Improved documentation of wound care with a structured encounter form in the pediatric emergency department

Assessing the reliability of pediatric emergency medicine billing code assignment for future consideration as a proxy workload measure

OBJECTIVES

Prediction of pediatric emergency department (PED) workload can allow for optimized allocation of resources to improve patient care and reduce physician burnout. A measure of PED workload is thus required, but to date no variable has been consistently used or could be validated against for this purpose. Billing codes, a variable assigned by physicians to reflect the complexity of medical decision making, have the potential to be a proxy measure of PED workload but must be assessed for reliability. In this study, we investigated how reliably billing codes are assigned by PED physicians, and factors that affect the inter-rater reliability of billing code assignment.

METHODS

A retrospective cross-sectional study was completed to determine the reliability of billing code assigned by physicians (n = 150) at a quaternary-level PED between January 2018 and December 2018. Clinical visit information was extracted from health records and presented to a billing auditor, who independently assigned a billing code-considered as the criterion standard. Inter-rater reliability was calculated to assess agreement between the physician-assigned versus billing auditor-assigned billing codes. Unadjusted and adjusted logistic regression models were used to assess the association between covariables of interest and inter-rater reliability.

RESULTS

Overall, we found substantial inter-rater reliability (AC2 0.72 [95% CI 0.64-0.8]) between the billing codes assigned by physicians compared to those assigned by the billing auditor. Adjusted logistic regression models controlling for Pediatric Canadian Triage and Acuity scores, disposition, and time of day suggest that clinical trainee involvement is significantly associated with increased inter-rater reliability.

CONCLUSIONS

Our work identified that there is substantial agreement between PED physician and a billing auditor assigned billing codes, and thus are reliably assigned by PED physicians. This is a crucial step in validating billing codes as a potential proxy measure of pediatric emergency physician workload.

Orthopaedic Resident Use of an Electronic Medical Record Template Does Not Improve Documentation for Pediatric Supracondylar Humerus Fractures

INTRODUCTION

Pediatric supracondylar humerus fractures are associated with a high incidence of nerve injury. Therefore, it is imperative that documentation be complete and accurate. This investigation compares orthopaedic resident history and physical (H&P) documentation of pediatric supracondylar fractures for completeness and accuracy with and without the use of an electronic medical record template.

METHODS

The electronic medical record H&P documentation of 119 supracondylar humerus fractures surgically treated at a single pediatric institution was retrospectively reviewed. Templated and nontemplated groups were compared for documentation completeness and accuracy. Definitive diagnosis of a nerve palsy was made by a supervising orthopaedic attending surgeon.

RESULTS

Forty-two cases had a templated H&P and 77 did not. The H&P documentation in the templated group was markedly more complete than that in the nontemplated group. However, the accuracy of the H&P documentation to identify nerve palsy was not statistically different between the two groups. Overall, the voluntary use of the orthopaedic template declined over time.

CONCLUSION

Resident use of an orthopaedic template for documenting the H&P of pediatric supracondylar humerus fractures compared with nontemplated notes resulted in more complete documentation but only comparable accuracy.

LEVEL OF EVIDENCE

III.

A Review of Data Quality Assessment in Emergency Medical Services

INTRODUCTION

Data quality is an important issue in emergency medicine. The unique characteristics of emergency care services, such as high turn-over and the speed of work may increase the possibility of making errors in the related settings. Therefore, regular data quality assessment is necessary to avoid the consequences of low quality data. This study aimed to identify the main dimensions of data quality which had been assessed, the assessment approaches, and generally, the status of data quality in the emergency medical services.

METHODS

The review was conducted in 2016. Related articles were identified by searching databases, including Scopus, Science Direct, PubMed and Web of Science. All of the review and research papers related to data quality assessment in the emergency care services and published between 2000 and 2015 (n=34) were included in the study.

RESULTS

The findings showed that the five dimensions of data quality; namely, data completeness, accuracy, consistency, accessibility, and timeliness had been investigated in the field of emergency medical services. Regarding the assessment methods, quantitative research methods were used more than the qualitative or the mixed methods. Overall, the results of these studies showed that data completeness and data accuracy requires more attention to be improved.

CONCLUSION

In the future studies, choosing a clear and a consistent definition of data quality is required. Moreover, the use of qualitative research methods or the mixed methods is suggested, as data users' perspectives can provide a broader picture of the reasons for poor quality data.

Does incorporation of a clinical support template in the electronic medical record improve capture of wound care data in a cohort of veterans with diabetic foot ulcers?

PURPOSE

The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention.

METHODS

From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding.

RESULTS

The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ = 15.99, P < .001), complete documentation of coding for diagnoses and procedures (χ = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures (χ = 14.96, P < .001).

CONCLUSIONS

An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.

Clinician identification of youth abusing over-the-counter products for weight control in a large U.S. integrated health system

BACKGROUND

Abuse of over-the-counter (OTC) products, such as diet pills and laxatives, for weight control by adolescents is well-documented and can precipitate serious medical conditions. Yet only a small percentage of youth with disordered weight control behaviors receive treatment. The objective of this study was to examine how often clinicians communicate with youth with symptoms consistent with abuse of OTC products for weight control about possible use of these products. We used electronic medical records and administrative claims for services for 53,229 12 to 17 year old patients receiving care from an integrated health system in the U.S. Northwest from August 2007 to December 2010. We examined electronic text of clinical notes to identify encounters in which the clinician noted one of 10 metabolic conditions potentially associated with abuse of OTC products (diet pills, laxatives, diuretics, ipecac, orlistat, and alli®) for weight control and then assessed whether clinicians noted communication with adolescent patients about possible use of OTC products for weight control.

RESULTS

We identified 130 (0.2% of sample) patients with clinical notes indicating one or more of the metabolic conditions. In clinical notes for only four (3.1%) of these patients did clinicians document suspicion or communication about possible abuse of the OTC products. All four had a previous eating disorder diagnosis. In the 12 months subsequent to the clinical encounter in which a metabolic disturbance was identified, medical notes for only three (2.3%) of the 130 patients indicated clinician suspicion or communication about possible abuse of these products or an eating disorder.

CONCLUSIONS

Clinicians are missing a critical window of opportunity to query adolescents when presenting with suspicious metabolic disturbances about possible abuse of OTC products for weight control. Clinicians may need more training to detect OTC product abuse, and electronic medical records should prompt more thorough enquiry.

Junior doctor skill in the art of physical examination: a retrospective study of the medical admission note over four decades

OBJECTIVES

To investigate the hypothesis that junior doctors' examination skills are deteriorating by assessing the medical admission note examination record.

DESIGN

Retrospective study of the admission record.

SETTING

Tertiary care hospital.

METHODS

The admission records of 266 patients admitted to Wellington hospital between 1975 and 2011 were analysed, according to the total number of physical examination observations (PEOtot), examination of the relevant system pertaining to the presenting complaint (RelSystem) and the number of body systems examined (Nsystems). Subgroup analysis proceeded according to admission year, level of experience of the admitting doctor (registrar, house surgeon (HS) and trainee intern (TI)) and medical versus surgical admission notes. Further analysis investigated the trend over time in documentation with respect to cardiac murmurs, palpable liver, palpable spleen, carotid bruit, heart rate, funduscopy and apex beat location and character.

RESULTS

PEOtot declined by 34% from 1975 to 2011. Surgical admission notes had 21% fewer observations than medical notes. RelSystem occurred in 94% of admissions, with no decline over time. Medical notes documented this more frequently than surgical notes (98% and 86%, respectively). There were no differences between registrars and HS, except for the 2010s subgroup (97% and 65%, respectively). Nsystems declined over the study period. Medical admission notes documented more body systems than surgical notes. There were no differences between registrars, HSs and TIs. Fewer examinations were performed for palpable liver, palpable spleen, cardiac murmur and apex beat location and character over the study period. There was no temporal change in the positive findings of these observations or heart rate rounding.

CONCLUSIONS

There has been a decline in the admission record at Wellington hospital between 1975 and 2011, implying a deterioration in local doctors' physical examination skills. Measures to counter this trend are discussed.

Use of templates for clinical documentation in psychiatric evaluations-beneficial or counterproductive for residents in training?

In psychiatry, as in other disciplines, electronic templates are replacing handwritten records to meet health care financing regulations and requirements of third-party payers. We address whether these checklists are helpful for residents, especially those beginning training, in learning the foundational skills of their discipline and in recording a comprehensive set of patient data. An informal survey of our residents suggests that residents find the templates useful, though they have advantages and disadvantages. We also review relevant literature from psychiatry and other fields on the use of electronic templates and pose questions about how we might gauge the usefulness of the templates in residents' training and in obtaining valid data for clinical decision-making.

A study of the difference in volume of information in chief complaint and present illness between electronic and paper medical records

The introduction of an electronic medical record (EMR) has been rapidly accelerating in South Korea. The EMR was expected to improve quality of care, readability, availability, and the quality of data. However, the reluctance of healthcare providers to use the EMR may have caused a reduction of information recorded in EMRs. The purpose of this study was to identify whether there was any loss of information following the introduction of a narrative text-based EMR in the recording of chief complaint and present illness in inpatient medical records. Inpatient medical records of a university hospital were retrospectively evaluated for one month before and one month after the introduction of the EMR in June 2006. The volume of information for chief complaint and present illness was measured by number of words in Korean and normalised bytes. Change in volume of information was measured by two-way ANOVA and multiple regression analyses, controlling for doctors' gender, age, and grade/year of residents, patients' readmission status, reasons for admission and service department to assess any effect of the introduction of an EMR. Total numbers of paper-based medical records (PMRs) and EMRs for analysis were 1,159 and 1,122, respectively. Forty-three doctors participated in the study. Thirty-one (72%) doctors were less than 30 years of age. Number of words proved a better outcome measure (R²=22 for CC, R²=36 for PI) than normalised bytes (R²=18 for CC, R²=35 for PI) for measuring volume of information. Results showed that the volume of information in the chief complaint and present illness was not decreased after the introduction of the EMR, except when the dependent variable was measured by number of words in the present illness. The study showed that the introduction of the EMR did not reduce the volume of information documented for chief complaint and present illness in inpatient medical records. However, further studies are needed to identify how to control the probable loss of information as showed in present illness measured by number of words.

Emergency department documentation templates: variability in template selection and association with physical examination and test ordering in dizziness presentations

Background

Clinical documentation systems, such as templates, have been associated with process utilization. The T-System emergency department (ED) templates are widely used but lacking are analyses of the templates association with processes. This system is also unique because of the many different template options available, and thus the selection of the template may also be important. We aimed to describe the selection of templates in ED dizziness presentations and to investigate the association between items on templates and process utilization.

Methods

Dizziness visits were captured from a population-based study of EDs that use documentation templates. Two relevant process outcomes were assessed: head computerized tomography (CT) scan and nystagmus examination. Multivariable logistic regression was used to estimate the probability of each outcome for patients who did or did not receive a relevant-item template. Propensity scores were also used to adjust for selection effects.

Results

The final cohort was 1,485 visits. Thirty-one different templates were used. Use of a template with a head CT item was associated with an increase in the adjusted probability of head CT utilization from 12.2% (95% CI, 8.9%-16.6%) to 29.3% (95% CI, 26.0%-32.9%). The adjusted probability of documentation of a nystagmus assessment increased from 12.0% (95%CI, 8.8%-16.2%) when a nystagmus-item template was not used to 95.0% (95% CI, 92.8%-96.6%) when a nystagmus-item template was used. The associations remained significant after propensity score adjustments.

Conclusions

Providers use many different templates in dizziness presentations. Important differences exist in the various templates and the template that is used likely impacts process utilization, even though selection may be arbitrary. The optimal design and selection of templates may offer a feasible and effective opportunity to improve care delivery.

Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review

BACKGROUND

Quality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs.

METHODS

The review was based on a PubMed search of all articles reporting an outcome from a trauma QI program.

RESULTS

Thirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings.

CONCLUSIONS

Trauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes.

Bicycle injury documentation before and after charting intervention

BACKGROUND

Previous studies have shown that routinely completed free-text emergency department medical records contain limited information necessary for injury surveillance. We instituted an injury documentation sheet into our emergency department records to evaluate the impact on completeness of bicycle injury documentation rates.

METHODS

The pretest/posttest study design used E-codes to identify bicycle-related injuries. A standardized data collection tool was utilized to review these charts. Time periods before (January 1 to December 31, 2004) and after (January 1 to June 30, 2005) institution of a standardized documentation sheet were reviewed. Data were entered into the computer program, Epistat, and scores were used for comparison.

RESULTS

Initial review (n = 667) revealed mean age of patients 8.6 years, with 46% African American and 67% male. Helmet usage was documented in 49% of the charts (81 were wearing helmets; 245 were not wearing helmets). Mechanism of injury was documented as bicycle alone in 587, bicycle versus car in 13, and bicycle versus stationary object in 64. After implementation of an injury data sheet (n = 205), it was found that the mean age was 9.24 years, with 51% African American and 43% male. Helmet use was documented in 77% of cases (26 wearing helmets; 132 not wearing). Mechanism was documented as bicycle alone in 125, bicycle versus car in 66, and bicycle versus stationary object in 14. Helmet use was much more frequently documented after the initiation of an injury documentation reminder sheet (z = 6.97; P < 0.001; 95% confidence interval, 20.2-35.8).

CONCLUSION

The use of standard injury documentation prompts increased completeness of documentation. With improved documentation, more accurate injury surveillance can be performed.