minutes preparing the family for the inevitable. Our time investment brought reality to a family, and helped the nursing staff greatly (their report to us).

The third patient was admitted for a TIA and happened to have elevated troponins. Her stress test was negative.

The fourth patient did very well – he had a minor amputation of the tip of his toe. His response to IV antibiotics was dramatic.

The fifth patient had a rapidly improved sodium level. We worried about how fast her sodium increased and spent significant time designing ways to slow down the sodium increase. We discharge her 2 days later with a total return of her baseline mental status.

The sixth patient did not have achalasia, rather he had diffuse esophageal spasm. The challenge we had was finding an acceptable treatment for his DES.

The seventh patient had his biopsy, and then we discharged him for outpatient radiation therapy.

The eighth patient continued to improve and was eventually discharge to a rehab facility.

The final patient was discharged after being afebrile for 48 hours. She responded well to antibiotics, but no firm diagnosis was made because blood cultures and throat cultures were negative.

I ask again – how should we judge quality for these patients? We had diagnostic problems, unusual management problems, social situations and end-of-life discussions. I believe we did a reasonable job last Monday, but I also do not believe that anyone could provide me a measurement of our quality.

This is the problem with quality measurement. We have too many diverse situations that we address each day. Often we care for unusual problems. Often we have diagnostic issues – achalasia vs. DES, etiology of hyponatremia, reason for high fever in a tonsillitis patient. We have management problems that do not easily fit into performance measures.

Any quality measures that would pertain to these 9 patients would paint an incomplete picture of our care and our tasks. We should challenge all attempts to measure something and call it quality of care. To repeat one of my favorite quotes from Donabedian

Judgments of quality are incomplete when only a few dimensions are used and decisions about each dimension are made on the basis of partial evidence.

Related posts:

1. The focus of 9 inpatients
2. Happy’s daily checklist for medical inpatients
3. 17 days at the VA – day 13
4. 17 days at the VA – Day 3
5. Can we measure quality?

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