ISCEV standard for clinical pattern electroretinography (2024 update)

The pattern electroretinogram (PERG) is a localized retinal response evoked by a contrast-reversing pattern, usually a black and white checkerboard, which provides information about macular and retinal ganglion cell function. This document, from the International Society for Clinical Electrophysiology of Vision (ISCEV; www.iscev.org ) presents an updated and revised Standard for clinical PERG testing. This replaces the 2013 and all earlier versions. Minimum protocols for basic PERG stimuli, recording methods and reporting are specified, to promote consistency of methods for diagnosis and monitoring purposes, while responding to evolving clinical practices and technology. The main changes in the updated ISCEV Standard for clinical PERG include expanded guidance about large stimulus fields, stimulus parameters for simultaneous PERG and pattern visual evoked potential recording, baseline drift correction, and use of consistent ambient room lighting. These changes aim to provide a clinically relevant document about current practice which will facilitate good quality recordings and inter-laboratory comparisons.

Benefit-Risk Assessment of mRNA COVID-19 Vaccines in Children Aged 6 Months to 4 Years in the Omicron Era

BACKGROUND

There is no risk and benefit assessment of COVID-19 vaccination for children younger than 5 years using a single health outcomes scale. The objective of this study is to compare the expected risk and benefits of the mRNA primary series of COVID-19 vaccines for children aged 6 months to 4 years in the United States using a single health outcome scale in the Omicron era.

METHODS

The expected benefits and risks of the primary two-dose series of mRNA COVID-19 vaccines for children aged 6 months to 4 years were stratified by sex, the presence of underlying medical conditions, the presence of infection-induced immunity, and the type of mRNA vaccine (BNT162b2 or mRNA-1273). A scoping literature review was conducted to identify the indicators in the decision tree model. The benefit-risk ratio was the outcome of interest.

RESULTS

The benefit-risk ratios ranged from 200.4 in BNT162b2 for males aged 6-11 months with underlying medical conditions and without infection-induced immunity to 3.2 in mRNA-1273 for females aged 1-4 years without underlying medical conditions and with infection-induced immunity.

CONCLUSIONS

The expected benefit of receiving the primary series of mRNA vaccines outweighed the risk among children ages 6 months to 4 years regardless of sex, presence of underlying medical conditions, presence of infection-induced immunity, or type of mRNA vaccines. However, the continuous monitoring of the COVID-19 epidemiology as well as vaccine effectiveness and safety is important.

ISCEV and IPS guideline for the full-field stimulus test (FST)

The full-field stimulus test (FST) is a psychophysical technique designed for the measurement of visual function in low vision. The method involves the use of a ganzfeld stimulator, as used in routine full-field electroretinography, to deliver full-field flashes of light. This guideline was developed jointly by the International Society for Clinical Electrophysiology of Vision (ISCEV) and Imaging and Perimetry Society (IPS) in order to provide technical information, promote consistency of testing and reporting, and encourage convergence of methods for FST. It is intended to aid practitioners and guide the formulation of FST protocols, with a view to future standardisation.

7 Scoping review of homonymous hemianopia in childhood

Cerebral visual impairment (CVI) encompasses a heterogeneous group of disorders and a spectrum of types of visual impairments. Research is needed to characterise the different forms of CVI and identify the specific needs of these groups to inform individualised patient care. Homonymous hemianopia (HH) is a definable visual field defect that affect some children with CVI. As part of a new research programme, we conducted a scoping review of the literature on HH in children and young people to map current knowledge and identify evidence gaps.We used the PRISMA extension for Scoping Reviews methodology. Multiple online databases were searched using terms associated with 'homonymous hemianopia' and 'children'. This yielded 1588 papers which were screened by two reviewers. Of these 1001 were excluded at abstract screen and a further 415 excluded after full text review, with full text unavailable for 15. Data were extracted and charted from 157 studies and additional grey literature.Interim analysis shows reported studies are predominantly from high income countries with a paucity of higher-level evidence, and a preponderance of case reports. Most papers reported causative pathology and diagnosis of HH. There was minimal attention to or evidence relating to intervention. Child-specific grey literature on HH was limited.This review collates the current evidence-base for HH in children. It demonstrates the important evidence-gap relating to intervention in these cases that would help inform more individualised care. Similar scoping reviews may be prove useful in assessing the evidence relating to other definable groups within the CVI umbrella.

Risk and Benefit of mRNA COVID-19 Vaccines for the Omicron Variant by Age, Sex, and Presence of Comorbidity: A Quality-Adjusted Life Years Analysis

The development of the mutant omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the coronavirus disease 2019 (COVID-19) pandemic raised the importance of reevaluating the risk and benefit of COVID-19 vaccines. With a decision tree model, we calculated the benefit-risk ratio and the benefit-risk difference of receiving monovalent messenger RNA (mRNA) COVID-19 vaccine (primary 2 doses, a third dose, and a fourth dose) in the 4-5 months after vaccination using quality-adjusted life years. The analysis was stratified by age, sex, and the presence of comorbidity. Evidence from peer-reviewed publications and gray literature was reviewed on September 16, 2022, to inform the study. Benefit-risk ratios for receipt of the BNT162b2 vaccine (Pfizer-BioNTech) ranged from 6.8 for males aged 12-17 years without comorbidity for the primary doses to 221.3 for females aged ≥65 years with comorbidity for the third dose. The benefit-risk ratios for receipt of the mRNA-1273 vaccine (Moderna) ranged from 7.2 for males aged 18-29 years without comorbidity for the primary doses to 101.4 for females aged ≥65 years with comorbidity for the third dose. In all scenarios of the one-way sensitivity analysis, the benefit-risk ratios were more than 1, irrespective of age, sex, comorbidity status, and type of vaccine, for both primary and booster doses. The benefits of mRNA COVID-19 vaccines in protecting against the omicron variant outweigh the risks, irrespective of age, sex, and comorbidity.

Visual outcomes and predictors in optic pathway glioma: a single centre study

BACKGROUND/AIMS

Optic pathway gliomas (OPGs) may cause progressive visual loss despite chemotherapy. Newer, less toxic treatments might be given earlier, depending on visual prognosis. We aimed to investigate the prognostic value of visual evoked potentials (VEP) and optical coherence tomography (OCT).

METHODS

A retrospective study of OPG patients (treated 2003-2017) was conducted. Primary outcome was PEDIG category visual acuity in better and worse eyes (good < = 0.2, moderate 0.3-0.6 and poor > = 0.7 logMAR). Binary logistic regression analysis was used to identify predictors of these outcomes.

RESULTS

60 patients (32 Neurofibromatosis type 1 [NF1] and 28 sporadic) had median presentation age 49 months (range 17-183) (NF1) and 27 months (range 4-92) (sporadic). Median follow up was 82 months (range 12-189 months). At follow up 24/32 (75%) of NF1 children and 14/28 (50%) of sporadic children had good better eye visual acuity and 11/32 (34%) of NF1 children and 15/28 (54%) of sporadics had poor worse eye acuity. Mean peripapillary retinal nerve fibre layer (RNFL) thickness predicted good better eye final acuity (OR 0.799, 95%CI 0.646-0.987, p = 0.038). Presenting with visual symptoms (OR 0.22 95% CI 0.001-0.508, p = 0.017) and poorer VEP scores (OR 2.35 95% CI 1.1-5.03, p = 0.027) predicted poor worse eye final acuity. 16 children had homonymous hemianopias at follow up, predicted by poor presenting binocular VEP score (OR 1.449 95%CI 1.052-1.995, p = 0.02).

CONCLUSIONS

We found that both RNFL thickness on OCT and VEP were useful in predicting future visual acuity and vision and potentially in planning treatment. We had a high prevalence of homonymous hemianopia.

Designing Practical Motivational Interviewing Training for Mental Health Practitioners Implementing Behavioral Lifestyle Interventions: Protocol for 3 Pilot Intervention Studies

BACKGROUND

Motivational interviewing (MI) is an evidence-based, patient-centered communication method shown to be effective in helping persons with serious mental illness (SMI) to improve health behaviors. In clinical trials where study staff conducted lifestyle interventions incorporating an MI approach, cardiovascular disease (CVD) risk profiles of participants with SMI showed improvement. Given the disproportionate burden of CVD in this population, practitioners who provide somatic and mental health care to persons with SMI are ideally positioned to deliver patient-centered CVD risk reduction interventions. However, the time for MI training (traditionally 16-24 hours), follow-up feedback, and the coaching required to develop and maintain patient-centered skills are significant barriers to incorporating MI when scaling up these evidence-based practices.

OBJECTIVE

We describe the design and development of the following 2 scalable MI training approaches for community mental health practitioners: real-time brief workshops and follow-up asynchronous avatar training. These approaches are being used in 3 different pilot implementation research projects that address weight loss, smoking cessation, and CVD risk reduction in people with SMI who are a part of ALACRITY Center, a research-to-practice translation center funded by the National Institute of Mental Health.

METHODS

Clinicians and staff in community mental health clinics across Maryland were trained to deliver 3 distinct evidence-based physical health lifestyle interventions using an MI approach to persons with SMI. The real-time brief MI workshop training for ACHIEVE-D weight loss coaches was 4 hours; IMPACT smoking cessation counselors received 2-hour workshops and prescribers received 1-hour workshops; and RHYTHM CVD risk reduction program staff received 4 hours of MI. All workshop trainings occurred over videoconference. The asynchronous avatar training includes 1 common didactic instructional module for the 3 projects and 1 conversation simulation unique to each study's target behavior. Avatar training is accessible on a commercial website. We plan to assess practitioners' attitudes and beliefs about MI and evaluate the impact of the 2 MI training approaches on their MI skills 3, 6, and 12 months after training using the MI Treatment Integrity 4.2.1 coding tool and the data generated by the avatar-automated scoring system.

RESULTS

The ALACRITY Center was funded in August 2018. We have implemented the MI training for 126 practitioners who are currently delivering the 3 implementation projects. We expect the studies to be complete in May 2023.

CONCLUSIONS

This study will contribute to knowledge about the effect of brief real-time training augmented with avatar skills practice on clinician MI skills. If MI Treatment Integrity scoring shows it to be effective, brief videoconference trainings supplemented with avatar skills practice could be used to train busy community mental health practitioners to use an MI approach when implementing physical health interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44830.

Crosstalk between CD4+ T Cells and Airway Smooth Muscle in Pediatric Obesity-related Asthma

Rationale: Pediatric obesity-related asthma is a nonatopic asthma phenotype with high disease burden and few effective therapies. RhoGTPase upregulation in peripheral blood T helper (Th) cells is associated with the phenotype, but the mechanisms that underlie this association are not known. Objectives: To investigate the mechanisms by which upregulation of CDC42 (Cell Division Cycle 42), a RhoGTPase, in Th cells is associated with airway smooth muscle (ASM) biology. Methods: Chemotaxis of obese asthma and healthy-weight asthma Th cells, and their adhesion to obese and healthy-weight nonasthmatic ASM, was investigated. Transcriptomics and proteomics were used to determine the differential effect of obese and healthy-weight asthma Th cell adhesion to obese or healthy-weight ASM biology. Measurements and Main Results: Chemotaxis of obese asthma Th cells with CDC42 upregulation was resistant to CDC42 inhibition. Obese asthma Th cells were more adherent to obese ASM compared with healthy-weight asthma Th cells to healthy-weight ASM. Compared with coculture with healthy-weight ASM, obese asthma Th cell coculture with obese ASM was positively enriched for genes and proteins involved in actin cytoskeleton organization, transmembrane receptor protein kinase signaling, and cell mitosis, and negatively enriched for extracellular matrix organization. Targeted gene evaluation revealed upregulation of IFNG, TNF (tumor necrosis factor), and Cluster of Differentiation 247 (CD247) among Th cell genes, and of Ak strain transforming (AKT), Ras homolog family member A (RHOA), and CD38, with downregulation of PRKCA (Protein kinase C-alpha), among smooth muscle genes. Conclusions: Obese asthma Th cells have uninhibited chemotaxis and are more adherent to obese ASM, which is associated with upregulation of genes and proteins associated with smooth muscle proliferation and reciprocal nonatopic Th cell activation.

Scaling Evidence-Based Interventions to Improve the Cardiovascular Health of People With Serious Mental Illness

People with serious mental illnesses (SMIs) experience excess mortality, driven in large part by high rates of cardiovascular disease (CVD), with all cardiovascular disease risk factors elevated. Interventions designed to improve the cardiovascular health of people with SMI have been shown to lead to clinically significant improvements in clinical trials; however, the uptake of these interventions into real-life clinical settings remains limited. Implementation strategies, which constitute the "how to" component of changing healthcare practice, are critical to supporting the scale-up of evidence-based interventions that can improve the cardiovascular health of people with SMI. And yet, implementation strategies are often poorly described and rarely justified theoretically in the literature, limiting the ability of researchers and practitioners to tease apart why, what, how, and when implementation strategies lead to improvement. In this Perspective, we describe the implementation strategies that the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness is using to scale-up three evidenced-based interventions related to: (1) weight loss; (2) tobacco smoking cessation treatment; and (3) hypertension, dyslipidemia, and diabetes care for people with SMI. Building on concepts from the literature on complex health interventions, we focus on considerations related to the core function of an intervention (i.e., or basic purposes of the change process that the health intervention seeks to facilitate) vs. the form (i.e., implementation strategies or specific activities taken to carry out core functions that are customized to local contexts). By clearly delineating how implementation strategies are operationalized to support the interventions' core functions across these three studies, we aim to build and improve the future evidence base of how to adapt, implement, and evaluate interventions to improve the cardiovascular health of people with SMI.

What is in? What is out? Updating the British Society for Cutaneous Allergy facial series

BACKGROUND

Allergic contact dermatitis (ACD) to cosmetics is widely reported. To ensure we are accurately diagnosing ACD, patch test series should be continually reviewed to identify relevant and emerging allergens and highlight those that are outdated. The current British Society for Cutaneous Allergy (BSCA) facial series recommends 26 allergens and was last modified in 2012.

OBJECTIVES

To review and update the BSCA facial series.

METHODS

We retrospectively reviewed the results from 12 UK and Ireland patch test centres' facial series from January 2016 to December 2017. We recorded the number of allergens tested in each centre and the detection rate for each allergen. Using a 0·3% positive rate as the inclusion threshold, we established which allergens in the BSCA facial series had positive patch test rates < 0·3% and > 0·3%. Allergens not in the BSCA facial series that had a positive patch test rate > 0·3% were identified.

RESULTS

Overall, 4224 patients were patch tested to the facial series. The number of allergens included in individual centres' facial series ranged from 24 to 66, with a total of 103 allergens tested across all centres. Twelve of the 26 allergens in the BSCA facial series had a positive patch test rate < 0·3% and 14 had a rate > 0·3%. Twenty-five allergens not recommended in the BSCA facial series had a positive patch test rate > 0·3%.

CONCLUSIONS

This audit has highlighted the significant variation in practice that exists among patch test centres, despite a recommended facial series. The BSCA facial series has been updated and now contains 24 allergens. Fifteen allergens remain, 11 allergens have been dropped and nine new allergens have been added.

Reducing Three Infections Across Cardiac Surgery Programs: A Multisite Cross-Unit Collaboration

Using a pre–post design, this study examined the impact of a multifaceted program to simultaneously improve 3 health care–associated infections and patient safety culture throughout the cardiac surgery service line in 11 hospitals. Interventions included the Comprehensive Unit-based Safety Program to improve safety culture and evidence-based bundles to prevent central line–associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated pneumonia (VAP). CLABSIs and SSIs showed a downward trend over 2 years, then the rates returned to levels similar to baseline in the third year. VAP rate changes were difficult to interpret because of the VAP definition change. Patient safety culture domain “hospital management support” showed significant improvement, but feedback and communication about errors and staffing declined. Simultaneous implementation of multiple interventions across units is challenging. The findings highlight the importance of sustainment efforts and suggest future work should anticipate both positive and negative change in safety culture dimensions.

Using a society database to evaluate a patient safety collaborative: the Cardiovascular Surgical Translational Study

AIM

To assess the utility of using external databases for quality improvement (QI) evaluations in the context of an innovative QI collaborative aimed to reduce three infections and improve patient safety across the cardiac surgery service line.

METHODS

We compared changes in each outcome between 15 intervention hospitals (infection reduction protocols plus safety culture intervention) and 52 propensity score-matched hospitals (feedback only).

RESULTS

Improvement trends in several outcomes among the intervention hospitals were not statistically different from those in comparison hospitals.

CONCLUSION

Using external databases such as those of professional societies may permit comparative effectiveness assessment by providing concurrent comparison groups, additional outcome measures and longer follow-up. This can better inform evaluation of continuous QI in healthcare organizations.

Implementing a fracture liaison service open model of care utilizing a cloud-based tool

PURPOSE

Although half of women and one-quarter of men aged 50 and older will sustain an acute low-trauma fracture, less than a quarter receive appropriate secondary fracture prevention. The goal of this quality improvement demonstration project was to implement a Fracture Liaison Service (FLS) focused on secondary prevention of an osteoporotic fracture in three open health care systems aided by a cloud-based tool.

METHODS

The pre-post study design examined the proportion of men and women over age 50 who received appropriate assessment (bone mineral density, vitamin D levels) and treatment (calcium/vitamin D, pharmacologic therapy) in the six months following a recently diagnosed fracture. The pre-study (Pre FLS) included a retrospective chart review for baseline data (N = 344 patients) within each health care system. In the post-evaluation (Post FLS, N = 148 patients), the FLS coordinator from each health care system examined these parameters following enrollment and for 6 months following the recently diagnosed fracture. Data were managed in the cloud-based FLS application tool.

RESULTS

Ninety-three participants completed the program. The FLS program increased the percentage of patients receiving bone mineral density testing from 21% at baseline to 93% (p < 0.001) Post FLS implementation. Assessments of vitamin D levels increased from 25 to 84% (p < 0.001). Patients prescribed calcium/vitamin D increased from 36% at baseline to 93% (p < 0.001) and those prescribed pharmacologic treatment for osteoporosis increased on average from 20 to 54% (p < 0.001) Post FLS.

CONCLUSIONS

We conclude that the FLS model of care in an open health care system, assisted by a cloud-based tool, significantly improved assessment and/or treatment of patients with a recently diagnosed osteoporotic fracture. Future studies are necessary to determine if this model of care is scalable and if such programs result in prevention of fractures. Mini-Abstract: The goal was to implement a Fracture Liaison Service (FLS) focused on secondary prevention of an osteoporotic fracture in open health care systems aided by a cloud-based tool. This model significantly improved assessment and/or treatment of patients with a recently diagnosed fracture.

Reducing preventable harm: observations on minimizing bloodstream infections

Purpose The purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms. Design/methodology/approach An existing theory of how hospitals succeeded in reducing rates of central line-associated bloodstream infections was refined, drawing from the literature and experiences in facilitating improvement efforts in thousands of hospitals in and outside the USA. Findings The following common interventions were implemented by hospitals able to reduce and sustain low infection rates. Hospital and intensive care unit (ICU) leaders demonstrated and vocalized their commitment to the goal of zero preventable harm. Also, leaders created an enabling infrastructure in the way of a coordinating team to support the improvement work to prevent infections. The team of hospital quality improvement and infection prevention staff provided project management, analytics, improvement science support, and expertise on evidence-based infection prevention practices. A third intervention assembled Comprehensive Unit-based Safety Program teams in ICUs to foster local ownership of the improvement work. The coordinating team also linked unit-based safety teams in and across hospital organizations to form clinical communities to share information and disseminate effective solutions. Practical implications This framework is a feasible approach to drive local efforts to reduce bloodstream infections and other preventable healthcare-acquired harms. Originality/value Implementing this framework could decrease the significant morbidity, mortality, and costs associated with preventable harms.

Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events

OBJECTIVES

Ventilator-associated events are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the National Institute of Health and Agency for Healthcare Research and Quality funded a two-state collaborative to reduce ventilator-associated events. We describe the collaborative's impact on ventilator-associated event rates in 56 ICUs.

DESIGN

Longitudinal quasi-experimental study.

SETTING

Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015.

INTERVENTIONS

We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork, and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multidisciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a Web-based portal.

MEASUREMENTS AND RESULTS

ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007). During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively.

CONCLUSIONS

A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in ventilator-associated event, infection-related ventilator-associated complication, and probable ventilator-associated pneumonia. Our study is the largest to date affirming that best practices can prevent ventilator-associated events.

Analysis of the Tony!™ Variable Geometry VDT Keyboard

This study utilizes a variable geometry keyboard to analyze the optimal configuration for a split QWERTY-type keyboard. The measured criteria were muscle activity as measured by EMG and reported operator discomfort. A variable geometry keyboard, simultaneously adjustable in opening angle (yaw) and lateral angle (roll) was obtained. The upward slope (tilt) was preset at 10%. The study manipulated the keyboard geometry to assess the difference in musculoskeletal activity between using (1) a conventional, flat, linear keyboard; (2) a neutral, undeviated wrist position; and (3) two forearm positions that essentially eliminate pronation. Eight experienced subjects with no prior history of wrist injury or other pathology were tested. EMG activity of four relevant muscle groups was measured on each subject for each of the four keyboard positions. The study suggested an 18° opening angle and a 30°–60° lateral angle as optimal when compared with a flat, standard keyboard (they minimize objective EMG activity and subjective discomfort).

Eliminating Central Line–Associated Bloodstream Infections: A National Patient Safety Imperative

Background.

Several studies demonstrating that central line–associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections.

Methods.

We conducted a collaborative cohort study to evaluate the impact of the national “On the CUSP: Stop BSI” program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented.

Results.

A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16–18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50–0.65) at 16–18 months after implementation.

Conclusion.

Coincident with the implementation of the national “On the CUSP: Stop BSI” program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.

Development of a cloud-based application for the Fracture Liaison Service model of care

The aims of this study are to develop a cloud-based application of the Fracture Liaison Service for practitioners to coordinate the care of osteoporotic patients after suffering primary fractures and provide a performance feedback portal for practitioners to determine quality of care. The application provides continuity of care, improved patient outcomes, and reduced medical costs.

INTRODUCTION

The purpose of this study is to describe the content development and functionality of a cloud-based application to broadly deploy the Fracture Liaison Service (FLS) to coordinate post-fracture care for osteoporotic patients.

METHODS

The Bone Health Collaborative developed the FLS application in 2013 to support practitioners' access to information and management of patients and provide a feedback portal for practitioners to track their performance in providing quality care. A five-step protocol (identify, inform, initiate, investigate, and iterate) organized osteoporotic post-fracture care-related tasks and timelines for the application. A range of descriptive data about the patient, their medical condition, therapies and care, and current providers can be collected. Seven quality of care measures from the National Quality Forum, The Joint Commission, and the Centers for Medicare and Medicaid Services can be tracked through the application.

RESULTS

There are five functional areas including home, tasks, measures, improvement, and data. The home, tasks, and data pages are used to enter patient information and coordinate care using the five-step protocol. Measures and improvement pages are used to enter quality measures and provide practitioners with continuous performance feedback. The application resides within a portal, running on a multitenant, private cloud-based Avedis enterprise registry platform. All data are encrypted in transit and users access the application using a password from any common web browser.

CONCLUSION

The application could spread the FLS model of care across the US health care system, provide continuity of care, effectively manage osteoporotic patients, improve outcomes, and reduce medical costs.

Towards expanding the acute care team: Learning how to involve families in care processes

INTRODUCTION

Effective teamwork is known to be important to improving health care outcomes. Current research often highlights teamwork among health care professionals without consideration of approaches to including family as part of the health care team. In this study, the authors assess family and provider openness to expanding the care team to include family participation and introduce the Family Involvement Menu as a tool to facilitate family engagement.

METHOD

They collected 37 family surveys and 37 clinician surveys to understand the perception, comfort level, experience, and interest of family and clinicians in including family in the care of the patient. The majority of family reported being interested and comfortable in participating in care (95% and 92%, respectively).

RESULTS

The majority of clinicians considered family already to be part of the health care team (92%) though only 16% reported routinely inviting families to participate in direct patient care all the time. Multiple direct patient care activities were identified as promising opportunities for family engagement. Barriers to family engagement reported included the family being scared (19%), uncomfortable (19%), or unwilling (14%) or nurses not having enough time (14%) to involve families.

DISCUSSION

Engaging family has the potential to increase nursing availability for other tasks, enhance relationship building, and is an opportunity to introduce early education for family, better preparing them for transition of care and discharge. The Family Involvement Menu supports family engagement and can be a strategy to include family members as part of the health care team.

Congenital high myopia and central macular atrophy: a report of 3 families

AIMS

To report the clinical phenotype in a series of four children from three families with the rare association of high myopia, central macular atrophy, and normal full-field electroretinography (ERG).

METHODS

Four male patients were ascertained with reduced vision, nystagmus, and atrophy of the macula from early childhood. Patients underwent full ophthalmic examination, electrophysiological testing, and retinal imaging.

RESULTS

Minimum duration of follow-up was 8 years. At last review, visual acuity ranged from 0.22 to 1.20 logMAR (6/9.5-6/95 Snellen) at a mean age of 10.5 years (median 9.5 years, range 9-14 years). Refractive error ranged from a spherical equivalent of -7.40 D to -24.00 D. Three had convergent squint. Fundus examination and imaging demonstrated bilateral macular atrophy in all patients that varied from mild atrophy of the retinal pigment epithelium (RPE) to well-demarcated, punched-out atrophic lesions of retina, RPE, and choroid. Flash ERG was normal under photopic and scotopic conditions in all patients. Pattern ERG, performed in three patients, was consistent with mild to severe macular dysfunction. Progression of the area of atrophy was evident in one patient and of the myopia in two patients but all patients had stable visual acuity.

CONCLUSIONS

Patients with congenital high myopia and macular atrophy present in infancy with reduced visual acuity and nystagmus. The macular atrophic lesions vary in size and severity but electrophysiological testing is consistent with dysfunction confined to the macula. There was no deterioration in visual acuity over 8-10 years of monitoring.

Multi-centre variability of ISCEV standard ERGs in two normal adults

BACKGROUND

The reproducibility of an individual's full-field ERG between centres has not previously been investigated.

METHODS

ERGs were recorded using both silver thread and skin electrodes from the same two normal adult subjects at 15 UK centres using routine, local protocols and a highly standardised, 'ISCEV-specified' protocol matching the values specified in the ISCEV standard; where the ISCEV standard allows options, a single value was chosen.

RESULTS

Inter-ocular differences were small, and amplitudes were smaller for skin than silver thread electrodes. No centre produced outlying data points, and ERGs across all 15 centres were remarkably similar. Amplitude variability was less for local protocols (using LED flashes) than for the ISCEV-specified protocol using xenon flashes (22 vs. 24 %, p = 0.01), but peak time variability was less for the ISCEV-specified protocol (6.1 vs. 7.4 %, p = 0.001). Only the DA 0.01 ERG correlated with photometric variability. The bifidity of the DA 3 a-wave doubled its peak time variability compared with the DA 10 a-wave.

CONCLUSIONS

Inter-centre amplitude variability was typically within clinically significant thresholds, suggesting that inter-centre variability with suitable standardisation may not add more to total variability than inter-subject variability. Variability improvements gained by the tighter specifications of the ISCEV-specified protocol were possibly more than lost due to imprecisions of xenon flashtubes. Peak time variability was far lower than amplitude variability, corresponding with acceptable variability of biochemical assays. These results represent a vindication of the existence of an ERG standard and suggest that further standardisation would lend itself to greater reproducibility of ERGs worldwide.

Collaborative Cohort Study of an Intervention to Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit

Objective.

To evaluate the impact of a multifaceted intervention on compliance with evidence-based therapies and ventilator-associated pneumonia (VAP) rates.

Design.

Collaborative cohort before-after study.

Setting.

Intensive care units (ICUs) predominantly in Michigan.

Interventions.

We implemented a multifaceted intervention to improve compliance with 5 evidence-based recommendations for mechanically ventilated patients and to prevent VAP. A standardized CDC definition of VAP was used and maintained at each site, and data on the number of VAPs and ventilator-days were obtained from the hospital's infection preventionists. Baseline data were reported and postimplementation data were reported for 30 months. VAP rates (in cases per 1,000 ventilator-days) were calculated as the proportion of ventilator-days per quarter in which patients received all 5 therapies in the ventilator care bundle. Two interventions to improve safety culture and communication were implemented first.

Results.

One hundred twelve ICUs reporting 3,228 ICU-months and 550,800 ventilator-days were included. The overall median VAP rate decreased from 5.5 cases (mean, 6.9 cases) per 1,000 ventilator-days at baseline to 0 cases (mean, 3.4 cases) at 16–18 months after implementation (P < .001) and 0 cases (mean, 2.4 cases) at 28-30 months after implementation (P < .001). Compared to baseline, VAP rates decreased during all observation periods, with incidence rate ratios of 0.51 (95% confidence interval, 0.41–0.64) at 16–18 months after implementation and 0.29 (95% confidence interval, 0.24–0.34) at 28–30 months after implementation. Compliance with evidence-based therapies increased from 32% at baseline to 75% at 16–18 months after implementation (P < .001) and 84% at 28–30 months after implementation (P < .001).

Conclusions.

A multifaceted intervention was associated with an increased use of evidence-based therapies and a substantial (up to 71%) and sustained (up to 2.5 years) decrease in VAP rates.

A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?

PURPOSE

Teamwork is essential for ensuring the quality and safety of health care delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, and team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research.

METHODS

A keyword search of the PubMed database was conducted in February 2013. Keyword combinations focused on 3 areas: (1) teamwork, (2) the ICU, and (3) training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team interventions within the ICU (ie, intradepartment) were selected for inclusion.

RESULTS

Teamwork has been investigated across an array of research contexts and task types. The terminology used to describe team factors varied considerably across studies. The most common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies.

CONCLUSIONS

Team research is burgeoning in the ICU, yet low-hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined, and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work.

Toward Improving Patient Safety Through Voluntary Peer-to-Peer Assessment

Health care has primarily used retrospective review approaches to identify and mitigate hazards, with little evidence of measurable and sustained improvements in patient safety. Conversely, the nuclear power industry has used a prospective peer-to-peer (P2P) assessment process grounded in open information exchange and cooperative organizational learning to realize substantial and sustainable improvements in safety. In comparing approaches, it is evident that health care’s sluggish progress stems from weaknesses in hazard identification and mitigation and in organizational learning. This article proposes creating and implementing a structured prospective P2P assessment model in health care, similar to that used in the nuclear power industry, to accelerate improvements in patient safety.

Variation in local institutional review board evaluations of a multicenter patient safety study

Several highly visible quality improvement (QI) projects led to controversy over their ethical oversight, attracting attention from institutional review boards (IRBs) and the Office for Human Research Protection. While QI research has increased dramatically, there is limited empirical evidence regarding how multiple IRBs review the same study. This paper describes the variations in local IRB reviews for the same a multicenter QI study. The study, entitled "Locating Errors through Networked Surveillance", used multiple data collection methods to identify patient safety risks in cardiovascular operating room services. This study involved 2-day site visits to 5 hospitals by the research team to observe cardiac surgery procedures and interview staff regarding clinical practice and hazards. Surveys were self-administered. The IRB process varied widely across the 5 hospitals. Reviews ranged from full committee review and approval with verbal consent required from patients and operating room staff, to an IRB determining the study exempt from review and participant consent. The time to IRB approval ranged from 6 weeks to 6 months. This variation suggests there is wide interpretation of the Federal regulations put in place to guide IRBs. The adoption of uniformity would not only reduce inefficiencies but also attenuate the perceived arbitrary nature of current IRB review processes that often inappropriately influence hypothesis-generation and study design.

Semiconductor optical amplifiers grown on a metamorphic substrate for long wavelength applications

A semiconductor optical amplifier is grown on an InAsP metamorphic substrate to extend the long wavelength accessibility of the amplifier. The amplifier is shown to produce gain at wavelength exceeding 1640 nm while containing large tensile strain in the quantum wells. Also a laser diode is fabricated from the same device structure.

Electrical characteristics of core-shell p-n GaAs nanowire structures with Te as the n-dopant

GaAs nanowire (NW)-based p-n photovoltaic devices, with two distinct p and n spatial distributions and where Te was the n-dopant, have been studied by impedance spectroscopy in the 10(3)-10(7) Hz frequency range and the - 1.5-1.5 V bias range. For a large n-core/p-shell overlap region within NWs in a coaxial geometry, the p-n junction properties (DC rectification and p-n depletion capacitance) are found to prevail. The impedance data at low bias for both NW devices show large frequency dispersions with relaxation frequencies that are compatible with carrier re-emission times from traps due to GaAs surface states. An increasing conductance with increasing frequency for low bias is observed, suggesting hopping transport through localized states. For large bias the conductance increases exponentially with bias and is frequency independent, indicating conduction through extended states in this regime.

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study

OBJECTIVES

To evaluate the extent to which intensive care units participating in the initial Keystone ICU project sustained reductions in rates of catheter related bloodstream infections. Design Collaborative cohort study to implement and evaluate interventions to improve patients' safety.

SETTING

Intensive care units predominantly in Michigan, USA.

INTERVENTION

Conceptual model aimed at improving clinicians' use of five evidence based recommendations to reduce rates of catheter related bloodstream infections rates, with measurement and feedback of infection rates. During the sustainability period, intensive care unit teams were instructed to integrate this intervention into staff orientation, collect monthly data from hospital infection control staff, and report infection rates to appropriate stakeholders.

MAIN OUTCOME MEASURES

Quarterly rate of catheter related bloodstream infections per 1000 catheter days during the sustainability period (19-36 months after implementation of the intervention).

RESULTS

Ninety (87%) of the original 103 intensive care units participated, reporting 1532 intensive care unit months of data and 300 310 catheter days during the sustainability period. The mean and median rates of catheter related bloodstream infection decreased from 7.7 and 2.7 (interquartile range 0.6-4.8) at baseline to 1.3 and 0 (0-2.4) at 16-18 months and to 1.1 and 0 (0.0-1.2) at 34-36 months post-implementation. Multilevel regression analysis showed that incidence rate ratios decreased from 0.68 (95% confidence interval 0.53 to 0.88) at 0-3 months to 0.38 (0.26 to 0.56) at 16-18 months and 0.34 (0.24-0.48) at 34-36 months post-implementation. During the sustainability period, the mean bloodstream infection rate did not significantly change from the initial 18 month post-implementation period (-1%, 95% confidence interval -9% to 7%).

CONCLUSIONS

The reduced rates of catheter related bloodstream infection achieved in the initial 18 month post-implementation period were sustained for an additional 18 months as participating intensive care units integrated the intervention into practice. Broad use of this intervention with achievement of similar results could substantially reduce the morbidity and costs associated with catheter related bloodstream infections.

View the world through a different lens: shadowing another provider

The shadowing tool promotes understanding of other professions' roles in patient care.

Developing process-support tools for patient safety: finding the balance between validity and feasibility

The Johns Hopkins Quality and Safety Research Group, which has developed many process-support tools--three of which are reported in this issue--describes its approach to tool development.

GaAs core--shell nanowires for photovoltaic applications

We report the use of Te as an n-type dopant in GaAs core-shell p-n junction nanowires for use in photovoltaic devices. Te produced significant change in the morphology of GaAs nanowires grown by the vapor-liquid-solid process in a molecular beam epitaxy system. The increase in radial growth of nanowires due to the surfactant effect of Te had a significant impact on the operating characteristics of photovoltaic devices. A decrease in solar cell efficiency occurred when the Te-doped GaAs growth duration was increased.

Planning and implementing a systems-based patient safety curriculum in medical education

Using a successful 6-step approach to medical curriculum development, a multidisciplinary systems-based safety curriculum for first-year medical students was developed and implemented. A targeted needs assessment was completed based on students' perceptions of patient safety. Goals and objectives identified were the following: (1) provide a practical framework to identify defects, (2) identify patient hazards, (3) investigate an adverse event, (4) understand incident reporting, (5) understand the impact of teamwork and communication in safety, (6) acquire skills to improve teamwork and communication, and (7) learn to disclose medical mistakes. Students were able to identify many of the teamwork and communication problems entrenched in our current health care culture. Interactive learning was important to the learning process and, on evaluation, deemed a valuable experience. The findings indicate that this is an effective curriculum development strategy and that systems-based patient safety was effective in changing perceptions of patient harm and the provider's role in patient safety.

The organization of intensive care unit physician services*

OBJECTIVE

To describe the organization of physician services in intensivist-staffed intensive care units (ICU) reporting that they meet vs. do not meet the Leapfrog Physician Staffing standard, and to describe ICU directors' perceptions of the quality of care in their unit.

DESIGN

Hospitals that were asked to participate in the 2001 and 2002 Leapfrog surveys regarding implementation of the ICU Physician Staffing standard were sampled. Survey instruments were developed and used to determine organizational characteristics, status regarding implementing and meeting the standard, financing of physician staffing, and perceptions of clinical performance.

SUBJECTS

ICU directors.

MEASUREMENTS AND MAIN RESULTS

Intensivists staffed ICUs in 100% of hospitals meeting the standard, and in 59% not meeting the standard. Mean percentage of patients visited on rounds by intensivists in ICUs who met (80 +/- 14.58) vs. did not meet (57.5 +/- 23.20) the standard showed no statistical difference, Wilcoxon rank-sum test = -1.99, p = .065. Only 25% (three of 12) of intensivists in ICUs meeting the standard had authority to write patient orders on all patients, compared to 65% (11 of 17) in ICUs not meeting the standard. Intensivists were present at least 8 hrs/day in 83% (ten of 12) of ICUs meeting and 18% (three of 17) of ICUs not meeting the standard. Provision of medical liability insurance for physicians occurred in 58% (seven of 12) of ICUs meeting and 25% (four of 16) of ICUs not meeting the standard (p = .003). ICU directors rated quality of ICU care as excellent in 70% of ICUs meeting and 35% of ICUs not meeting the standard.

CONCLUSIONS

ICUs now classify themselves as meeting or not meeting the ICU Physician Staffing standard. Yet, there is wide variation in organizational characteristics among ICUs meeting the standard, and between those meeting and not meeting the standard. The criteria defined by the Leapfrog Group for meeting the ICU Physician Staffing standard must be clearly defined if hospitals are to meet the standard.

Toward learning from patient safety reporting systems

PURPOSE

To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety.

MATERIALS AND METHODS

Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm.

RESULTS

Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm.

CONCLUSIONS

The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.

Impact of the Leapfrog Group's intensive care unit physician staffing standard

PURPOSE

The aim of this study was to describe hospital efforts to meet the Leapfrog Group's intensive care unit (ICU) physician staffing (IPS) standard; compare adopters and committers with resisters relative to perceived benefits, barriers and motivating factors; and examine implementation strategies.

MATERIALS AND METHODS

Chief medical officers (CMO) and ICU directors at hospitals in 6 US regions were surveyed between August 2003 and January 2004. Hospital classifications were based on level of IPS implementation pioneer (met before IPS), adopter (met after IPS by 2002 Leapfrog survey), committer (not met but committed to December 2004 implementation), and resister (refused to adopt IPS). Meeting IPS included intensivist staffing, 8 hours/day 7 days/week; sole patient care in ICU; 95% pager response time </=5 minutes; and physicians certified in critical care.

RESULTS

Forty-three (80%) CMOs and 42 (78%) ICU directors were interviewed. Adopters (100%), committers (80%), and resisters (45%) employed intensivists; 1 adopter (14%) met all criteria for standard. Main motivators for implementation were "quality of patient care" for CMO (79%) and ICU director (71%) adopter/committers. Incentives to implement were increasing intensivist authority (90% committers) and intensivist salary support (80% committers and 70% adopters). Main resister barriers were implementation costs (61% CMOs) and medical staff controversy (55% ICU directors).

CONCLUSION

Most hospitals-including half of those who publicly resisted the standard-made attempts to change physician staffing in their ICUs, based on the criteria outlined by the Leapfrog Group. Major barriers that need addressing are implementation costs and convincing hospital organizations and medical staff regarding the benefits of adopting the standard.

Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study

PURPOSE

The aim of this study is to determine if patient safety incidents and the system-related factors contributing to them systematically differ for medical versus surgical patients in intensive care units.

MATERIALS AND METHODS

We conducted a multicenter prospective study of 646 incidents involving adult medical patients and 707 incidents involving adult surgical patients that were reported to an anonymous patient safety registry over a 2-year period. We compared incident characteristics, patient harm, and associated system factors for medical versus surgical patients.

RESULTS

The proportion of safety incidents reported for medical versus surgical patients differed for only 3 of 11 categories: equipment/devices (14% vs 19%; P = .02), "line, tube, or drain" events (8% vs 13%; P = .001), and computerized physician order entry (13% vs 6%; P < or = .001). The type of patient harm associated with incidents also did not differ. System factors were similar for medical versus surgical patients, with training and teamwork being the most important factors in both groups.

CONCLUSIONS

Medical and surgical patients in the intensive care unit experience very similar types of safety incidents with similar associated patient harm and system factors. Common initiatives to improve patient safety for medical and surgical patients should be undertaken with a specific focus on improving training and teamwork among the intensive care team.

Creating high reliability in health care organizations

OBJECTIVE

The objective of this paper was to present a comprehensive approach to help health care organizations reliably deliver effective interventions.

CONTEXT

Reliability in healthcare translates into using valid rate-based measures. Yet high reliability organizations have proven that the context in which care is delivered, called organizational culture, also has important influences on patient safety. MODEL FOR IMPROVEMENT: Our model to improve reliability, which also includes interventions to improve culture, focuses on valid rate-based measures. This model includes (1) identifying evidence-based interventions that improve the outcome, (2) selecting interventions with the most impact on outcomes and converting to behaviors, (3) developing measures to evaluate reliability, (4) measuring baseline performance, and (5) ensuring patients receive the evidence-based interventions. The comprehensive unit-based safety program (CUSP) is used to improve culture and guide organizations in learning from mistakes that are important, but cannot be measured as rates.

CONCLUSIONS

We present how this model was used in over 100 intensive care units in Michigan to improve culture and eliminate catheter-related blood stream infections--both were accomplished. Our model differs from existing models in that it incorporates efforts to improve a vital component for system redesign--culture, it targets 3 important groups--senior leaders, team leaders, and front line staff, and facilitates change management-engage, educate, execute, and evaluate for planned interventions.

Variation in caregiver perceptions of teamwork climate in labor and delivery units

OBJECTIVE

To test the psychometric soundness of a teamwork climate survey in labor and delivery, examine differences in perceptions of teamwork, and provide benchmarking data.

DESIGN

Cross-sectional survey of labor and delivery caregivers in 44 hospitals in diverse regions of the US, using the Safety Attitudes Questionnaire teamwork climate scale.

RESULTS

The response rate was 72% (3382 of 4700). The teamwork climate scale had good internal reliability (overall alpha = 0.78). Teamwork climate scale factor structure was confirmed using multilevel confirmatory factor analyses (CFI = 0.95, TLI = 0.92, RMSEA = 0.12, SRMR(within) = 0.04, SRMR(between) = 0.09). Aggregation of individual-level responses to the L&D unit-level was supported by ICC (1) = 0.06 (P < 0.001), ICC (2) = 0.83 and mean r (wg(j)) = 0.83. ANOVA demonstrated differences between caregivers F (7, 3013) = 10.30, P < 0.001 and labor and delivery units, F (43, 1022) = 3.49, P < 0.001. Convergent validity of the scale scores was measured by correlations with external teamwork-related items: collaborative decision making (r = 0.780, P < 0.001), use of briefings (r = 0.496, P < 0.001) and perceived adequacy of staffing levels (r = 0.593, P < 0.001).

CONCLUSION

We demonstrate a psychometrically sound teamwork climate scale, correlate it to external teamwork-related items, and provide labor and delivery teamwork benchmarks. Further teamwork climate research should explore the links to clinical and operational outcomes.

Coded Chief Complaints--automated analysis of free-text complaints

OBJECTIVES

To describe a new chief-complaint categorization schema, the development of a computer text-parsing algorithm to automatically classify free-text chief complaints into this schema, and use of these coded chief complaints to describe the case mix of a community emergency department (ED).

METHODS

Coded Chief Complaints for Emergency Department Systems (CCC-EDS) is a new and untested schema of 228 chief complaints, grouped within dimensions of type and system. A computerized text-parsing algorithm for automatically reading and classifying free-text chief complaints into 1 of these 228 coded chief complaints was developed by using a consecutive derivation sample of 46,602 patients who presented to a community teaching-hospital ED in 2004. Descriptive statistics included frequency of patients presenting with the 228 coded chief complaints; percentage of free-text complaints not categorizable by the CCC-EDS; and admission rate, age, and gender differences by chief complaint.

RESULTS

In the derivation sample, the text-parsing algorithm classified 87.5% of 45,329 ED visits with non-null free-text chief complaints into 1 of 194 coded chief complaints. The text-parsing algorithm successfully classified 87.3% of the free-text chief complaints in a validation sample. The five most common coded chief complaints were Abdominal Pain (3,734 visits), Fever (2,234), Chest Pain (2,183), Breathing Difficulty (2,030), and Cuts-Lacerations (2,028).

CONCLUSIONS

The CCC-EDS is a new comprehensive, granular, and useful classification schema for categorizing chief complaints in an ED. A CCC-EDS text-parsing algorithm successfully classified the majority of free-text chief complaints from an ED computer log. These coded chief complaints were used to describe the case mix of a community teaching-hospital ED.