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Fazal F, Adil ML, Ijaz T, Ahmad Khan S, Imran Butt A, Abid A, Bashir MN, Ambreen S, Chaudhry TZ, Malik BH. Improving the Quality and Completeness of Discharge Summaries at a Tertiary Care Hospital in Pakistan: A Quality Improvement Project. Cureus 2024; 16:e56134. [PMID: 38487648 PMCID: PMC10938087 DOI: 10.7759/cureus.56134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 03/17/2024] Open
Abstract
Introduction Discharge summaries (DS) allow continued patient care after being discharged from the hospital. Only a few quality improvement projects (QIPs) focused on assessing and improving the quality and completeness of DS at tertiary care hospitals have been undertaken in Pakistan. This QIP aimed to evaluate and enhance the quality and completeness of DS at a tertiary care hospital in Pakistan to facilitate seamless healthcare transitions. Methods A QIP was conducted in the medical unit of a tertiary care hospital in Rawalpindi, Pakistan. The DS were assessed using the e-discharge summary self-assessment checklist devised by the Royal College of Physicians (RCP). This QIP was done by the plan, do, study, act (PDSA) cycle. The PDSA cycle comprised two audit cycles and an intervention in between them. The first audit cycle (AC) was conducted on 150 DS. Its duration was from March 2023 to June 2023. An educational workshop was conducted before the re-audit cycle (RAC) to address deficiencies and reinforce the implementation of the guidelines provided by the RCP. The RAC was conducted from June 2023 to August 2023. 100 DS were studied and analyzed to assess for improvement in the completeness of DS. Frequencies and percentages were calculated in each audit cycle. The Chi-squared test was applied to compare the statistical difference between the results of both audit cycles. Results A total of 150 DS were analyzed in the first AC and 100 DS in the RAC. The results of the first AC show that the details of any allergies were recorded only in 3% of the DS; this percentage significantly improved to 51% after the RAC (p-value <0.05). Relevant past medical history was included in 52% and 88% of the DS during the first AC and RAC, respectively (p-value <0.05). Secondary diagnoses were written in 54% and 71% of the DS during the first AC and RAC, respectively (p-value <0.05). Details of relevant investigations were included in 60% and 88% of the DS during the first AC and RAC, respectively (p-value <0.05). The post-discharge management plan was written in 90% and 98% of the DS during the first AC and RAC, respectively (p-value <0.05). The follow-up plan was written clearly in 65% and 93% of the DS during the first AC and RAC, respectively (p-value <0.05). Conclusion The DS was found to be incomplete after analyzing the results of the first AC. The details related to allergies, medications, operations, and procedures were found to be missing in the majority of the cases. No mention of the patient's concerns or expectations was made in the DS. The results of the RAC showed improvement in the level of completeness of DS. The majority of the weak points observed after the first AC seemed to have improved after the RAC, which shows that intervention proved to be quite effective in improving the completeness and quality of DS. The RAC showed significant improvement in the completeness of the details relating to investigations, allergies, past medical history, secondary diagnoses, and the post-discharge follow-up plan. QIP must be routinely carried out to assess and improve the completeness and quality of DS at hospitals.
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Affiliation(s)
- Faizan Fazal
- Department of Medicine, Holy Family Hospital, Rawalpindi, PAK
| | - Maham L Adil
- Department of Medicine, Holy Family Hospital, Rawalpindi, PAK
| | - Talha Ijaz
- Department of Medicine, Holy Family Hospital, Rawalpindi, PAK
| | | | | | - Areesha Abid
- Department of Medicine, Holy Family Hospital, Rawalpindi, PAK
| | - Muhammad N Bashir
- Department of Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK
| | - Saima Ambreen
- Department of Medicine, Holy Family Hospital, Rawalpindi, PAK
| | - Taha Z Chaudhry
- Department of Medicine, Holy Family Hospital, Rawalpindi, PAK
| | - Bilal H Malik
- Department of Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Eissa AYH, Mohamed Elhassan AZW, Ahmed AZH, Elgadi A, Manhal GAA, Fadul MH, Ahmed MI, Fadul A, Mekki II. The Quality of Discharge Summaries at Al-Shaab Hospital, Sudan, in 2022: The First Cycle of a Clinical Audit. Cureus 2023; 15:e41620. [PMID: 37565093 PMCID: PMC10410477 DOI: 10.7759/cureus.41620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2023] [Indexed: 08/12/2023] Open
Abstract
Background The discharge summary is a vital component of the modern health system. It is defined as a synopsis of information regarding events occurring during the inpatient care of a patient, to allow for a safe, quick, and effective patient-centered discharge process. It contains important information about the patient's hospital stay, including the reason for admission, treatment received, and follow-up needed. Low-quality discharge summaries pose a great risk to patient healthcare since the most frequent reason for error in clinical settings is poor communication. In the United Kingdom, the Professional Record Standards Body (PRSB) has adopted the Academy of Medical Royal Colleges (AoMRC) "Standards for the Clinical Structure and Content of Patient Records" and produced a standard discharge summary form. This study aimed to assess the quality of discharge summaries at Al-Shaab Hospital in Sudan in terms of information, filling adequacy, and adherence to international guidelines and evaluate the discharge interviews. Methods A cross-sectional institution-based study was conducted in the period of September to December 2022 at Al-Shaab Teaching Hospital in Khartoum, Sudan. Systematic random sampling was used to select the study participants from the discharged patients. A total of 70 patients were met in their wards over a period of two months, and the contents of their discharge cards were compared to items on an online checklist based on the Professional Record Standards Body (PRSB) and the Academy of Medical Royal Colleges (AoMRC) standard discharge summary. The patients were also interviewed to assess their knowledge regarding their discharge information. Results The hospital's discharge summary form contained only four headings: date, patient name, age, and ID number. The assessed cards were found to be missing valuable information, including date of admission (missing in 83%), filling doctor's name (missing in 71%), and medication changes (missing in 70%). Only half of the summaries were clearly readable. The majority of patients had poor knowledge regarding their medication side effects (89%) and how to act in an emergency (86%), while knowledge of medication doses and follow-up details was good in 80% and 66%, respectively. Conclusion The patients are discharged with inadequately filled discharge forms. This may be due to the poor design of the form, so a newly designed form will be proposed, based on international standards. The discharge interview is also in need of improvement, to make sure patients are fully aware of their condition.
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Affiliation(s)
| | | | | | - Ammar Elgadi
- Faculty of Medicine, University of Khartoum, Khartoum, SDN
| | | | | | | | - Abdalla Fadul
- Department of Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | - Islah Ismail Mekki
- Department of Respiratory Medicine, Al-Shaab Teaching Hospital, Khartoum, SDN
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3
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Friedman N, Erez-Granat O, Inbar A, Dubnov-Raz G. Obesity screening in the pediatric emergency department - A missed opportunity? Heliyon 2022; 8:e12473. [PMID: 36590528 PMCID: PMC9801120 DOI: 10.1016/j.heliyon.2022.e12473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 10/25/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives There is a low rate of body mass index measurements and obesity screening in primary pediatric care. Pediatric emergency department (PED) visits, with their large volumes and routine weight measurements, provide a unique opportunity to identify and address obesity. The study objectives were to examine the rate of addressing obesity in the PED and to identify its predicting factors. Methods From electronic medical records of PED visits during 2010-2019, we extracted data on age, gender, weight, time, listed diagnoses, and discharge texts. The primary outcome was a listed diagnosis of "obesity" on discharge letters of children with obesity. Secondary outcomes were addressing weight in the discharge letter and written recommendations for obesity-related treatment. Mixed models were used to test for associations between each of the three outcomes and patient/visit characteristics. Results There were 150,250 PED visits by 88,253 different children and adolescents. Obesity was found in 10,691 children (12.1%). Among these, listed "obesity" diagnosis was present in only 240 (1.5%) visits. Text addressing overweight/obesity was recorded in 721 (4.4%) visits, and weight-related recommendations were documented in 716 (4.4%) visits. "Obesity" was documented in females more often than in males, in older children, in children with higher weights, and in visits conducted during the mornings. Conclusions The rate of obesity diagnosis in the PED was extremely low, hence the potential screening ability of the PED in this matter is highly under-utilized. PEDs could increase the recognition of obesity, thus assisting in the global efforts in tackling this disease.
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Affiliation(s)
- Nir Friedman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Pediatric Emergency Department, Meir Medical Center, Kfar Saba, Israel,Corresponding author.
| | - Ortal Erez-Granat
- The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel,Pediatric Emergency Department, Meir Medical Center, Kfar Saba, Israel
| | - Alon Inbar
- The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Gal Dubnov-Raz
- The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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4
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Jagannath S, Sarcevic A, Multak N, Myers S. Understanding Paper-Based Documentation Practices in Medical Resuscitations to Inform the Design of Electronic Documentation Tools. Pediatr Emerg Care 2021; 37:e436-e442. [PMID: 30586038 DOI: 10.1097/pec.0000000000001676] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Despite growing use of electronic health records, many resuscitation settings still use paper-based documentation. The fast-paced and safety-critical nature of trauma and medical resuscitation environments pose challenges for real-time documentation. This study aims to understand paper-based documentation practices and inform the design of efficient electronic documentation solutions for supporting safety-critical medical processes. METHODS Data were collected through in situ observations of nurse documenters during resuscitation events and postevent interviews with nurses. These data were analyzed using frequency distribution and qualitative, open-coding techniques. Data analysis focused on the following 3 main documentation factors: temporal distribution of documentation, total number of filled out sections on the paper flow sheet across all resuscitations, and completeness of documentation per resuscitation. RESULTS Findings from this study highlight the time-critical nature of these settings, showing that 74% of the documentation was completed within the first 15 minutes of the resuscitation. Some sections of the paper flow sheet were filled out more than others, and a few sections were left incomplete across all events. Interviews with nurses provided insight about documentation experiences in a fast-paced environment, including variable usage of flow sheet based on nurse experience level and patient scenarios, supplemental documentation mechanisms, and information needs and preferences. CONCLUSIONS Several design implications are discussed to inform the design of effective electronic documentation systems. Design implications focus on layout structure, prepopulating items, section placement, and completion status of the flow sheet. Future plans for research focus on combining video review with in situ observations and conducting detailed interviews with nurses to better understand their documentation experiences and preferences.
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Affiliation(s)
- Swathi Jagannath
- From the College of Computing and Informatics, Drexel University, Philadelphia, PA
| | - Aleksandra Sarcevic
- From the College of Computing and Informatics, Drexel University, Philadelphia, PA
| | - Nina Multak
- School of Physician Assistant Studies, University of Florida College of Medicine, Gainesville, FL
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5
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Farrell NM, Killius K, Kue R, Langlois BK, Nelson KP, Golenia P. A Comparison of Etomidate, Ketamine, and Methohexital in Emergency Department Rapid Sequence Intubation. J Emerg Med 2020; 59:508-514. [PMID: 32739131 DOI: 10.1016/j.jemermed.2020.06.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/30/2020] [Accepted: 06/06/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Rapid sequence intubation (RSI) is routinely used for emergent airway management in the emergency department (ED). It involves the use of induction, and paralytic agents help facilitate endotracheal tube placement. OBJECTIVE In response to a previous national drug shortage resulting in the use of alternative induction agents for RSI, we describe the effectiveness and safety of ED RSI with ketamine or methohexital compared with etomidate. METHODS We conducted a retrospective, single-center observational study from March 1-August 31, 2012 describing RSI with etomidate, ketamine, and methohexital. All adult patients undergoing RSI in the ED who received etomidate prior to its shortage and methohexital or ketamine during the shortage were included. RESULTS The study included 47, 9, and 26 patients in the etomidate, ketamine, and methohexital groups, respectively. Successful intubation on the first attempt occurred in 74.5%, 55.6%, and 73.1% of the etomidate, ketamine, and methohexital groups, respectively. The mean number of intubation attempts and time to intubation seemed to be similar in all groups. At least three intubation attempts were required in 22.2% and 7.7% of the ketamine and methohexital groups, respectively, compared with none in the etomidate group. Two aspirations were observed in the etomidate group. CONCLUSION Methohexital and etomidate had similar rates of successful intubation on the first attempt and seem to be more effective than ketamine. Etomidate may reduce the need for three or more intubation attempts. Larger, prospective studies are needed to determine if ketamine or methohexital are more effective than etomidate for RSI.
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Affiliation(s)
- Natalija M Farrell
- Department of Pharmacy, Boston Medical Center, Boston, Massachusetts; Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Kelly Killius
- Department of Pharmacy, Boston Medical Center, Boston, Massachusetts
| | - Ricky Kue
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Breanne K Langlois
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Kerrie P Nelson
- Department of Biostatistics, Boston University, Boston, Massachusetts
| | - Peter Golenia
- Department of Pharmacy, Boston Medical Center, Boston, Massachusetts
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Marco CA, Bryant M, Landrum B, Drerup B, Weeman M. Refusal of emergency medical care: An analysis of patients who left without being seen, eloped, and left against medical advice. Am J Emerg Med 2019; 40:115-119. [PMID: 31704062 DOI: 10.1016/j.ajem.2019.158490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Emergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care. METHODS This prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey. RESULTS Among 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p < 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p < 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%). CONCLUSION ED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.
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Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, United States.
| | - Morgan Bryant
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
| | - Brock Landrum
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
| | - Brenden Drerup
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
| | - Mitchell Weeman
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
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7
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BAGNASCO A, COSTA A, CATANIA G, ZANINI M, GHIROTTO L, TIMMINS F, SASSO L. Improving the quality of communication during handover in a Paediatric Emergency Department: a qualitative pilot study. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2019; 60:E219-E225. [PMID: 31650057 PMCID: PMC6797885 DOI: 10.15167/2421-4248/jpmh2019.60.3.1042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 07/19/2019] [Indexed: 11/16/2022]
Abstract
Introduction There is a dearth of literature that specifically addresses the handover reporting process among healthcare staff working in children's Emergency Department (ED). Widespread gaps in service provision, such as gaps in communication in handover reports to ambulance staff have been noted in the general literature on the topic. There are also improvements observed in handover when a structured mnemonic was encouraged. Structured reports improve communication, safety and may reduce medication errors. Thus, the improvement of handover reporting in children's ED has important implications for children's healthcare practice. However, little is known about communication processes during handover reports in Italian children's ED or its consequences for errors or risks. Methods A qualitative description methodology was used. Semi-structured interviews were used to collect data from five children's ED nurses. Thematic content analysis was used to identify common themes. Results Emergent themes were: interpersonal influences on handover; structural issues; and local contextual factors. Conclusions The findings of this pilot study prompted the need for a standardized tool that improves communication during handover. As such, standardizing the communication process during handover could be effectively resolved by using a mnemonic tool adapted for handover in a paediatric emergency department.
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Affiliation(s)
- A. BAGNASCO
- Department of Health Sciences, University of Genoa, Italy
- Correspondence: Annamaria Bagnasco, Department of Health Sciences, University of Genoa, via Pastore 1, 16132 Genoa, Italy - Tel. +39 010 3538515 - E-mail:
| | - A. COSTA
- Accident & Emergency Department G. Gaslini Children’s Hospital, Italy
| | - G. CATANIA
- Department of Health Sciences, University of Genoa, Italy
| | - M. ZANINI
- Department of Health Sciences, University of Genoa, Italy
| | - L. GHIROTTO
- Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - F. TIMMINS
- School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | - L. SASSO
- Department of Health Sciences, University of Genoa, Italy
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8
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Awareness of diagnosis and follow up care after discharge from the Emergency Department. Australas Emerg Care 2019; 22:221-226. [PMID: 31624010 DOI: 10.1016/j.auec.2019.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients currently receive discharge summaries including investigation results, medical assessment and follow up requirements with health professionals on discharge from the emergency department (ED). This study aimed to evaluate if a simplified discharge information card in addition to current care improved patients' awareness of their discharge diagnosis and requirements for follow-up appointment. METHODS A prospective pre-post design interventional study was conducted. The pre-intervention phase collected data from patients who did not receive the discharge card. The post-intervention phase occurred after implementing the discharge card. Participants underwent brief interviews to assess awareness of diagnosis and follow-up appointment requirements after discharge. Responses were compared to the plan in the medical notes and concordance determined. RESULTS There were 112 patients in the pre-intervention group and 117 in the post-intervention group. Awareness of discharge diagnosis improved from 73.2% (95% CI: 64.3-80.5) of pre-interventions participants to 89.7% (95% CI: 82.9-94.0) for participants receiving the discharge card (p<0.001; NNT 6.1 patients). Statistically significant improvements were observed regarding knowledge of follow-up destination and timing. CONCLUSION A short discharge information card improved awareness of discharge diagnoses and follow-up requirements. Such interventions that empower patients with knowledge about their health, should be considered prior to discharge from EDs.
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Lai FW, Kant JA, Dombagolla MH, Hendarto A, Ugoni A, Taylor DM. Variables associated with completeness of medical record documentation in the emergency department. Emerg Med Australas 2019; 31:632-638. [PMID: 30690885 DOI: 10.1111/1742-6723.13229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The completeness of ED medical record documentation is often suboptimal. We aimed to determine the variables associated with documentation completeness in a large, tertiary referral ED. METHODS We audited 1200 randomly selected medical records of patients who presented with either abdominal pain, cardiac chest pain, shortness of breath or headache between May-July 2013 and May-July 2016. Data were collected on patient and treating doctor variables. Documentation completeness was assessed using a 0-10 point scoring tool designed for the study. A maximum score was achieved if each of 10 pre-determined important items, specific to the presenting complaint, were documented (five medical history items, five physical examination items). Data were analysed using multivariate regression. RESULTS The presenting year, day and time, patient age and gender, preferred language, interpreter requirement, discharge destination and doctor gender were not associated with documentation completeness (P > 0.05). Patients with triage category 3 or pain score of 6-7 had higher documentation scores (P < 0.05). Compared to interns, registrars (effect size -0.72, 95% CI -1.02 to -0.42, P < 0.01) and consultants (-1.62, 95% CI -1.95 to -1.29, P < 0.01) scored significantly less. The headache patient subgroup scored significantly less than the other patient subgroups (-0.35, 95% CI -0.63 to -0.08, P = 0.01). For all presenting complaint subgroups, examination findings were less well documented than history items (P < 0.001). CONCLUSION Documentation completeness is less among senior doctors, headache patients and for examination findings. Research should determine if the supervision responsibilities of senior doctors affects documentation and if medico-legal and patient care implications exist.
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Affiliation(s)
- Fiona Wy Lai
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | | | - Andreas Hendarto
- Bairnsdale Regional Health Service, Bairnsdale, Victoria, Australia
| | - Antony Ugoni
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Melbourne, Victoria, Australia
| | - David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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10
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Rose M, Newton C, Boualam B, Bogne N, Ketchum A, Shah U, Mitchell J, Tanveer S, Lurie T, Robinson W, Duncan R, Thom S, Tran QK. Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection. World J Emerg Med 2019; 10:94-100. [PMID: 30687445 DOI: 10.5847/wjem.j.1920-8642.2019.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute aortic dissection (AoD) is a hypertensive emergency often requiring the transfer of patients to higher care hospitals; thus, clinical care documentation and compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) is crucial. The study assessed emergency providers (EP) documentation of clinical care and EMTALA compliance among interhospital transferred AoD patients. METHODS This retrospective study examined adult patients transferred directly from a referring emergency department (ED) to a quaternary academic center between January 1, 2011 and September 30, 2015. The primary outcome was the percentage of records with adequate documentation of clinical care (ADoCC). The secondary outcome was the percentage of records with adequate documentation of EMTALA compliance (ADoEMTALA). RESULTS There were 563 electronically identified patients with 287 included in the final analysis. One hundred and five (36.6%) patients had ADoCC while 166 (57.8%) patients had ADoEMTALA. Patients with inadequate documentation of EMTALA (IDoEMTALA) were associated with a higher likelihood of not meeting the American Heart Association (AHA) ED Departure SBP guideline (OR 1.8, 95% CI 1.03-3.2, P=0.04). Male gender, handwritten type of documentation, and transport by air were associated with an increased risk of inadequate documentation of clinical care (IDoCC), while receiving continuous infusion was associated with higher risk of IDoEMTALA. CONCLUSION Documentation of clinical care and EMTALA compliance by Emergency Providers is poor. Inadequate EMTALA documentation was associated with a higher likelihood of patients not meeting the AHA ED Departure SBP guideline. Therefore, Emergency Providers should thoroughly document clinical care and EMTALA compliance among this critically ill group before transfer.
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Affiliation(s)
- Mark Rose
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, USA
| | - Carina Newton
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, USA
| | | | - Nancy Bogne
- University of Maryland at College Park, College Park, USA
| | - Adam Ketchum
- University of Maryland at College Park, College Park, USA
| | - Umang Shah
- University of Maryland at College Park, College Park, USA
| | | | - Safura Tanveer
- University of Maryland at College Park, College Park, USA
| | - Tucker Lurie
- University of Maryland, School of Medicine, Baltimore, USA
| | - Walesia Robinson
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, USA
| | - Rebecca Duncan
- Program of Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, Baltimore, USA
| | - Stephen Thom
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, USA
| | - Quincy Khoi Tran
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, USA.,Program of Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, Baltimore, USA
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11
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Lorenzetti DL, Quan H, Lucyk K, Cunningham C, Hennessy D, Jiang J, Beck CA. Strategies for improving physician documentation in the emergency department: a systematic review. BMC Emerg Med 2018; 18:36. [PMID: 30558573 PMCID: PMC6297955 DOI: 10.1186/s12873-018-0188-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/12/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documentation often varies in terms of timeliness, legibility, clarity and completeness. While many educational and other approaches have been implemented in hospital settings, the extent to which these interventions can improve the quality of documentation in emergency departments (EDs) is unknown. METHODS We conducted a systematic review to assess the effectiveness of approaches to improve ED physician documentation. Peer reviewed electronic databases, grey literature sources, and reference lists of included studies were searched to March 2015. Studies were included if they reported on outcomes associated with interventions designed to enhance the quality of physician documentation. RESULTS Nineteen studies were identified that report on the effectiveness of interventions to improve physician documentation in EDs. Interventions included audit/feedback, dictation, education, facilitation, reminders, templates, and multi-interventions. While ten studies found that audit/feedback, dictation, pharmacist facilitation, reminders, templates, and multi-pronged approaches did improve the quality of physician documentation across multiple outcome measures, the remaining nine studies reported mixed results. CONCLUSIONS Promising approaches to improving physician documentation in emergency department settings include audit/feedback, reminders, templates, and multi-pronged education interventions. Future research should focus on exploring the impact of implementing these interventions in EDs with and without emergency medical record systems (EMRs), and investigating the potential of emerging technologies, including EMR-based machine-learning, to promote improvements in the quality of ED documentation.
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Affiliation(s)
- Diane L Lorenzetti
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N4N1, Canada.
| | - Hude Quan
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N4N1, Canada
| | - Kelsey Lucyk
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N4N1, Canada
| | - Ceara Cunningham
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N4N1, Canada
| | - Deirdre Hennessy
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N4N1, Canada
| | - Jason Jiang
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N4N1, Canada
| | - Cynthia A Beck
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N4N1, Canada
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Gerolamo AM, Jutel A, Kovalsky D, Gentsch A, Doty AM, Rising KL. Patient-Identified Needs Related to Seeking a Diagnosis in the Emergency Department. Ann Emerg Med 2018; 72:282-288. [DOI: 10.1016/j.annemergmed.2018.02.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/05/2018] [Accepted: 02/16/2018] [Indexed: 11/30/2022]
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Manias E, Gerdtz M, Williams A, McGuiness J, Dooley M. Communicating about the management of medications as patients move across transition points of care: an observation and interview study. J Eval Clin Pract 2016; 22:635-43. [PMID: 26762967 DOI: 10.1111/jep.12507] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2015] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES As patients move across transition points, effective medication management is critical for patient safety. The aims of this study were to examine how health professionals, patients and family members communicate about managing medications as patients moved across transition points of care and to identify possible sources of communication failure. METHOD A descriptive approach was used involving observations and interviews. The emergency departments and medical wards of two hospitals were involved. Observations focused on how health professionals managed medications during interactions with other health professionals, patients and family members, as patients moved across clinical settings. Follow-up interviews with participants were also undertaken. Thematic analysis was completed of transcribed data, and descriptive statistics were used to analyse characteristics of communication failure. RESULTS Three key themes were identified: environmental challenges, interprofessional relationships, and patient and family beliefs and responsibilities. As patients moved between environments, insufficient tracking occurred about medication changes. Before hospital admission, patients participated in self-care medication activities, which did not always involve exemplary behaviours or match the medications that doctors prescribed. During observations, 432 instances of communication failure (42.8%) were detected, which related to purpose, content, audience and occasion of the communication. CONCLUSIONS Extensive challenges exist involving the management of medications at transition points of care. Bedside handovers and ward rounds can be utilized as patient counselling opportunities about changes in the medication regimen. Greater attention is needed on how patients in the community make medication-related decisions.
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Affiliation(s)
- Elizabeth Manias
- School of Nursing and Midwifery, Deakin University, Melbourne, Victoria, Australia. .,Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia. .,Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.
| | - Marie Gerdtz
- Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Emergency Department, The Royal Melbourne Hospital, Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Allison Williams
- Monash Nursing Academy, Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Josephine McGuiness
- Pharmacy Department, The Alfred, Prahran, Victoria, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Michael Dooley
- Pharmacy Department, The Alfred, Prahran, Victoria, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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14
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Cabilan CJ, Eley RM. Review article: Potential of medical scribes to allay the burden of documentation and enhance efficiency in Australian emergency departments. Emerg Med Australas 2015; 27:507-511. [DOI: 10.1111/1742-6723.12460] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Cara J Cabilan
- Emergency Department; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Robert M Eley
- Emergency Department; Princess Alexandra Hospital; Brisbane Queensland Australia
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
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15
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Wimsett J, Harper A, Jones P. Review article: Components of a good quality discharge summary: a systematic review. Emerg Med Australas 2014; 26:430-8. [PMID: 25186466 DOI: 10.1111/1742-6723.12285] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The present study aims to inform the use of discharge summaries as a marker of the quality of communication between ED and primary care; this systematic review aims to identify a consensus on the key components of a high-quality discharge summary. METHOD A systematic search of the major medical and allied health databases and Google Scholar was conducted, using predetermined criteria for inclusion. Two authors independently reviewed the full texts of potentially relevant studies to determine eligibility for inclusion. Data were extracted using a standard form, and the level of evidence was assessed using a predetermined scale. RESULTS We screened 827 articles, and 84 articles underwent full-text review. Thirty-two studies were included, and 15 studies were level A or B studies. The agreement between authors for level of evidence was good: k = 0.62 (95% confidence interval [CI] 0.4-0.84) and for which components were included was 1011/1056, 95.7% (95% CI 94.3-96.8%). Thirty-four components were identified; however, only four were ranked as important by ≥80% of respondents or scored ≥80% on a scale of importance. These were: discharge diagnosis, treatment received, investigation results and follow-up plan. The quality of information contained in summaries was incompletely assessed in most studies. CONCLUSION The key components to include in a discharge summary are the discharge diagnosis, treatment received, results of investigations and the follow up required. The limited evidence pertaining to ED discharges was consistent with this. The adequacy of the components rather than just their presence or absence should also be considered when assessing the quality of discharge summaries.
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Affiliation(s)
- Jordon Wimsett
- Emergency Department, Wellington Hospital, Wellington, New Zealand
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Bell EJ, Takhar SS, Beloff JR, Schuur JD, Landman AB. Information technology improves Emergency Department patient discharge instructions completeness and performance on a national quality measure: a quasi-experimental study. Appl Clin Inform 2013; 4:499-514. [PMID: 24454578 DOI: 10.4338/aci-2013-07-ra-0046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 10/07/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To compare the completeness of Emergency Department (ED) discharge instructions before and after introduction of an electronic discharge instructions module by scoring compliance with the Centers for Medicare and Medicaid Services (CMS) Outpatient Measure 19 (OP-19). METHODS We performed a quasi-experimental study examining the impact of an electronic discharge instructions module in an academic ED. Three hundred patients discharged home from the ED were randomly selected from two time intervals: 150 patients three months before and 150 patients three to five months after implementation of the new electronic module. The discharge instructions for each patient were reviewed, and compliance for each individual OP-19 element as well as overall OP-19 compliance was scored per CMS specifications. Compliance rates as well as risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) comparing the overall OP-19 scores and individual OP-19 element scores of the electronic and paper-based discharge instructions were calculated. RESULTS The electronic discharge instructions had 97.3% (146/150) overall OP-19 compliance, while the paper-based discharge instructions had overall compliance of 46.7% (70/150). Electronic discharge instructions were twice as likely to achieve overall OP-19 compliance compared to the paper-based format (RR: 2.09, 95% CI: 1.75 - 2.48). The largest improvement was in documentation of major procedures and tests performed: only 60% of the paper-based discharge instructions satisfied this criterion, compared to 100% of the electronic discharge instructions (RD: 40.0%, 95% CI: 32.2% - 47.8%). There was a modest difference in medication documentation with 92.7% for paper-based and 100% for electronic formats (RD: 7.3%, 95% CI: 3.2% - 11.5%). There were no statistically significant differences in documentation of patient care instructions and diagnosis between paper-based and electronic formats. CONCLUSION With careful design, information technology can improve the completeness of ED patient discharge instructions and performance on the OP-19 quality measure.
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Affiliation(s)
| | | | - J R Beloff
- Brigham and Women's Hospital , Boston, MA
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Reis PGTDA, Nakakogue C, Nakakogue T, Nasr A, Tomasich FDS, Collaço IA. Orientações de alta: cartões padronizados ajudam na compreensão dos pacientes do pronto socorro? Rev Col Bras Cir 2013; 40:335-41. [DOI: 10.1590/s0100-69912013000400014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 10/20/2012] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: determinar se a adição de cartões padronizados de alta ilustrados melhora a compreensão dos pacientes do pronto socorro. MÉTODOS: estudo prospectivo, randomizado e intervencionista com uma amostra de 228 pacientes que receberam alta do pronto socorro. Todos os pacientes foram entrevistados e testados quanto ao grau de compreensão das orientações de alta, sendo que uma parte havia recebido a intervenção com cartões padronizados e outra não, constituindo o grupo controle. RESULTADOS: a média de orientações domiciliares do grupo que recebeu o cartão de alta foi superior ao do grupo controle, com significância estatística de p=0,009. Se fracionado tal dado segundo faixas etárias, aquela compreendida entre 16 e 35 anos, para ambos os sexos, foi a qual a média de orientações do grupo com o cartão é melhor, estatisticamente, do que a média do grupo controle (p=0,01). A diferença entre as médias de orientações entre o grupo controle e o cartão para os pacientes submetidos a procedimentos foi significativa estatisticamente (p= 0,02) e em uma estratificação segundo o número de procedimentos, a significância aumenta quando aquele é igual a 1 (p=0,001) e diminui quanto mais procedimentos são realizados. CONCLUSÃO: A instituição de cartões de alta padronizados foi associada com a melhoria na compreensão dos pacientes. Sem substituir as orientações verbais, que estabelecem o diálogo e a aproximação médico-paciente, os cartões figuram como elementos auxiliares, facilitando as orientações e entendimento do cuidado.
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O'Connor AE, Lukin WG, Brazil VA. Take a deep breath … and talk. Med J Aust 2013; 198:535. [DOI: 10.5694/mja12.11573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 02/01/2013] [Indexed: 11/17/2022]
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Bagnasco A, Tubino B, Piccotti E, Rosa F, Aleo G, Di Pietro P, Sasso L, Gambino L, Passalacqua D. Identifying and correcting communication failures among health professionals working in the Emergency Department. Int Emerg Nurs 2012. [PMID: 23207054 DOI: 10.1016/j.ienj.2012.07.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to identify effective corrective measures to ensure patient safety in the Paediatric Emergency Department (ED). METHODS In order to outline a clear picture of these risks, we conducted a Failure Mode and Effects Analysis (FMEA) and a Failure Mode, Effects, and Criticality Analysis (FMECA), at a Emergency Department of a Children's Teaching Hospital in Northern Italy. The Error Modes were categorised according to Vincent's Taxonomy of Causal Factors and correlated with the Risk Priority Number (RPN) to determine the priority criteria for the implementation of corrective actions. RESULTS The analysis of the process and outlining the risks allowed to identify 22 possible failures of the process. We came up with a mean RPN of 182, and values >100 were considered to have a high impact and therefore entailed a corrective action. CONCLUSIONS Mapping the process allowed to identify risks linked to health professionals' non-technical skills. In particular, we found that the most dangerous Failure Modes for their frequency and harmfulness were those related to communication among health professionals.
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Affiliation(s)
- Annamaria Bagnasco
- Health Sciences Department, University of Genoa, Via Pastore 1, 16132 Genova, Italy.
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