Chart Review Method Research Articles

Longitudinal diffusion changes following postoperative delirium in older people without dementia.

To investigate the effect of postoperative delirium on longitudinal brain microstructural changes, as measured by diffusion tensor imaging. We studied a subset of the larger Successful Aging after Elective Surgery (SAGES) study cohort of older adults (≥70 years) without dementia undergoing elective surgery: 113 participants who had diffusion tensor imaging before and 1 year after surgery. Postoperative delirium severity and occurrence were assessed during the hospital stay using the Confusion Assessment Method and a validated chart review method. We investigated the association of delirium severity and occurrence with longitudinal diffusion changes across 1 year, adjusting for age, sex, vascular comorbidity, and baseline cognitive performance. We also assessed the association between changes in diffusion and cognitive performance across the 1-year follow-up period, adjusting for age, sex, education, and baseline cognitive performance. Postoperative delirium occurred in 25 participants (22%). Delirium severity and occurrence were associated with longitudinal diffusion changes in the periventricular, frontal, and temporal white matter. Diffusion changes were also associated with changes in cognitive performance across 1 year, although the cognitive changes did not show significant association with delirium severity or occurrence. Our study raises the possibility that delirium has an effect on the development of brain microstructural abnormalities, which may reflect brain changes underlying cognitive trajectories. Future studies are warranted to clarify whether delirium is the driving factor of the observed changes or rather a correlate of a vulnerable brain that is at high risk for neurodegenerative processes.

Potential Causative Factors for Saccular Disorders: Association with Smoking and Other Laryngeal Pathologies

To describe risk factors, clinical presentation, and outcome of patients with saccular disorders. Case control with chart review METHODS: A single center retrospective study. Case group included all adult patients, presenting with saccular disorders (saccular cyst or laryngocele), between the years 2010 and 2015. A matched group of patients with vocal fold cyst served as the control. Twenty-nine patients met the inclusion criteria: 15 males and 14 females; the mean age was 60.5(±11.2). The median follow-up period was 10 months (range 2-48). Overall, 75.9% (22) had a positive smoking history; 55.2% (16) were active and 20.7% (6) were past smokers. The median pack- years of all smokers in the saccular disorder group was 40 (range 1-67). Saccular disorder patients demonstrated significantly higher prevalence of active smoking when compared to control patients (55.2% versus 17.9%, P = 0.014). Sixty-nine percent of the patients had some synchronous vocal fold comorbidity. The leading vocal fold comorbidity was Reinke's edema in 41% (12). Synchronous vocal fold comorbidities were significantly more prevalent in smokers compared with nonsmokers-82% (18 of 22) and 29% (2 of 7), respectively (P = 0.008). Surgical treatment was performed on 26 patients; all of whom underwent complete resection, either by endoscopic (92%), external (4%), or combined external and endoscopic (4%) approaches. There was a single case of recurrence (4%), 10 months following initial resection. Saccular disorders are associated with smoking and synchronous vocal fold comorbidity. Complete resection is recommended as surgical outcome is excellent.

Evaluating Medication Errors for Hospitalized Patients : The Jordanian Experience = تقييم الأخطاء الدوائية لمرضى المستشفى : التجربة الأردنية

To investigate the rate, frequency, and severity of medication errors detected by a clinical pharmacist at a teaching hospital in Amman, Jordan. Secondly, to determine the risk factors associated with the occurrence of these errors. This prospective observational study used two methods of medication error detection, direct observation and the chart review method. Both methods were conducted in the internal medicine ward between June and December 2013. In the selected shifts, all procedures performed on the patients were observed and recorded by the clinical pharmacist. The number and types of medication errors were documented. Risk factors associated with more medication errors were then tested using multiple univariate regression to identify potential risk factors. All collected data were entered into SPSS and analyzed accordingly. The study included 283 patients and 15 nurses. A total of 803 medication errors per 6396 opportunities for errors (12.6%) were observed. The most frequent errors were administration errors (n= 739, 20.2%), transcription errors (n= 40, 1.5%), dispensing errors (n= 21, 0.8%) and prescribing errors (n= 3, 0.1%). Risk factors associated with the total number of detected medication errors were mainly shorter nurse's experience in the ward (R2 = 0.456, p< 0.042) and patients with higher number of prescribed doses (R2 = 0.451, p< 0.025). This study revealed that medication errors happening in a teaching hospital occur mainly during the administration and transcription stages of the medication use process. Shorter nurse experience and caring for inpatients with more complicated therapeutic regimens can lead to higher rates of medication errors.

Abnormal Pap Tracking in Resident Clinics – What Is Our Standard and Can We Do Better? [6O

INTRODUCTION: Screening tests are only as valuable as the quality of the system in which they are performed. To reduce cancer rates, tracking patients' care after pap testing is fundamental. Electronic health records (EHR) have made reporting of abnormal test results more efficient and reliable, but how are they being used? We investigated current protocols for tracking abnormal cytology results in Obstetrics &amp; Gynecology resident clinics to better understand how future physicians are trained in this important quality assurance task. METHODS: A brief survey designed using REDCap, a secure, web-based application, was sent out to all 249 Obstetrics &amp; Gynecology residency programs within the FRIEDA database. RESULTS: Of the 249 residency programs, 54 (22%) responded, 51 (94%) perform colposcopy, and 47 (87%) programs provide treatment. Twenty-five (46%) of respondents have a tracking system for abnormal results with 21 (45%) of the 47 programs providing treatment, tracking post-treatment follow-up care. Follow-up is confirmed by chart review in 18 (72%) of the 25 programs who perform tracking, while 6 (24%) use EHR reports or disease management capability. CONCLUSION: The majority of residency programs perform colposcopy and treatment, yet less than 50% of the programs track abnormal results to assure appropriate patient follow-up. The majority of programs who perform tracking do so by the time consuming method of chart review, with only 6 programs (11%) leveraging the efficiency and reliability of their EHR to assist with this quality assurance task. Resident clinics and clinical practices of all types might consider this an area for future quality improvement.

Electronic health record innovations: Helping physicians - One less click at a time.

Physician burnout is becoming an epidemic, due to the pressures of being productive, an imperfect electronic health record (EHR) system, and limited face-to-face time with patients. Poor usability in EHR-user interface can force users to go through more steps (i.e. more clicks on the computer) in accomplishing a task. This increased 'click burden' is a source of frustration for physicians. In the light of increased click burden and time due to meaningful use requirements, there is a need to improve the physician's experience by creating innovations in EHR. This case study describes an attempt by physicians at NewYork-Presbyterian Brooklyn Methodist Hospital to enhance the EHR experience with more efficient methods of documentation, chart review, ordering and patient safety. The EHR innovations trialled in this study were: a mobile documentation application; abnormal test results auto-populated into an EHR patient summary; physician alerts to reduce inappropriate test ordering; and a system of safety alerts on a dashboard. These innovations led to decreased click burden and allowed physicians to spend less time on the computer and more time with patients. Physician-driven changes to EHR systems have the potential to streamline virtual workflows and the management of health information and to improve patient safety, reduce physician burnout and increase physician job satisfaction.

Diagnosing delirium in very elderly intensive care patients

To determine the incidence of delirium in elderly intensive care patients and to compare incidence using two retrospective chart-based diagnostic methods and a hospital reporting measure (ICD-10). Retrospective study. An ICU in a large metropolitan private hospital in Melbourne, Australia. English-speaking participants (n=348) 80+ years, admitted to ICU for >24 hours. Medical files of ICU patients admitted October 2009-October 2012 were retrospectively assessed for delirium using the Inouye chart review method, DSM-IV diagnostic criteria and ICD-10 coding data. General patient characteristics, first onset of delirium symptoms, source of delirium information, administration of delirium medication, hospital and ICU length of stay, 90 day mortality were documented. Delirium was found in 11-29% of patients, the highest incidence identified by chart review. Patients diagnosed with delirium had higher 90 day mortality, and those meeting criteria for all three methods had longer hospital and ICU length of stay. ICU delirium in the elderly is often under-reported and strategies are needed to improve staff education and diagnosis.

Evaluation of inappropriate prescribing to the hospitalized elderly patients in Al Shifa hospital, Gaza, Palestine

Background: The current study aimed to assess the prevalence of inappropriate prescribing (IP) for hospitalized elderly patients at Al Shifa Hospital, Gaza, Palestine. Methods: This study was a retrospective cross-sectional study. A total of 2385 prescribed drugs for 380 elderly inpatients in internal, cardiology, and respiratory departments were screened for IP. Four criteria were used to detect IP using chart review method; Drug-drug interactions (DDIs), drug contra-indications (CI), duplication of therapy and Beers' criteria 2012. Results: The results showed that 44.2% of patients had at least one IP. Around 33.2% of the patients had DDIs, 19.2% had IP according to Beers' criteria and 1.1% had drug CI. There was no duplication of therapy. A total of 323 IP instances were detected. Of them, 74% for DDIs and 24.8% for Beers' criteria. The prevalence of overall IP was significantly influenced by age (p-value=0.024), polypharmacy (p-value<0.001), degree of morbidity (p-value<0.001), and departments (p-value=0.018). The prevalence of DDIs was influenced by polypharmacy (p-value<0.001), degree of morbidity (p-value=0.001), and departments (p-value=0.005). Finally, the prevalence of IP according to Beers' criteria was significantly influenced by departments with the highest in the cardiology department (29.7%) (P-value=0.007). Conclusions: Although the overall IP was common, it was not far higher than that reported worldwide. The majority of IP was DDIs. Age, polypharmacy, degree of morbidity and departments influenced the occurrence of IP.

Implementation of a Lactation Support Program in a Primary Care Pediatric Practice

Background and Objective. Breastfeeding has been shown to have an overall impact on the health and well-being of mothers and infants. Statistically, national and state breastfeeding rates are below the Healthy People 2020 target goals. A review of literature concluded that lactation support increased the overall rates of breastfeeding throughout the first year of life. The objectives of this quality improvement project were to increase the rates of breastfeeding at 2 weeks and 2 months of age by providing lactation support to the mother–infant dyad, to provide education for health care providers on the evidence-based recommendation for lactation support, and implement the program as standard of care. Methods. The quality improvement project used a retrospective chart review method to collect data. Data collection was done on the provision of lactation support for infants with the ICD-9 code of newborn feeding issues (779.31). Feeding methods were documented at 2 weeks and 2 months of age. Data were collected with regard to the numbers of referrals made before and after healthcare provider education. Results. Lactation support yielded higher rates of breastfeeding duration and exclusivity at 2 months of age yet referral rates demonstrated no significant difference. Conclusions and Implications. Research has shown that lactation support in the early postpartum period can increase breastfeeding rates throughout the first year of life. The lactation support program is standard of care for those newborns that meet evidence-based criteria, including excessive weight loss, inadequate stool output, and difficulty with breastfeeding with an ICD-9 code of newborn feeding issues (779.31).

Hemilaminectomy approach for intradural extramedullary spinal tumors: an analysis of 164 patients.

OBJECT The authors report their experience with the use of a minimally invasive hemilaminectomy approach for the excision of intradural extramedullary (IDEM) tumors of the spinal cord. METHODS Included were 164 consecutive patients (167 tumors in total), treated between January 2004 and December 2014, in whom the hemilaminectomy approach for IDEM spinal cord tumors was planned. The clinicoradiological data of patients presenting to Christian Medical College were analyzed retrospectively using a computerized chart-review method. Preoperative MRI localization was used in 51 cases. RESULTS The mean age (± SD) of the patients was 42.6 ± 16.6 years, and the mean duration of symptoms was 20.8 ± 27.8 months. The average tumor size was 2.4 ± 1.7 cm. Forty-four tumors were cervical, 5 were cervicothoracic, 72 were thoracic, 7 were thoracolumbar, and 39 were lumbar. Forty-two tumors were ventrally located, whereas 11 were ventrolateral; the rest were either dorsal or dorsolateral. The most common pathologies were schwannoma (110 cases) and meningioma (31 cases). Total excision was achieved for 93% of the tumors. The average duration of surgery was 1.6 ± 0.6 hours. CONCLUSIONS The hemilaminectomy approach to the removal of intradural tumors was quick and safe and resulted in minimal morbidity and no mortality. Preoperative MRI localization improved accuracy and reduced operating time by eliminating the need for intraoperative fluoroscopy.

An analysis of drug stock-outs in rural Western Kenya and subsequent patient impact

strengthening in low resource settings. Investments in electronic medical record (EMR) systems offer promise for improved information for patient and public health program management. Strong data quality (DQ) is a precursor to strong data use. Routine DQ assessment (DQA) within EMR systems can be resource-intensive when using typical methods of audit and chart review. Automated database queries on the completeness, accuracy and timeliness of data offer an efficient alternative. This DQA focuses on Haiti’s national EMR iSante a system deployed in 119 health care facilities and containing longitudinal data for more than 400,000 patients. Methods: This mixed-methods evaluation focused on data related to HIV care and treatment. We first used a qualitative Delphi process to identify DQ priorities among local HIV experts, followed by a quantitative DQA on these priority data elements. The quantitative DQA examined 13 indicators of completeness, accuracy and timeliness of data using retrospective data from HIV patients, collected during more than 3.5 million encounters from 2005e June 2013. We described levels of DQ for each indicator over time, and examined the consistency of within-site performance. Using generalized linear models (GLM) with logit link and binomial errors for each of the 13 DQ indicators, we examined associations between DQ results and site and system characteristics, such as facility type, urban vs. rural location, and number of iSante system users. Findings: Ninety-five sites using the iSante data system were included in the evaluation. On average, completeness was high for demographic data but low for clinical data, accuracy of age data was low, and timeliness of data entry was low. For most indicators, DQ tended to improve over time, both overall and within specific sites. DQ was highly variable across sites, and sites which performed strongly in some indicators performed weakly in others. In adjusted analyses, site and system factors with generally favorable and statistically significant associations with DQ indicators were University hospital type, private sector governance, presence of more advanced IT infrastructure, greater site experience, greater maturity of the iSante system, having more overall system users but fewer new users. Interpretation: The heterogeneity in performance on various priority DQ indicators across sites indicates that excellent DQ is achievable in Haiti, but that many sites have much work to do to improve their DQ performance. A dynamic, interactive “data quality dashboard” within iSante could bring transparency and motivate improvement. Further investment in the IT infrastructure supporting iSante, including assuring stable power supply, and in on-going training for new users, is also warranted. Funding: Health Resources and Services Administration (#U91HA0680); US Centers for Disease Control and Prevention (#5U2GGH000549-03). Abstract #: 02ITIS025

Interactive Cohort Identification of Sleep Disorder Patients Using Natural Language Processing and i2b2.

Nationwide Children's Hospital established an i2b2 (Informatics for Integrating Biology & the Bedside) application for sleep disorder cohort identification. Discrete data were gleaned from semistructured sleep study reports. The system showed to work more efficiently than the traditional manual chart review method, and it also enabled searching capabilities that were previously not possible. We report on the development and implementation of the sleep disorder i2b2 cohort identification system using natural language processing of semi-structured documents. We developed a natural language processing approach to automatically parse concepts and their values from semi-structured sleep study documents. Two parsers were developed: a regular expression parser for extracting numeric concepts and a NLP based tree parser for extracting textual concepts. Concepts were further organized into i2b2 ontologies based on document structures and in-domain knowledge. 26,550 concepts were extracted with 99% being textual concepts. 1.01 million facts were extracted from sleep study documents such as demographic information, sleep study lab results, medications, procedures, diagnoses, among others. The average accuracy of terminology parsing was over 83% when comparing against those by experts. The system is capable of capturing both standard and non-standard terminologies. The time for cohort identification has been reduced significantly from a few weeks to a few seconds. Natural language processing was shown to be powerful for quickly converting large amount of semi-structured or unstructured clinical data into discrete concepts, which in combination of intuitive domain specific ontologies, allows fast and effective interactive cohort identification through the i2b2 platform for research and clinical use.

Impaired olfaction and risk of delirium or cognitive decline after cardiac surgery.

To determine the prevalence of impaired olfaction in individuals presenting for cardiac surgery and the independent association between impaired olfaction and postoperative delirium and cognitive decline. Nested prospective cohort study. Academic hospital. Individuals undergoing coronary artery bypass, valve surgery, or both (n = 165). Olfaction was measured using the Brief Smell Identification Test, with impaired olfaction defined as an olfactory score below the fifth percentile of normative data. Delirium was assessed using a validated chart review method. Cognitive performance was assessed using a neuropsychological testing battery at baseline and 4 to 6 weeks after surgery. Impaired olfaction was identified in 54 of 165 participants (33%) before surgery. Impaired olfaction was associated with greater adjusted risk of postoperative delirium (relative risk = 1.90, 95% confidence interval = 1.17-3.09, P = .009). There was no association between impaired olfaction and change in composite cognitive score in the overall study population. Impaired olfaction is prevalent in individuals undergoing cardiac surgery and is associated with greater adjusted risk of postoperative delirium but not cognitive decline. Impaired olfaction may identify unrecognized vulnerability to postoperative delirium in individuals undergoing cardiac surgery.

Incidence and Characteristics of Polycythemia Vera, Essential Thrombocythemia and Primary Myelofibrosis in Thailand: A 5-Year Retrospective Study

Background: Polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF) are members of myeloproliferative neoplasm group. They shared common features such as JAK2 V617F+ mutation, thrombosisor hemorrhage, progression to marrow fibrosis or acute leukemia.Objective: To study incidence and clinical characteristics of PV, ET and PMF with complications and treatment modalities in Thailand.Study Designs: Retrospective chart reviewMethods: All JAK2 V617F+ and V617F- mutation patients during 2008-2012 were reviewed for demographic data, diagnosis of PV, ET and PMF according to WHO 2008 criteria, complications and treatment.Results: 363 of 735 patients were 140 PV, 172 ET, 47 PMF and 4 MPN-U. 372 patients were excluded due to routine thrombotic workup (98), secondary erythrocytosis (97), reactive thrombocytosis (55), CML (26), HES/eosinophilia (24), MPN/MDS (3), others (69). In PV, JAK2 V617F+ and JAK2 exon 12 mutation patients were 106 and 2. PV showed male:female ratio of 85:55, mean age 57.7 year (11-86), mean hemoglobin 17.6 g/dl (6.7-24.6), and received aspirin (125), hydroxyurea (116), phlebotomy (84), clopidogrel (10), warfarin (7), anagrelide (6), busulfan (5) and each for interferon, oxymethalone, corticosteroid, and JAK inhibitor. Thrombosis:hemorrhage was 34:16. Myelofibrosis and AML transformation were 7 and 2. In ET, JAK2 V617F+ patients were 121. ET showed male:female ratio of 83:89, mean age 59.45 year (14-91), mean platelet count 924,168/mm3 (283,000-2,235,000), and received aspirin (140), hydroxyurea (139), anagrelide (47), warfarin (11), clopidogrel (7), erythropoietin (6), oxymethalone (3), busulfan (3), corticosteroid (2), interferon (1) and splenectomy (1). Thrombosis:hemorrhage was 52:16. Myelofibrosis and AML transformation were 4 and 1. In PMF, JAK2 V617F+ patients were 32. PMF showed male:female ratio of 21:26, mean age 62.2 year (23-81), mean hemoglobin 8.6 g/dl (3.7-15.5), mean subcostal splenic size 10 cm (1-26) and received hydroxyurea (26), erythropoietin (16), corticosteroid (10), oxymethalone (8), JAK inhibitor (7), transfusion dependency (6), aspirin (3), warfarin (2) and each for anagrelide, thalidomide, splenectomy and allogeneic transplantation. Thrombosis:hemorrhage was 4:5. AML transformation was 4. In multivariate analysis, previous thrombosis, clopidogrel use, splenomegaly, alcohol use and JAK2 V617F+ were independent risk factors for thrombosis.Conclusion: PV, ET and PMF carry high risk for vascular events. DisclosuresKhuhapinant:Roche: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Celgene: Honoraria. Phikulsod:Novartis: Honoraria. Siritanaratkul:Novartis: Research Funding; Roche: Research Funding; Janssen: Research Funding.

Pseudo-outbreak of rotavirus infection in a neonatal intensive care unit.

A rotavirus outbreak in a neonatal intensive care unit (NICU) may have catastrophic consequences for young infants receiving critical care. From May 13, 2011 to July 11, 2011, a significant increase in stool samples testing positive for rotavirus antigens in the NICU of a university affiliated hospital was observed. Due to lack of clinical presentations suggestive of rotavirus infection in the patients and the rarity of rotavirus infection in the NICU in the past, a pseudo-outbreak was suspected. Infection control measures were reinforced initially. To investigate the outbreak, a prospective laboratory-based active surveillance of all infants in the NICU was conducted right after the cluster was identified. Repeated testing using a modified enzyme immunoassay (EIA) kit, rotavirus RNA polyacrylamide gel electrophoresis (PAGE), reverse transcription polymerase chain reaction (RT-PCR), and retrospective chart review methods were used to confirm the pseudo-outbreak. Seven infants in the NICU, with or without gastrointestinal symptoms, tested positive for the rotavirus antigen using the old version of an EIA kit, which indicated a possible outbreak. Active surveillance with repeated tests for recollected stool samples using a modified EIA kit showed negative results in all 24 infants in the NICU. Seven stored stool samples from four infants, which previously tested positive for the rotavirus antigen, tested negative for rotavirus using the modified EIA kit, PAGE, and RT-PCR. Chart reviews showed no clinical difference between index cases and controls. False positivity might arise from unsatisfactory specificity of the old EIA kit. After the introduction of the modified EIA kit, no rotavirus was detected in the NICU for at least 7 months. This cluster of patients who tested positive for the rotavirus antigen in stools was confirmed to be a pseudo-outbreak. Interpretation of the old EIA for rotavirus in an NICU setting should be done with caution until the mechanism of the false-positive reaction is elucidated.

COLLECTION, DETECTION, ASSESSMENT, MONITORING AND PREVENTION OF ADVERSE DRUG REACTIONS OF ANTI-EPILEPTIC DRUGS

An adverse drug reaction (ADR) as defined by World Health Organization (WHO) is a noxious, unintended effect of a drug, occur ring at normal doses in humans for prophylaxis, diagnosis or therapy of disease or for the modification of physiological function. ADRs rank among the top ten leading causes of mortality. The adverse effects (AEs) of antiepileptic drugs (AEDs) are highly prevalent and can be potentially life threatening . The objective of this study is to identify the ADR by chart review method, to determine the causality of the ADR by Naranjo’s algorithm, to analyze the severit y of the ADR by modified Hartwig method and to motivate the health care prof essionals to report ADRs in Neu rology ward of Gauhatu Medical College and Hospital (GMCH), Guwahati , Assam, India. Preventability of ADR is done by Schumock and Thorton preventability scale. A prospective observational and hospital bas ed case control study (Jan 2011 - Dec 2011 ) was carried out in th e Neu rology ward of GHMC, including both out - patient and in - patient departments. All the values are statistically determined and expressed as Mean ± SD Graph Pad prism - 5 statistical software was used for the data analysis. Statistical significance was def ined as p < 0.05. All P values were two tailed. Out of the 2880 patients treated with AEDs for various indications, 85 (2.95 %) patients were reported with an incidence of 1 or more ADRs. The most common ADR involved the CNS (44 cases). Among them ataxia w as found to be the most frequently reported (15 cases), followed by nystagmus (14 cases) and somnolence (9 cases). 37 cases involved the skin and connective tissue, the most common complaint being gum hypertrophy (23 cases). GI apparatus and liver involved 41 cases, the most frequent being nausea/vomiting (21 cases) and poor appetite (12 cases). Out of the 134 ADRs recorded, most of the ADRs were of Type A (n = 80, 59.70 %), followed by Type C (n = 37, 27.61 %), Type B (n = 16, 11.94 %) and Type D (n = 1, 0 .75 %). Phenytoin resulted in a total of 38 (44.7 %) ADRs when prescribed as mono therapy followed by Sodium Valproate which caused a total of 19 (22.35 %) ADRs when prescribed alone. Anti - epileptic drugs have narrow therapeutic index, physician should be encouraged to do therapeutic drug monitoring in order to ensure effective treatment and prevent adverse drug reactions.

Preoperative Systemic Antimicrobial Prophylaxis in Contaminated Middle Ear Surgery for Cholesteatoma

Objectives: Evaluate the efficacy of combined anti-staphylococcal and anti-pseudomonal preoperative antibiotics for preventing surgical site infections following tympanoplasty and mastoidectomy (TM) with contaminated cholesteatoma. Methods: Study Design: Retrospective chart review Method: Medical records of patients who underwent TM for cholesteatoma were reviewed. Only cases considered to have contaminated or dirty/infected surgical fields were included. Patients were excluded if there was preexisting infection or intraoperative finding requiring systemic antibiotic therapy. The primary outcome measure was postoperative perichondritis, pinna abscess, peri-otic cellulitis, and peri-otic abscess requiring systemic antibiotics or surgical intervention. Results: The charts of 362 patients who underwent TM were reviewed. 195 met inclusion criteria. Preoperative antibiotics included clindamycin and ceftazidime or gentamicin. Patients treated with no perioperative antibiotics had an infection rate of 11% and those treated with perioperative antibiotics had a rate of 1% ( P = .02). Conclusions: The use of preoperative antibiotics to cover staphylococcal and pseudomonal species prevented surgical site infections as compared to no perioperative antibiotics.

The relationship between a chief complaint of "altered mental status" and delirium in older emergency department patients.

Altered mental status is a common chief complaint among older emergency department (ED) patients. Patients with this chief complaint are likely delirious, but to the authors' knowledge, this relationship has not been well characterized. Additionally, health care providers frequently ascribe "altered mental status" to other causes, such as dementia, psychosis, or depression. The objective was to determine the relationship between altered mental status as a chief complaint and delirium. This was a secondary analysis of a cross-sectional study designed to validate three brief delirium assessments, conducted from July 2009 to March 2012. English-speaking patients who were 65 years or older and in the ED for <12 hours were included. Patients who were comatose or nonverbal or unable to follow simple commands prior to the acute illness were excluded. Chief complaints were obtained from the ED nurse triage assessment. The reference standard for delirium was a comprehensive psychiatrist assessment using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivity, specificity, positive likelihood ratio (LR), and negative LR with their 95% confidence intervals (CIs) were calculated using the psychiatrist's assessment as the reference standard. A total of 406 patients were enrolled. The median age was 73.5 years old (interquartile range [IQR] = 69 to 80 years), 202 (49.8%) were female, 57 (14.0%) were nonwhite race, and 50 (12.3%) had delirium. Twenty-three (5.7%) of the cohort had chief complaints of altered mental status. The presence of this chief complaint was 38.0% sensitive (95% CI = 25.9% to 51.9%) and 98.9% specific (95% CI = 97.2% to 99.6%). The negative LR was 0.63 (95% CI = 0.50 to 0.78), and the positive LR was 33.82 (95% CI = 11.99 to 95.38). The absence of a chief complaint of altered mental status should not reassure the clinician that delirium is absent. This syndrome will be missed unless it is actively looked for using a validated delirium assessment. However, patients with this chief complaint are highly likely to be delirious, and no additional delirium assessment is necessary.

A tale of two methods: chart and interview methods for identifying delirium.

To compare chart- and interview-based methods for identification of delirium. Prospective cohort study. Two academic medical centers. Individuals aged 70 and older undergoing major elective surgery (N = 300) (majority orthopedic surgery). Participants were interviewed daily during hospitalization for delirium using the Confusion Assessment Method (CAM; interview-based method), and their medical charts were reviewed for delirium using a validated chart-review method (chart-based method). Rate of agreement of the two methods and characteristics of those identified using each approach were examined. Predictive validity for clinical outcomes (length of stay, postoperative complications, discharge disposition) was compared. In the absence of a criterion standard, predictive value could not be calculated. The cumulative incidence of delirium was 23% (n = 68) according to the interview-based method, 12% (n = 35) according to the chart-based method, and 27% (n = 82) according to the combined approach. Overall agreement was 80%; kappa was 0.30. The methods differed in detection of psychomotor features and time of onset. The chart-based method missed delirium in individuals that the CAM identified who were lacking features of psychomotor agitation or inappropriate behavior. The CAM-based method missed chart-identified cases occurring during the night shift. The combined method had high predictive validity for all clinical outcomes. Interview- and chart-based methods have specific strengths for identification of delirium. A combined approach captures the largest number and broadest range of delirium cases.

Revisiting Retrospective Chart Review: An Evaluation of Nursing Home Palliative and End-of-Life Care Research

Objective: Retrospective chart review is a popular method of data collection in palliative and end-of-life care research. This paper provides an evaluation of the reliability and validity of this method in the long-term care home-based palliative and end-of-life care research literature. Methods: Eight criteria were used to critically evaluate the reliability and validity of the retrospective chart review data collection methods in (n=13) studies meeting inclusion criteria. Results: Only two criteria: defining both the important variables, and inclusion and exclusion criteria, which largely demonstrate validity, were consistently well described in this body of literature. However, the criteria used to mainly demonstrate the reliability of the method, especially data abstractors’ monitoring and blinding, and testing for inter-rater reliability, were not well addressed. Conclusion: Overall, there was a limited description of the measures used for evaluating the validity, and especially the reliability of the retrospective chart review method included in the long-term care home-based, palliative care literature. As such, readers should proceed with caution when using this source of literature to inform palliative care research and practice, and carefully consider the inclusion of the measures of validity and reliability. Additionally, palliative care researchers should carefully consider the source of data as well as an instructional guideline when engaging in retrospective chart reviews.

Staying Out of Trouble

Staying Out of Trouble