Standardization of Emergency Department Clinical Note Templates: A Retrospective Analysis across an Integrated Health System

BACKGROUND AND OBJECTIVE

 Clinical documentation is essential for conveying medical decision-making, communication between providers and patients, and capturing quality, billing, and regulatory measures during emergency department (ED) visits. Growing evidence suggests the benefits of note template standardization; however, variations in documentation practices are common. The primary objective of this study is to measure the utilization and coding performance of a standardized ED note template implemented across a nine-hospital health system.

METHODS

 This was a retrospective study before and after the implementation of a standardized ED note template. A multi-disciplinary group consensus was built around standardized note elements, provider note workflows within the electronic health record (EHR), and how to incorporate newly required medical decision-making elements. The primary outcomes measured included the proportion of ED visits using standardized note templates, and the distribution of billing codes in the 6 months before and after implementation.

RESULTS

 In the preimplementation period, a total of six legacy ED note templates were being used across nine EDs, with the most used template accounting for approximately 36% of ED visits. Marked variations in documentation elements were noted across six legacy templates. After the implementation, 82% of ED visits system-wide used a single standardized note template. Following implementation, we observed a 1% increase in the proportion of ED visits coded as highest acuity and an unchanged proportion coded as second highest acuity.

CONCLUSION

 We observed a greater than twofold increase in the use of a standardized ED note template across a nine-hospital health system in anticipation of the new 2023 coding guidelines. The development and utilization of a standardized note template format relied heavily on multi-disciplinary stakeholder engagement to inform design that worked for varied documentation practices within the EHR. After the implementation of a standardized note template, we observed better-than-anticipated coding performance.

5-Methylheptadecane: Sex Pheromone of the Broom Twig Miner, Leucoptera Spartifoliella, a Biological Control Agent for the Scotch Broom

The broom twig miner, Leucoptera spartifoliella (Hübner) is a highly specific biological control agent for the Scotch broom, Cytisus scoparius (L.). Cytisus scoparius has become a major invasive weed spreading in North America, South America, Australia and both the South and North Island of New Zealand, causing a major disturbance to the ecology of the area where it has been established. Currently, there is no tool available to monitor the population density, dispersal, and establishment of L. spartifoliella. This work was undertaken to identify the sex pheromone of L. spartifoliella and develop a monitoring tool for this biological control agent. Analysis of the extract of the female sex pheromone gland by gas chromatography/mass spectrometry and chemical ionization identified a single compound in the extract. Using the mass spectral data and synthesis of candidate compounds, this compound was identified as 5-methylheptadecane. In a field trapping trial, testing various doses (0.01, 0.1 and 1 mg) of 5-methylheptadecane and virgin females as a positive control, the highest male catch obtained was in traps baited with the 1 mg dose. When testing two releasing substrates for the pheromone (i.e. a glass vial containing a cotton ball and another containing white septum), the male catch in a trap baited with a glass vial with the cotton ball was significantly higher than in a trap baited with a white septum. The identification of the sex pheromone of L. spartifoliella will help to detect and determine population densities, distribution, and dispersal of L. spartifoliella.

N-(3-methylbutyl)butanamide: A novel amide in the venom of female social wasps, Vespula vulgaris

In New Zealand's ancient Fuscospora spp. or beech forests, two invasive Vespula social wasps Vespula vulgaris (L.) and Vespula germanica (F.) have become significant problems, adversely affecting native birds and invertebrate biodiversity. The nature of chemical communication in these two species is poorly understood, and this work was undertaken to identify the behaviourally active compounds in the venom of the common wasp, Vespula vulgaris (L.). Venom was removed from the stings of both workers and females and analyzed by coupled gas chromatography/electroantennographic detection (GC/EAD) and gas chromatography/mass spectrometry (GC/MS). Two compounds were present in the venom that consistently elicited EAD responses from the antennae of males and workers. Mass spectrometry analysis and syntheses of candidate structures revealed the structures to be N-(3-methylbutyl)acetamide (MBA) and N-(3-methylbutyl)butanamide (MBB). Gyne venom contains significantly larger amounts of MBA and MBB than worker venom. When these two compounds were tested in the field individually or as binary blends in combination with the known food odour (honeydew volatiles), only N-(3-methylbutyl)butanamide or blends containing this compound showed a strong repellent effect on workers to honeydew volatiles at all doses tested. This is the first report of the occurrence of N-(3-methylbutyl)butanamide in nature and the third amide to be identified in the venom of any social wasp. In addition, this work is the first to report the chemical analysis of the venom of V. vulgaris gyne. The repellency effect observed in this study of the venom compound suggests that our definition and understanding of the function of the alarm pheromone need to be reassessed.

Aerosol delivery of trail pheromone disrupts the foraging of the red imported fire ant, Solenopsis invicta

BACKGROUND

The fire ant, Solenopsis invicta, is one of the most aggressive and invasive species in the world. The trail pheromone Z,E-α-farnesene (91% purity) was prepared, and disruption of worker trail orientation was tested using an ethanol-based aerosol formulation presenting a single puff of this compound by airbrush and compressed air. Trail-following behaviour was recorded by overhead webcam and ants digitised before and after presentation of the aerosol treatment at four rates (1.6, 16, 160 and 1600 ng cm(-2)).

RESULTS

Ants preferred 110 ng cm(-1) over 11, 1.1 and 0.11 ng cm(-1) for trail following. Within seconds of presentation of 1600 ng cm(-2), the highest dose tested, trail disruption was observed. Disruption was evident as reduced arrival success and reduction in the trail integrity statistic (r(2)), as well as increased deviation from the trail (deg). The distribution of walking track angles was also flattened.

CONCLUSIONS

The feasibility of using aerosol for delivery of trail pheromone was demonstrated, but the need for high purity combined with the difficulty of commercial supply makes this technique impractical. However, the commercial production of Z,E-α-farnesene of high purity by industrial biotechnology or from (E)-nerolidol may be possible in future, which would facilitate further development of trail pheromone disruption of S. invicta.

Attraction and antennal response of the common wasp, Vespula vulgaris (L.), to selected synthetic chemicals in New Zealand beech forests

BACKGROUND

The common wasp, Vespula vulgaris (L.), and the German wasp, Vespula germanica (F.), are significant problems in New Zealand beech forests (Nothofagus spp.), adversely affecting native birds and invertebrate biodiversity. This work was undertaken to develop synthetic attractants for these species to enable more efficient monitoring and management.

RESULTS

Seven known wasp attractants (acetic acid, butyl butyrate, isobutanol, heptyl butyrate, octyl butyrate and 2,4-hexadienyl butyrate) were field tested, and only heptyl butyrate and octyl butyrate attracted significantly higher numbers of wasps than a non-baited trap. Accordingly, a series of straight-chain esters from methyl to decyl butyrate were prepared and field tested for attraction of social wasps. Peak biological activity occurred with hexyl butyrate, heptyl butyrate, octyl butyrate and nonyl butyrate. Polyethylene bags emitting approximately 18.4-22.6 mg day(-1) of heptyl butyrate were more attractive than polyethylene bags emitting approximately 14.7-16.8 mg day(-1) of heptyl butyrate in the field. Electroantennogram (EAG) studies indicated that queens and workers of V. vulgaris had olfactory receptor neurons responding to various aliphatic butyrates.

CONCLUSION

These results are the first to be reported on the EAG response and the attraction of social wasps to synthetic chemicals in New Zealand beech forests and will enable monitoring of social wasp activity in beech forests.

(Z)-11-Hexadecenal and (3Z,6Z,9Z)-tricosatriene: sex pheromone components of the red banded mango caterpillar Deanolis sublimbalis

The sex pheromone of the red banded mango caterpillar, Deanolis sublimbalis (Lepidoptera: Crambidae), a serious pest of the mango Mangifera indica (Anacardiaceae) in India and Southeast Asia and a recent invader into northern Australia, has been identified. Three candidate compounds were identified from pheromone gland extracts of female moths, using gas chromatography (GC), GC-electroantennographic detection and GC-mass spectrometric analyses, in conjunction with dimethyldisulfide derivatization. Field bioassays established that both (Z)-11-hexadecenal (Z11-16:Ald) and (3Z,6Z,9Z)-tricosatriene (3Z,6Z,9Z-23:Hy) were required for attraction of male D. sublimbalis moths, and 1000 microg of a 1:1 mix of Z11-16:Ald and 3Z,6Z,9Z-23:Hy was more attractive to male moths than caged virgin females. However, the binary blend was only attractive when the isomeric purity of the monounsaturated aldehyde was >99%, suggesting that the (E)-isomer was inhibitory. Although (Z)-11-hexadecen-1-ol (Z11-16:OH) was tentatively identified in gland extracts, the addition of this compound to the binary blend did not increase the numbers of moths captured. The pheromone can now be used in integrated pest management strategies.

(Z)-7-tricosene and monounsaturated ketones as sex pheromone components of the Australian guava moth Coscinoptycha improbana: identification, field trapping, and phenology

Pheromone gland extracts of the Australian guava moth Coscinoptycha improbana (Lepidoptera: Carposinidae), contained four compounds that elicited responses from male moth antennae in gas chromatography-electroantennogram detection (GC-EAD) analyses. These were identified by GC-mass spectrometry as (Z)-7-tricosene (Z7-23Hy), (Z)-7-octadecen-11-one (Z7-11-one-18Hy), (Z)-7-nonadecen-11-one (Z7-11-one-19Hy), and (Z)-7-tricosen-11-one (Z7-11-one-23Hy) at a ratio of 65:23.5:1.5:10, respectively. Z7-23Hy, Z7-11-one-18Hy, and Z7-11-one-23Hy have not previously been reported as lepidopteran sex pheromone components. Z7-11-one-18Hy was active as a single component, and was synergized by Z7-11-one-23Hy but not Z7-11-one-19Hy, although the latter compound was weakly attractive as a single component. Addition of Z7-23Hy further increased attraction. The amount of the major pheromone component, Z7-11-one-18Hy in female pheromone gland extracts was estimated to be 16.4 ng/female (N = 8). Phenological data gathered over a 12-mo period in 2002 and 2003 using the binary blend indicated that moths are active throughout the year. The pheromone has already been employed to monitor the spread of C. improbana in New Zealand and detect its presence in Queensland, Australia.

Identification of sex pheromone components of the painted apple moth: a tussock moth with a thermally labile pheromone component

The sex pheromone of the painted apple moth, Teia anartoides (Lymantriidae) was investigated using GC-EAD and GC-MS analysis, derivatization, TLC analysis, and field cage and field trapping bioassays. The major sex pheromone components were identified as (6Z,9Z)-henicosa-6,9-dien-11-one and (6Z,9Z)-henicosa-6,9-diene. Other minor components of pheromone gland extracts included (6Z)-9R, 10S-epoxyeicos-6-ene, (6Z)-9R,10S-epoxyhenicos-6-ene, (6Z,9Z)-henicosa-6,9-dien-11-ol, (6Z)-henicos-6-en-11-one, and (6Z, 8E)-henicosa-6,8-dien-11-one, but the roles of these minor components remain equivocal. In field cage and field experiments, a blend of all seven identified components [(6Z,9Z)-henicosa-6,9-dien-11-one (relative amount 100), (6Z,9Z)-henicosa-6,9-diene (100), (6Z)-9R,10S-epoxyeicos-6-ene (5), (6Z)-9R,10S-epoxyhenicos-6-ene (10), (6Z,9Z)-henicosa-6,9-dien-11-ol (5), (6Z)-henicos-6-en-11-one (1), and (6Z,8E)-henicosa-6,8-dien-11-one (25)] was as attractive to males as calling females, but tests with blends of the major component(s) with subsets of the minor components did not produce consistent results that unequivocally showed the various minor components to be critical components of the active blend. (6Z,9Z)-henicosa-6,9-dien-11-one is thermally labile and rearranges to (6Z,8E)-henicosa-6,8-dien-1-one and other products at ambient temperature, rendering the synthetic pheromone lure inactive after two days of field exposure.

Flexibility of technopolymer clasps compared with cobalt-chromium and titanium clasps

Patients often cite lack of retention and poor aesthetics as reasons for not wearing their partial dentures. Traditional metal alloy clasps have been shown to exert forces on abutment teeth that exceed those capable of producing tooth movement. In addition, metal display on anterior teeth is often unacceptable. The technopolymer materials are purported to have superior flexibility and exert less force than the metals. This study compared the flexibility and forces produced by technopolymer clasps with those exerted by cobalt-chromium and titanium clasps. The results showed that the technopolymer clasps were up to ten times as flexible as the metal clasps, and they returned to their pretest dimensions after being stretched. In addition, they exerted forces on the abutment teeth that fall within the range of those considered safe for use. This coupled with their pleasing aesthetics makes them suitable for use on periodontally compromised teeth, those with deep undercuts and on anterior teeth.