Inadequate Documentation Research Articles

The importance of independent chronology in integrating records of past climate change for the 60–8 ka INTIMATE time interval

This paper provides a brief overview of the most common dating techniques applied in palaeoclimate and palaeoenvironmental studies including four radiometric and isotopic dating methods (radiocarbon, 230Th disequilibrium, luminescence, cosmogenic nuclides) and two incremental methods based on layer counting (ice layer, varves). For each method, concise background information about the fundamental principles and methodological approaches is provided. We concentrate on the time interval of focus for the INTIMATE (Integrating Ice core, MArine and TErrestrial records) community (60–8 ka). This dating guide addresses palaeoclimatologists who aim at interpretation of their often regional and local proxy time series in a wider spatial context and, therefore, have to rely on correlation with proxy records obtained from different archives from various regions. For this reason, we especially emphasise scientific approaches for harmonising chronologies for sophisticated and robust proxy data integration. In this respect, up-to-date age modelling techniques are presented as well as tools for linking records by age equivalence including tephrochronology, cosmogenic 10Be and palaeomagnetic variations. Finally, to avoid inadequate documentation of chronologies and assure reliable correlation of proxy time series, this paper provides recommendations for minimum standards of uncertainty and age datum reporting.

Abstract 173: A Comparison of Administrative Claims Discharge Diagnosis with Electronic Medical Record Problem List in the Diagnosis of Acute Myocardial Infarction

Background: Administrative claims data are commonly used for measurement of mortality and readmissions in Acute Myocardial Infarction (AMI). With advent of the Electronic Medical Record (EMR), the electronic problem list offers new ways to capture diagnosis data. However, no data comparing the accuracy of administrative claims data and the EMR problem list exists. Methods: Two years of admissions at a single, quaternary medical center were analyzed to compare the presence of AMI diagnosis in administrative claims and EMR problem list data using a 2x2 matrix. To gain insights into this novel method, 25 patient admissions were randomly selected from each group to undergo physician chart review to adjudicate a clinical diagnosis of myocardial infarction based on the universal definition. Results: A total of 105,929 admissions from January 1, 2010 to December 31, 2011 were included. Where EMR problem list and administrative claims data were in agreement for or against AMI diagnosis they were highly accurate. Where administrative claims data, but not EMR problem list, reported AMI the most common explanation was true AMI with missing EMR problem list diagnoses (60%). Less common reasons for discordance in this category include: (1) administrative coding error (20%), (2) computer algorithm error (8%), (3) patient death before EMR problem list created (4%), (4) EMR problem list not used (4%) and (5) AMI diagnosis was removed from EMR problem list (4%). Where EMR problem list, but not administrative claims data, reported AMI the most common explanation was no AMI with historical diagnosis of AMI from a previous admission (60%). Less common reasons for discordance in this category include: (1) AMI present but not the principal diagnosis (32%), (2) administrative coding error (4%) and (3) erroneous EMR problem list entry (4%). Conclusion: Compared to administrative and chart review diagnoses, we found that using the EMR problem list to identify patient admissions with a principal diagnosis of AMI will overlook a subset of patients primarily due to inadequate clinical documentation. Additionally, the EMR problem list does not discriminate the admission principal diagnosis from the secondary diagnoses.

Abstract 245: Achieving Appropriate Use Metrics for Angioplasty

Background: With the development of appropriate use metrics for coronary angioplasty, application of these criteria to the NYS PCI data base resulted in 14.3% of PCIs in NYS being deemed “inappropriate”. While “inappropriate” has been changed to “rarely appropriate’’ in professional society guidelines, public interpretation of this designation, medicolegal issues, and reimbursement for procedures in this category remain concerns. Because the bulk of PCI procedures are ad hoc, appropriateness of treatment is largely determined by preprocedural documentation and treatment. Procedure: The 2010 SBUH “inappropriate” PCI rate from NYS was utilized as a baseline and compared with post intervention Qtr 4, 2012 - Qtr 3, 2013. Trained abstractors audited charts to identify patients that would potentially be classified “inappropriate” and determine which data elements were missing most frequently. A preprocedural screening tool was developed and implemented to establish PCI appropriateness as supported by adequate documentation and preprocedural medical therapy. Pretest outpatient NP screening identified and addressed concerns identified by using the preprocedural tool. A monthly meeting was organized where Physician Specific compliance reports that had been created were reviewed. Results: Baseline “inappropriate” interventions at SBUH comprised 24.8% of total PCI. Inappropriate classification was due to both inadequate documentation and less than optimal medical therapy. Implementation of the PCI AU tool resulted in a sustained decline in the “inappropriate” procedures to 1.6% (NCDR mean 2.5% for this time period). An additional unanticipated benefit of the process has been that the feedback provided to referring attendings continues to improve required documentation and medical therapy supporting PCI revascularization. The tool will be shared at presentation. Conclusions: The combination development of a PCI screening tool for potential ad hoc intervention patients and outpatient review of documentation and medical therapy allowed a substantial improvement in PCI appropriateness. Appropriate feedback to referring physicians augmented the effect of these process changes and improved appropriate utilization.

English

Little is known about the quality of procedures performed on general internal medicine inpatients. Many general medical in-patients require diagnostic or therapeutic procedures, such as thoracentesis, paracentesis, joint aspiration, and lumbar puncture. While some data exist regarding the safety of specific procedures, little is known about other important measures of quality, such as success rate, adequacy of the diagnostic specimens obtained, wait time, accuracy and completeness of clinical documentation, and patient satisfaction. Although increasing numbers of procedures are being performed by interventional radiologists, the impacts of this shift have not been well studied.During the course of a 2-week quality improvement audit, the authors observed a high frequency of unsuccessful bedside procedures, instances of inappropriate diagnostic testing, inadequate documentation, and lapses in communication. This should be a call to action for general internists to better characterize the quality of in-patient procedures.

Shortfalls in residents' transfer documentation: challenges for emergency department staff.

Increasing numbers of residents are transferred from aged care facilities to emergency departments. Frequently, residents arrive with inadequate documentation regarding their presenting complaint or medical history, making it difficult for emergency department staff to make decisions about care. A retrospective review of emergency department records was undertaken for residents transferred from residential aged care facilities to two emergency departments in Melbourne, Victoria in 2012. 2880 resident transfers were included in the sample, of which 408 transfers were randomly selected for documentation review. Clinically important documentation was frequently absent including: the reason for transfer to the ED (n=197, 48.2%); baseline cognitive function (n=244, 59.7%); and vital signs at time of complaint (n=285, 69.9%). When the reason for transfer was absent, residents with an altered conscious state had more investigations and spent longer in the emergency department than when the reason for transfer was recorded. Inadequate documentation negatively impacted the resident's journey through the emergency department. There is evidence that inadequate documentation contributes to poor patient outcomes. To minimise the gaps in the transfer documentation regular staff development and quality assurance programs may be required in residential aged care facilities.

Short-term outcomes of the implementation of a computer-based breast cancer risk assessment program during screening mammography.

Barriers to assessing a patient's risk for breast cancer include the inadequate documentation of family history, the complexity of risk calculation and model selection, and a lack of awareness of risk on the part of the patient and/or provider. We have established computer-based, real-time assessment of a patient's risk for breast cancer at the time of having a mammogram. To facilitate identifcation of high-risk patients who need genetic counseling and testing and magnetic resonance imaging screening based on the results of the risk assessment. Since November 23, 2010, all mammogram patients have completed questionnaires using a wireless tablet. On the basis of a real-time calculation for a patient's risk of BRCA1/BRCA2 mutation (Myriad, Tyrer-Cuzick, BRCAPRO) and lifetime risk of breast cancer (Gail, Claus, Tyrer-Cuzick, BRCAPRO) using Hughes riskApps, patients were categorized as high risk (≥ 10% BRCA mutation or ≥ 20% lifetime breast cancer risk) or average risk and received a risk assessment letter. The risk data was integrated into our mammography information system (PenRad) at the same time. High-risk patients were contacted to facilitate evaluation. As of June 30, 2012, a total of 24,213 unaffected patients completed the risk assessment. There were 2,196 patients (9.1%) identifed as high risk: 1,051 (4.3%) had a BRCA mutation risk, 1,570 (6.5%) had lifetime breast cancer risk, and 425 (1.8%) had risk for both. Of the high-risk patients, 416 (18.7%) were evaluated by our APN and/or genetic counselor. Of the 231 who were evaluated by a genetic counselor, 97 had genetic testing and 9 (8.3%) were BRCA positive. Annual MRI screening was recommended to 254 patients. We have successfully implemented breast cancer risk assessment through our screening mammography service. Results suggest that 9.1% of our patients can beneft from risk assessment, 4.3% should consider genetic testing, and 6.5% may benefit from screening MRI. We strive to improve compliance through patient education.

Classificação do atraso e da incapacidade no desenvolvimento precoce com a CIF – OMS

As iniciativas para prevenir ou reduzir o atraso de desenvolvimento em crianças estão bem estabelecidas na EU e em Portugal, mas o uso de inadaptadas formas de classificação e registo de incapacidade na infância introduz significativa variabilidade na descrição das crianças em programas de intervenção precoce, Isso acarreta problemas na definição de critérios de elegibilidade, na descrição uniforme da população e na derivação das estimativas de incidência e prevalência. É assim necessário um método abrangente de classificação e documentação que possa abarcar as dimensões de incapacidade e limitações funcionais nos primeiros seis anos de vida. A Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) da OMS, 2001, fornece um referencial universal para definir a funcionalidade, actividade, participação e factores ambientais. A Classificação Internacional das Doenças (CID – 10) permite atender a condições de saúde específicas que essas crianças possam acumular, fornecendo informação complementar sobre as etiologias, condições de saúde e manifestações funcionais de deficiência. Neste artigo, descreve-se um recente algoritmo que integra os códigos dessas duas classificações em 4 categorias principais correspondentes ao modelo da COF. Esse sistema de classificação tem vindo a ser largamente aplicado nos EUA, na codificação de razões de elegibilidade (National Early Intervention Longitudinal Study) sendo, também, descrita a experiência da sua adaptação em Portugal, com sucesso, na classificação e documentação das características das crianças em intervenção precoce.DOI: http://dx.doi.org/10.17575/rpsicol.v17i1.437

Open Source Software Selection Using an Analytical Hierarchy Process (AHP)

There are many potential and good open source software (OSS) products available on the market with a free license. However, with various choices, the adoption rate is still low among potential users because there is not an agreed acceptable set of criteria to evaluate and select various OSS. The criteria of selection may differ between the stakeholders within the organisations. There is a tendency that the user may have a biased perception of an OSS’s characteristics or capabilities for solving problems when selecting OSS products. Other restrictions are caused by inadequate documentation and user manuals, and immature products. Therefore, the users need to consider how to improve their decision making when selecting the most suitable OSS products. In this paper, the background research on the proposed OSS adoption and criteria of selection are discussed and explored. Then the research methodology, processes and implementation of the My Open Source Software Toolkit (MyOSST) v1.0 are covered. The analytical hierarchy process (AHP) was applied on the selection process and for the purpose of assisting the potential user to decide on the OSS products based on their preferred selection criteria. MyOSST v1.0 was tested and validated by IT professionals in one of the Malaysian universities. The results show that the tool is capable of assisting the decision making process for selecting an appropriate OSS product.

Technology Focus: Well Integrity (January 2014)

Technology Focus Statistics on well-integrity incidents are difficult to find in the literature. There are some examples of kick and blowout events, but normally they are scarce and focus on the number of incidents and their root causes. There is, however, one example of statistics that has been inspiring me throughout the years when I prepare my lectures on how we can drill, complete, and produce wells safely. It is one that is presented in the excellent textbook on high-pressure/high-temperature wells published by Aberdeen Drilling Schools that shows human factors related to offshore blowouts. On the basis of those statistics, I divided these factors into four groups: (1) inattention to operations (25%) and inadequate supervision/work supervision (20%); (2) improper maintenance of equipment (20%) and improper installation/inspection of equipment (2%); (3) inadequate documentation (2%) and improper method or procedure (11%); and (4) improper planning (12%). No direct human error involved was stated for the remaining 8%. Here, I will show how these factors can be addressed to make a well-integrity system efficient. The first group represents 45% of the human factors related to offshore blowouts. One efficient way to address it is through training and assurance of personnel competence. A well-integrity system implemented by any company of the oil industry can be robust only if it strongly considers this aspect. Regrettably, this topic only barely appears in the literature and conferences on the topic of well integrity. Recently, the International Oil and Gas Producers Association presented appropriate recommendations for technical enhancements to well-control training, examination, and certification that can be extended to other activities related to well integrity. The second group encompasses well-equipment-related issues. An adequate well-integrity system should have the necessary safety barriers in place, understood, tested, verified, and maintained. It should also have proper contingencies in case of failure of these primary barriers. The third group refers to documentation. Currently, there is a strong movement toward elaborating or revising regulations related to well integrity by entities such as the American Petroleum Institute and the International Organization for Standardization. Creation of new or improvement of existing design and operational procedures that result in safer operations throughout a well’s life cycle is mandatory for an effective well-integrity system. It is also important that any well-integrity anomaly be documented, analyzed, and transmitted to all involved parties. The last group refers to planning. Many well failures are a result of poor well design and operation planning. A strong well-integrity system should rely deeply on approaches such as risk assessment, management of changes, action plans, and design basis. JPT Recommended additional reading at OnePetro: www.onepetro.org. SPE/IADC 163417 Detection of Kicks Prompted by Losses and Direct- Measurement Well-Control Method Through Networked Drillstring With Along-String Pressure Evaluation by Daan Veeningen, NOV IntelliServ SPE/IADC 163445 Feasibility Study of Applying Intelligent Drillpipe in Early Detection of Gas Influx During Conventional Drilling by Karimi Vajargah, The University of Tulsa, et al. SPE/IADC 163438 Analysis of Potential Bridging Scenarios During Blowout Events by S.M. Wilson, Apache, et al.

Inadequate resuscitation documentation in older patients' clinical case notes

This research examined the quality of resuscitation decisions documented in the clinical notes of 99 older patients within 48 h of admission. Only 34 had current documentation that was frequently inconsistent and ambiguous, leaving patients at risk of receiving inappropriate and unwanted resuscitation. Clear guidelines with community input to guide the implementation and documentation of end-of-life decisions are essential.

Silenced Suffering

This article has two overall goals. First, to examine the current state of sexual violence research to highlight several shortcomings in the knowledge on partner sexual violence. Second, to describe several factors to consider in future research to facilitate a more in-depth understanding of partner sexual violence. Shortcomings of the research on partner sexual violence include (1) overreliance on dichotomous yes/no representations of sexual violence experiences; (2) lack of, or inadequate documentation of the scope and nature of partner sexual violence; (3) inadequate ways to account for impairment of consent under different circumstances; (4) difficulties in discriminating unwanted from nonconsensual sexual activities; and (5) limited information about the role sexual violence plays in the larger context of coercive control. In order to facilitate a more in-depth understanding of partner sexual assault, there is a need (1) to better understand the scope and nature of partner sexual assault and (2) to better understand the role partner sexual violence plays in coercive control. By improving the measurement of this phenomenon, victims, researchers, practitioners, and those involved in the justice system might be better equipped to respond to sexual violence among intimate partners.

Desakralizacja folkloru − jej przejawy muzyczne i kulturowe

The religious dimension of traditional culture – crucial to the understanding of the rituals which form a commentary on the cycle of the life of nature (annual rituals) and the life of humankind (family rituals) – is of particular importance, but it is also difficult to research. The ethnologists who documented folklore were sensitive to this aspect of culture (i.e. the suprasensory life) even as early as the eighteenth century, but they did not know how to document it correctly, and imposed their own ideas – e.g., deistic ones – on the mentality and the imagination of the rustic population as revealed in their art. Incomplete (i.e., concerned with selected aspects of culture and art) and not very accurate documentation (searching for folklore’s original versions, e.g., the brothers Grimm) resulted in the creation of standards of fairytales or songs which make reading their content and interpreting their form correctly more difficult today. Yet in folklore the content, the form and the function were organically bound together. This rather inadequate documentation encouraged erroneous interpretations, and even the mythologising of folklore in later periods, Documentation was shaped to fit in with the assumptions and ideas of the researchers, thus falsifying, in particular, the unique character of folk symbolism and poetics, the distinctiveness of folk thinking. In fact, it was not until the nineteenth century that Oskar Kolberg created reasonably full and reliable documentation of folk art – viewed in the context of traditional culture and nature – in his monumental work Lud, jego zwyczaje, sposób życia, mowa, podania, przysłowia, obrzędy, gusła, zabawy, pieśni, muzyka i tańce [People, their customs, way of life, speech, legends, proverbs, rituals, magic, games, songs, music and dances] (1856–1890 – 33 volumes). Ritual folklore, still quite active at that time, reveals both the multifunctionality of forms (associated with the musical and poetic styles), as well as the hierarchical order of functions and values – from the religious, through ethical, aesthetic, cognitive and socialising ones, to the ludic function.At the same time ritual folklore reveals a tendency towards an increasingly prominent emphasis on the ludic function, at the expense of functions concerned with belief, religion and philosophy. This can be seen in the gradual disappearance of archaic ritual chants with original tonal-melodic patterns, slow tempos and a-metric structure. These chants were a manifestation of a contemplative-reflective attitude towards the world and towards life, regarded as sacred. In the twentieth century, harvest chants represented a relic of this attitude. The unique nature of rustic culture expressed in these chants was investigated by E. JagiełłoŁysiowa (Elementy stylów życia ludności wiejskiej [Elements of lifestyles of the rural population], 1978). She emphasised the changes taking place in the attitudes of peasants towards nature, and in particular towards the nourishing Mother Earth and work on the land; these were losing the religious dimension in favour of an economic approach towards all work, while the ritual celebrations were gradually becoming predominantly a form of entertainment. Replacing the ritual chants with ditties, frequently of a lewd character (at one time these forms complemented each other), is a symptom of the changes – the disappearance of the contemplative-reflective attitude to the life of nature and humankind, the loss of the sacral dimension. The archaic style of chanting thus disappears as well.

Metrics for the Human Proteome Project 2013–2014 and Strategies for Finding Missing Proteins

One year ago the Human Proteome Project (HPP) leadership designated the baseline metrics for the Human Proteome Project to be based on neXtProt with a total of 13,664 proteins validated at protein evidence level 1 (PE1) by mass spectrometry, antibody-capture, Edman sequencing, or 3D structures. Corresponding chromosome-specific data were provided from PeptideAtlas, GPMdb, and Human Protein Atlas. This year, the neXtProt total is 15,646 and the other resources, which are inputs to neXtProt, have high-quality identifications and additional annotations for 14,012 in PeptideAtlas, 14,869 in GPMdb, and 10,976 in HPA. We propose to remove 638 genes from the denominator that are "uncertain" or "dubious" in Ensembl, UniProt/SwissProt, and neXtProt. That leaves 3844 "missing proteins", currently having no or inadequate documentation, to be found from a new denominator of 19,490 protein-coding genes. We present those tabulations and web links and discuss current strategies to find the missing proteins.

Resident Awareness of Documentation Requirements and Reimbursement: A Multi-Institutional Survey

The current economic environment necessitates efforts to prevent avoidable losses in clinical revenue in academic cardiothoracic surgery programs. Inadequate documentation frequently results in delayed, denied, or reduced reimbursement. With the recent increase in integrated residency programs, documentation and compliance are becoming increasingly dependent on junior residents; however, their understanding of reimbursement and documentation guidelines is currently unknown. An electronically distributed, multi-institutional survey of 6 general and subspecialty surgery programs was conducted consisting of open-ended numeric estimation of Medicare reimbursement for various levels of patient encounters. Closed-ended questions were used to assess resident knowledge of documentation requirements, accompanied by self-estimated compliance with those requirements. Thirty-seven percent (n = 106) of residents completed the survey. Most residents (77%) believe they play the primary role in documentation; however, knowledge of and compliance with higher level documentation practices range from 19% to 78% and 41% to 76%, respectively. On average, residents overestimate Medicare reimbursement of lower level encounters by as much as 77% and underestimate higher level encounters by as much as 38%. In many cases, the standard deviation of residents' estimates approaches the actual reimbursement value. Residents have a limited knowledge of documentation requirements. Self-reported compliance, even when guidelines are known, is low. Estimation of financial reimbursement is extremely variable. Residents overestimate reimbursement of lower level encounters and underappreciate reimbursement at higher levels. Ensuring appropriate reimbursement for services rendered will require formal cardiothoracic resident education and ongoing quality control.

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Introduction: Alteplase (recombinant tissue plasminogen activator) is the primary therapeutic option to noninvasively salvage an occluded catheter due to thrombus. The use of alteplase as a dwell to clear partially occluded central venous catheters has been well documented; however, the practice of using a low-dose 3-hour infusion has been in place for many years at our institution. The purpose of this study was to evaluate the efficacy and safety of alteplase infusions versus dwells to clear partially occluded central venous catheters in a pediatric intensive care unit (PICU) population over the same period of time. Methods: Medical records of PICU patients who received either an alteplase infusion or dwell as the primary treatment for a partial catheter occlusion from November 2006 through August 2011 were retrospectively reviewed for efficacy and safety. All types of central venous catheters were included. Infusion regimens were typically alteplase 0.1 mg/kg up to 2 mg mixed in 25 mL normal saline and infused over 3 hours; dwells consisted of 1 mg/mL alteplase instilled for up to 2 hours in doses ranging from 0.5 mg to 2 mg based on catheter lumen size per manufacturer recommendations. Efficacy was defined as documentated positive blood return from the catheter at the conclusion of the infusion or dwell. Physician, nursing and radiology documentation and laboratory values were reviewed to assess for bleeding events. Results: Of 346 alteplase orders, 261 were excluded for the following reasons: 2, systemic thrombolysis; 4, chest tube instillations; 19 infusions: dose not given or inadequate documentation to assess outcome; 192 dwells: full occlusion or unknown occlusion type. Eighty-five infusions and 64 dwells occurred during the study period and were included for analysis. Occlusions were cleared after the first alteplase dose in 71 of 85 (84%) of infusions compared to 49 of 64 (77%) of dwells; p=.289, 2-sided Fisher's exact test. In situations where the first dose failed to clear the occlusion, repeat doses were successful in one patient in the infusion group and in two patients in the dwell group, bringing the overall efficacy to 85% for infusions and 80% for dwells; p=.514. No bleeding events were attributed to alteplase. Conclusions: Alteplase low-dose 3-hour infusions were not found to be more effective than dwells for clearing partial central venous catheter occlusions in this retrospective study. The small sample size and the large number of cases with missing or inadequate documentation regarding catheter patency limited the interpretation of efficacy outcomes. Both regimens were associated with an acceptable safety profile.

Plant recruitment and survival as indicators of ecological restoration success in abandoned pasture land in Nurcoung, Victoria, Australia

IntroductionOne of the major impediments to developing better restoration strategies is the inadequate documentation of past restoration efforts. In 2008, Greening Australia commenced ecological restoration on the Nurcoung property in Victoria to enhance local biodiversity, and in this paper we report on the habitat restoration outcomes in the three Ecological Vegetation Classes (EVC) found on this property.MethodsPermanent sample plots (12 × 20 m) were randomly established in July 2010 in each of the restoration areas, with 9, 10, and 24 plots demarcated in Shallow Sands Woodland (SSW), Heathy Woodland (HW), and Sandstone Ridge Woodlands (SRW), respectively. Individual plots were prepared to include three seeded rows. Plots were assessed for seedling recruitment and survival in May 2010, April 2011, and May 2012. Records of individual seedling development included their height and cover, and their location within the plot.ResultsOur study shows that interaction between the age of the planted and direct-seeded vegetation and the nature of the EVC significantly affects the composition of plants and the soil surface in that species and, further, that soil cover parameters develop in different ways in the different experimental plots. A SIMPER analysis of soil cover parameters shows that most of the variation over the years of restoration is attributable to differences in the amount of bare soil recorded, rather than the amount of leaf-litter cover, and that these changes in soil cover parameters differ between EVCs over the sampling periods.The direct-seeding study shows that whilst most of the broadcast species were recruited, some species used in the Shallow Sands Woodland, the Heathy Woodland, and the Sandstone Ridge Shrubland did not show evidence of recruitment during the three sampling periods. Although the density of most seedlings increased in subsequent sampling years, the planted species Callitris gracilis, Callitris rhomboidea, Hakea muelleriana, and Melaleuca lanceolata did not survive.ConclusionsAs a result of the land use change, new assemblages of abiotic and biotic system components appear to lead to the development of stable alternative ecological states. These ‘novel’ ecosystems now play an important part of the natural resource base, requiring careful characterization to better understand current development trajectories and future states, and to inform management strategies to meet desired restoration outcomes. Although the study sites have been abandoned for a long time, broadcast seeds and plant seedlings show they can overcome internal resilience.

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Introduction: Each year more than half a million Americans die in or after ICU treatment and many others remain debilitated with severe functional and cognitive impairments. These growing numbers require more innovation within palliative care and have been identified as a healthcare priority. In 2006 after several years of research the care and communication bundle was published with support of many medical organizations. The bundle consists of identifing the medical decision-maker, determining advance directives and code status, distribution of a family information packet, regular pain assessment with optimal pain management, offering of social work and spiritual support and a interdisciplinary family meeting. Research has shown that consistent application of these elements has not occurred. Methods: In April of 2012 a intergrated multidisciplinary team was created to evaluate our compliance with the care and communication bundle. Our team was comprised of critical care physicians, nurse practitioners, physician assistants, nurses, a social worker, and an administrative assistant with data collection knowledge. The project occurred in a 18 bed Neurosurgical ICU in an 800 bed teaching and tertiary care center in New England. Results: The team performed a retrospective chart review over a 5 week period from April 2012-May 2012 to assess compliance with the bundle. There were 151 patients admitted during this period with 30 patients having length of stay >5 days. These charts were reviewed for identification of the medical decision-maker, determining advance directive status, investigation of resuscitation preference, distribution of family information leaflet, regular pain assessment, optimal pain management, the offering of spiritual support and social work, and the offering of a family meeting. The offering of social work support on day 3 was at 50% compliance and the offering of a family meeting on day 5 had 15% compliance. The team focused attention on those 2 elements of the bundle. The remaining elements had a compliance of 90-100%. The data collected was shared with all disciplines involved in care of the ICU patients. A survey of the ICU team was conducted as to barriers for compliance. Our unit social worker identified the lack of timely referrals and the medical providers identified the lack of social work involvement to establish these meetings, and losing track of patient's length of stay as barriers to compliance. Several providers also sighted that family meetings were occurring but there was inadequate documentation to capture these discussions. The administrative assistant for this team created a data sheet to allow tracking of patient's ICU length of stay and compliance with both social work and a family meeting being offered. She sent daily electronic mail to the unit social worker, ICU director, and chairs of the care and communication team to identify patients that were now day 3 and needed a social work consult and patients that were at day 5 and needed a family meeting offered. The medical team would then be asked to consult social services, and either social worker, staff nurse, or medical provider would offer a meeting to the patient and family. The care and communication team developed a standard note both paper and electronic for documentation of the family meeting. Retrospective chart reviews were performed for a 5 week period, 6 and 12 months after the start of these initiatives. Patient's charts with length of stay >5 days were reviewed. Patients' eligible were 58 of the 280 admissions during these time intervals. Social work was offered and involved 100% of the time at both reviews. Family meetings were offered 60% of the time at 6 month interval, and 80% at the 12 month interval. Conclusions: The creation of a intergrated multidisciplinary team improved daily compliance with care and communication bundle.

Evaluating Adherence To Clinical Guidelines For Thrombophilia Screening

Thrombophilia is responsible for a majority of unprovoked vascular thrombotic events, with a positivity rate of approximately 65 percent. Thrombophilia is diagnosed by a combination of genetic, activity-based, antigenic, and serologic tests. These evaluations incur significant costs and frequently require unnecessary consultation with specialists. Many of the tests also require follow-up to exclude transient alterations. In order to improve diagnostic yield, screening guidelines for inherited and acquired thrombophilia have been published by the College of American Pathologists and the International Society of Thrombosis and Haemostasis. This study evaluates diagnostic yield and adherence to clinical guidelines for thrombophilia screening at a major university teaching hospital. MethodsWe performed a retrospective review of laboratory Results for thrombophilia screening tests ordered between August 2010 and June 2013. A thrombophilia workup panel was defined as a group of 2 or more thrombophilia tests, including but not limited to protein C (PC), protein S (PS), and antithrombin (AT) activity. For activity-based and PS free antigen testing, the appropriate confirmatory period was defined as at least 30 days from the initial testing date. For LA and/or serologic evidence of anti-phospholipid antibodies, the appropriate confirmatory period was defined as at least 12 weeks from the initial testing date.Subsequently, approximately 10 percent of the charts were randomly selected for complete chart review. Chart histories were evaluated to assess compliance with the screening guidelines published by the College of American Pathologists and the International Society of Thrombosis and Hemostasis. Patients younger than 18 years of age and charts with inadequate documentation were excluded from full review. ResultsWe identified a total of 2081 patients who had thrombophilia screening, representing 4630 unique thrombophilia panels. First time panel orders had an 18% positivity rate, which was significantly lower than the expected positivity rate if guidelines were followed (p<0.01). Appropriate confirmatory testing of PC, PS, and AT deficiencies was performed in 6.0%, 13%, and 4.6% of cases, respectively. Verification of lupus anticoagulant (LA) and/or serologic anti-phospholipid antibodies (aPLs) was performed in 17% of cases. Overall, only 12% of abnormal Results had appropriate follow-up. When repeated, 40% of AT, 46% of PC, 50% of PS, and 39% of LA remained abnormal.Of the 213 charts reviewed, 113 were excluded due to insufficient documentation. Of the remaining 100 charts, only 27% followed the guidelines for both inherited and acquired thrombophilia screening. Inherited thrombophilia screening was more frequently ordered incorrectly (65%) than acquired thrombophilia screening (44%). Overall, 14% of incorrectly ordered panels were due to medication interactions, 95% due to incorrect indications, and 8% due to both reasons. We further evaluated appropriateness of thrombophilia screening by clinical service. Hematologists and oncologists most frequently followed screening guidelines (61%), followed by internists (40%), transplant surgeons (19%), and obstetrics/gynecologist (15%). Neurologists and nephrologists both had 0% percent adherence to screening guidelines. ConclusionThe majority of thrombophilia screening is ordered in the absence of adequate clinical indications and confirmatory testing is inconsistently performed. This leads to significantly increases in costs associated with improper testing and inadequate diagnosis of thrombophilia due to insufficient follow-up. Our study demonstrates an urgent need for educating health care professionals on the appropriate ordering of thrombophilia screening tests and for implementing laboratory intervention for incorrectly ordered tests. Disclosures:No relevant conflicts of interest to declare.

Quality Improvement in Austere Times: A Structured, Cost-Neutral Approach to Improving Note Documentation

The 2009 National Confidential Enquiry into patient outcome and Death (NCEPOD)1 reported that poor documentation is commonplace in all aspects of the management of surgical patients. In today’s litigious climate, inadequate documentation is a growing medicolegal problem.2 In our own department, two ‘near miss’ events relating to poor operation note documentation triggered an improvement exercise in operation note quality. In both cases, poor legibility and the use of abbreviations hampered understanding of the operation note by junior medical staff.

Progression of anal high‐grade squamous intraepithelial lesions to invasive anal cancer among HIV‐infected men who have sex with men

The incidence of anal cancer is elevated in human immunodeficiency virus (HIV)-infected men-who-have-sex-with-men (MSM) compared to the general population. Anal high-grade squamous intraepithelial lesions (HSIL) are common in HIV-infected MSM and the presumed precursors to anal squamous cell cancer; however, direct progression of HSIL to anal cancer has not been previously demonstrated. The medical records were reviewed of 138 HIV-infected MSM followed up at the University of California, San Francisco, who developed anal canal or perianal squamous cancer between 1997 and 2011. Men were followed up regularly with digital anorectal examination (DARE), high-resolution anoscopy (HRA) and HRA-guided biopsy. Although treatment for HSIL and follow-up were recommended, not all were treated and some were lost to follow-up. Prevalent cancer was found in 66 men. Seventy-two HIV-infected MSM developed anal cancer while under observation. In 27 men, anal cancer developed at a previously biopsied site of HSIL. An additional 45 men were not analyzed in this analysis due to inadequate documentation of HSIL in relation to cancer location. Of the 27 men with documented progression to cancer at the site of biopsy-proven HSIL, 20 men progressed from prevalent HSIL identified when first examined and seven men from incident HSIL. Prevalent HSIL progressed to cancer over an average of 57 months compared to 64 months for incident HSIL. Most men were asymptomatic, and cancers were detected by DARE. Anal HSIL has clear potential to progress to anal cancer in HIV-infected MSM. Early diagnosis is facilitated by careful follow-up. Carefully controlled studies evaluating efficacy of screening for and treatment of HSIL to prevent anal cancer are needed.