Inpatient Acute Care Settings Research Articles

Early Results of an Initiative to Assess Exposure to Firearm Violence in Ambulatory Care: Descriptive Analysis of Electronic Health Record Data.

Current research on firearm violence is largely limited to patients who received care in emergency departments or inpatient acute care settings or who died. This is because standardized disease classification codes for firearm injury only represent bodily trauma. As a result, research on pathways and health impacts of firearm violence is largely limited to people who experienced acute bodily trauma and does not include the estimated millions of individuals who were exposed to firearm violence but did not sustain acute injury. Assessing and collecting data on exposure to firearm violence in ambulatory care settings can expand research and more fully frame the public health issue. The aim of the study is to evaluate the demographic and clinical characteristics of patients who self-reported exposure to firearm violence during a behavioral health visit. This study assessed early data from an initiative implemented in 2022 across a national network of ambulatory behavioral health centers to support trauma-informed care by integrating structured data fields on trauma exposure into an electronic health record behavioral health patient assessment form (SmartForm), as such variables are generally not included in standard outpatient medical records. We calculated descriptive statistics on clinic characteristics, patient demographics, and select clinical conditions among clinics that chose to implement the SmartForm and among patients who reported an exposure to firearm violence. Data on patient counts are limited to positive reports of exposure to firearm violence, and the representativeness of firearm exposure among all patients could not be calculated due to unknown variability in the implementation of the SmartForm. There were 323 of 629 (51%) clinics that implemented the SmartForm and reported at least 1 patient exposed to firearm violence. In the first 11 months of implementation, 3165 patients reported a recent or past exposure to firearm violence across the 323 clinics. Among patients reporting exposure, 52.7% (n=1669) were male, 38.8% (n=1229) were Black, 45.7% (n=1445) had posttraumatic stress disorder, 37.5% (n=1186) had a substance abuse disorder (other than nicotine), and 11.7% (n=371) had hypertension. Current research on firearm violence using standardized data is limited to acute care settings and death data. Early results from an initiative across a large network of behavioral health clinics demonstrate that a high number of clinics chose to implement the SmartForm, resulting in thousands of patients reporting exposure to firearm violence. This study demonstrates that collecting standardized data on firearm violence exposure in ambulatory care settings is feasible. This study further demonstrates that resultant data from ambulatory settings can be used for meaningful analysis in describing populations affected by firearm violence. The results of this study hold promise for further collection of structured data on exposure to firearm violence in ambulatory settings.

A novel approach to attribute responsible physicians using inpatient claims.

More robust attribution methods are necessary to understand physician-level variation in quality of care across risk-adjusted inpatient measures. We address a gap in the literature involving attribution of physicians to inpatient stays using administrative claims data, in which rule-based methods often inadequately attribute physicians. Methodology comparison study using a cross-section of inpatient stays. A novel approach is proposed in which physicians' relative degrees of responsibility for inpatient stays are expressed through physician-specific attribution ratios informed by existing patient characteristics and comorbidities. Attribution results are compared with the rule-based benchmark method for 7 CMS-defined clinical cohorts, including a COVID-19 cohort. Using 6,835,460 unique patient encounters during 2020 (n = 136,339 in out-of-sample cohort), the proposed approach favored specialists generally considered responsible for primary clinical conditions when compared with the benchmark. The most salient shift within the acute myocardial infarction (+17.0%), heart failure (+20.2%), and coronary artery bypass graft (+4.0%) cohorts was toward the cardiovascular diseases specialty, and the chronic obstructive pulmonary disease (+24.0%) and pneumonia (+16.2%) cohorts resulted in a shift toward the pulmonary diseases specialty. The COVID-19 cohort resulted in considerable shifts toward infectious diseases and pulmonary diseases specialties (+17.4% and +14.1%, respectively). The stroke cohort experienced a considerable shift toward the neurology specialty (+42.2%). We provide a robust method to attribute physicians to patients, which is a necessary tool to understand physician-level variation in quality of care within the inpatient acute care setting. The proposed method provides consistency across facilities and eliminates unattributed patients resulting from unsatisfied business rules.

Reducing Patient Aggression Through a Nonviolent Patient De‐escalation Program: A Descriptive Quality Improvement Process

Patients commonly display aggressive and violent behaviors toward nursing staff, contributing to severe consequences. Healthcare institutions must develop and implement systems addressing this global safety problem. To improve clinical practice safety for inpatient acute care settings by providing healthcare teams throughout a large academic medical center with a Behavioral Emergency Response Team (BERT) program, that is, a system for reporting and de-escalating aggressive patient encounters. This descriptive quality improvement process took place within two inpatient acute care departments using simulation-based training, patient safety rounds, and a BERT activation system. Participant groups included nursing personnel who completed a baseline survey (n=302), telecommunication dispatchers (n=20), BERT responders (n=78), and bedside nursing staff (n=43) recipients of BERT program resources. Methods included a baseline questionnaire, pre- and post-intervention surveys, formal reports of aggressive patient encounters, documentation from patient safety rounds, and records of activated BERT responses. Data analysis included descriptive statistics, boxplots, and the Wilcoxon signed-rank test. This project mitigated patient aggression episodes by successfully designing and implementing an evidence-based BERT program. Findings suggested bedside nursing program participants felt more confident and capable of managing aggressive patient behaviors. A strong partnership between security officers and nursing staff limited the risk of harm to clinical staff by identifying and intervening with 41 potentially aggressive patients. Finally, formal reports of patient aggression episodes did not increase during this project, which may have indicated early prevention and detection of aggression while reflecting the broader problem of aggression under-reporting in nursing. Healthcare organizations need to have robust systems to manage aggressive patient encounters. Comprehensive strategies for managing patient aggression include simulation-based training, the use of BERT responders, and a strong partnership between nursing and security officer teams.

Implementing a Watcher Program to Improve Timeliness of Recognition of Deterioration in Hospitalized Children

PurposeEarly recognition and response to clinical deterioration is critical to patient safety. Failures or delays in recognition and response often manifest as emergency transfers to the intensive care unit (ICU). We describe implementation of a program to improve recognition and response to clinical deterioration within the pediatric inpatient acute care setting (i.e., medical-surgical, hematology-oncology, and intermediate care units). Design and methodsWe assembled an inter-professional team including nurses, physicians, and hospital leaders to evaluate preventable patient harm events associated with failures in identifying and responding to clinical deterioration and resultant emergency transfers to the intensive care unit (ICU). We evaluated an existing situational awareness framework incorporating principles of high-reliability organizations, refined the framework utilizing internal event analyses data, and subsequently implemented a program reducing emergency transfers. ResultsEmergency transfers to the ICU from acute care settings decreased by more than 70%, and to date, this improvement has sustained. Nurses report increased satisfaction and empowerment to proactively escalate their concerns, respond to changes in a patient's condition, and reduce uncertainty about the plan of care. ConclusionsThe program has enhanced situational awareness, reduced emergency transfers, and fostered a culture of accountability and collaboration in alignment with the organizational core value of safety. Practice implicationsDeveloping a reliable system to support the healthcare team in recognizing and responding to clinical deterioration reduces the risk of care delays. Applying situational awareness to other high-risk situations, additional areas for program expansion were identified, to include emergency department admissions and behavioral health patients.

Abstract P301: Evaluating the Impact of a Pharmacist-Managed Hypertension Collaborative Care Model in Vascular Neurology Patients in an Inpatient Acute Care Setting

Introduction: The utility of pharmacist-managed collaborative practice agreements (CPA) in the management of hypertension is well established in the outpatient setting. There has been little evaluation of the use of CPAs in the inpatient acute care setting, and none described specifically in the vascular neurology population. Treatment of hypertension is a critical intervention for the secondary prevention of acute ischemic stroke. This quality improvement project evaluated the implementation of a CPA for the inpatient acute care management of hypertension in vascular neurology patients at University of Virginia Health. Methods: A CPA was developed between the neurosciences clinical pharmacist group and the inpatient vascular neurology service, legally vetted, and implemented in June 2019. All vascular neurology patient charts in which an electronic CPA referral was placed from June 2019 through June 2020 were reviewed. Patients were excluded if they were discharged within 24 hours of the referral being placed. The primary objective was to describe and evaluate the implementation of a pharmacist-driven hypertension management practice in the inpatient acute care setting. All patient demographic and clinical data were analyzed using descriptive statistics. Secondary safety outcomes included documented hypotensive events (SBP <90) and acute kidney injury (AKI, increase in SCr by 0.3 mg/dl within 48 hours). Results: During the study period, 26 referrals were placed, and 19 patients were included for review. On average, patients were on 2 anti-hypertensive medications prior to admission. From the time of referral to discharge (mean 6 days), systolic blood pressure (SBP) was reduced on average by 36 mmHg (mean percentage reduction 20%) and diastolic blood pressure (DBP) by 12 mmHg (mean percentage reduction 7%). Ten patients (53%) met the goal of SBP < 140 at discharge. There were 5 hypotensive events and 4 instances of AKI, all of which were mild and recovered prior to discharge. Conclusion: A pharmacist-managed hypertension CPA was successfully implemented in vascular neurology patients in the inpatient acute care setting. The practice demonstrated improved blood pressure control and minimal adverse outcomes.

Computer-Assisted Wound Assessment and Care Education Program in Registered Nurses: Use of an Interactive Online Program by 418 Registered Nurses.

The purpose of this descriptive study was to evaluate use of a previously validated, online, interactive wound assessment and wound care clinical pathway in a group of RNs. Specific aims were to (a) evaluate the proportions of correct, partially correct, and incorrect algorithmic decisions and dressing selections, (b) compare response rates between nurses who are and who are not wound care certified, and (c) evaluate its ease of use, educational value, and applicability in clinical practice. Descriptive study. Participants were recruited using convenience and snowball sampling methods. Four hundred eighteen nurses completed all 15 assessments; nearly half held a bachelors' degree in nursing (189, 45%), more than two-thirds worked in an inpatient acute care settings (277, 68%), and 293 (70%) were not certified in wound care. After providing written informed consent and completing the participant demographics form, participants assessed 15 photographs of wounds with accompanying moisture descriptions and completed an algorithm and dressing selection for each. All responses were anonymously collected by the program. Existing, retrospective, program data were also downloaded and data from nurses who completed all assessments were extracted and analyzed. Descriptive statistics were used to analyze all variables. Selection outcomes and survey responses between nurses who were and who were not wound care certified were compared using a 2-sample Student t test assuming unequal variances. Individual responses for the first 6 wounds were compared to the last 6 wounds using a paired t test. The mean (M) proportions of fully or partially correct (operationally defined as safe but not fully correct) algorithm and dressing choice were 81% (SE: 0.88, 95% confidence level: 1.73) and 78.1% (SE: 0.70, 95% confidence level: 1.39), respectively. Wound care-certified nurses had higher mean algorithm scores than those who were not certified (M: 89.2%, SE: 1.27 vs M: 77.8%, SE: 1.10, P < .001). Most incorrect/partially correct choices were attributable to incorrect necrotic tissue assessment (n = 845, 58%). The difference between fully correct first 6 and last 6 algorithm choices was statistically significant (M: 310, SE: 0.02 vs M: 337, SE: 9.32, P = .04). On a Likert scale of 1 (not at all) to 5 (very), average scores for ease of program and algorithm use, educational value, and usefulness for clinicians ranged from M: 4.14, SE: 0.08 to M: 4.22, SE: 0.08. Results suggest that the algorithm is valid and has potential educational value. Initial evaluation also suggests that program refinements are needed. Evaluation of participant responses indicated potential problems with the definitions used for necrotic tissue or assessment knowledge deficits. Results also substantiate the importance of instructional design and testing online education programs. More research is needed to uncover potential gaps in nurses' wound care knowledge that may hamper evidence-based practices adoption and the need to develop effective, evidence-based education-delivery techniques.

Student perceptions and understanding of client-therapist interactions within the inpatient acute care environment: qualitative study.

Physical therapists practicing in inpatient acute care settings in the United States work in a 21st century health care system that requires professional competence in clinical reasoning and decision making. For doctor of physical therapy (DPT) students, the development of confidence in the patient evaluation and the professional skills necessary for managing the inpatient environment can be challenging. The study's purpose was to understand whether the early exposure of students to inpatient settings informed their understanding of the thought processes and actions of experienced clinicians during client interactions. A qualitative design was used. Thirty-three DPT students working in inpatient settings were recruited from 15 unique inpatient hospital (acute care and rehabilitation) facilities with a convenience sampling technique. Reflective data were collected for 1 month with clinician-facilitated discussion boards. Four themes emerged: environment, communication, evaluation, and client-therapist interaction. The themes informed a conceptual model depicting the observation by DPT students of factors that influenced interactions between clients and experienced clinicians in inpatient settings. Reflection on the what, the how, and the why that informed clinical decisions enabled students to recognize the situated nature of evaluation and treatment approaches. The use of a sample from 1 year of a DPT program at one university reduced the generalizability of the results. Limited research has examined student perceptions of the interactions of experienced clinicians with clients in inpatient acute care settings. More research is needed to understand the impact of exposing students to the thoughts and actions of therapists working in such settings earlier within DPT curricula.

Perceived top 10 highly effective interventions to prevent adult inpatient fall injuries by specialty area: A multihospital nurse survey

PurposeThis study identified the perceived top 10 highly effective interventions to prevent fall injuries of adult inpatients based on the perceptions of RN staff by specialty area in acute hospital settings. BackgroundThe fall prevention precautions to focus on may vary by patients' medical problems and thus by specialty area. MethodsThis cross-sectional nurse survey was conducted at five U.S. health systems (July 2011–February 2012, 68 study units, 10 specialty areas). 560 staff participants completed the survey, yielding an overall response rate of 25.81%. This work is part of a larger project. Descriptive statistics were used. ResultsEach specialty area had its own top 10 effective interventions identified by RNs. The complexity and differences in the top 10 highly effective interventions by the 10 included specialty areas are apparent. For example, only one common intervention (keeping hospital bed brakes locked) appeared in the lists from the medical units and surgical units. ConclusionAddressing the unique needs of the patient population by specialty area is essential. Adopting the perceived top 10 highly effective interventions for preventing injurious falls by specialty area with staff consensus might be more feasible for staff buy-in and compliance in inpatient acute care settings. Since patients' characteristics may change over time and the science in fall prevention is advancing, re-prioritizing effective interventions as needed every 2 years is recommended.

The Relationship of Bedside Nurses' Emotional Intelligence With Quality of Care

Emotional intelligence, a predictor of productivity and success, may impact behaviors responsible for quality of care. This study examined if emotional intelligence of units' bedside nurses is related to the quality of care delivered to the patients. In this study, emotional intelligence was found to be correlated to the number of Clostridium difficile infections, MRSA infections, patient falls with injury, and pressure ulcer screenings (P < .001) in the inpatient acute care setting.

Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems

ObjectiveMedication errors in hospitals are common, expensive, and sometimes harmful to patients. This study's objective was to derive a nationally representative estimate of medication error reduction in hospitals attributable to electronic prescribing through computerized provider order entry (CPOE) systems.Materials and methodsWe conducted a systematic literature review and applied random-effects meta-analytic techniques to derive a summary estimate of the effect of CPOE on medication errors. This pooled estimate was combined with data from the 2006 American Society of Health-System Pharmacists Annual Survey, the 2007 American Hospital Association Annual Survey, and the latter's 2008 Electronic Health Record Adoption Database supplement to estimate the percentage and absolute reduction in medication errors attributable to CPOE.ResultsProcessing a prescription drug order through a CPOE system decreases the likelihood of error on that order by 48% (95% CI 41% to 55%). Given this effect size, and the degree of CPOE adoption and use in hospitals in 2008, we estimate a 12.5% reduction in medication errors, or ∼17.4 million medication errors averted in the USA in 1 year.DiscussionOur findings suggest that CPOE can substantially reduce the frequency of medication errors in inpatient acute-care settings; however, it is unclear whether this translates into reduced harm for patients.ConclusionsDespite CPOE systems’ effectiveness at preventing medication errors, adoption and use in US hospitals remain modest. Current policies to increase CPOE adoption and use will likely prevent millions of additional medication errors each year. Further research is needed to better characterize links to patient harm.

The contribution of staff call light response time to fall and injurious fall rates: an exploratory study in four US hospitals using archived hospital data

BackgroundFall prevention programs for hospitalized patients have had limited success, and the effect of programs on decreasing total falls and fall-related injuries is still inconclusive. This exploratory multi-hospital study examined the unique contribution of call light response time to predicting total fall rates and injurious fall rates in inpatient acute care settings. The conceptual model was based on Donabedian's framework of structure, process, and health-care outcomes. The covariates included the hospital, unit type, total nursing hours per patient-day (HPPDs), percentage of the total nursing HPPDs supplied by registered nurses, percentage of patients aged 65 years or older, average case mix index, percentage of patients with altered mental status, percentage of patients with hearing problems, and call light use rate per patient-day.MethodsWe analyzed data from 28 units from 4 Michigan hospitals, using archived data and chart reviews from January 2004 to May 2009. The patient care unit-month, defined as data aggregated by month for each patient care unit, was the unit of analysis (N = 1063). Hierarchical multiple regression analyses were used.ResultsFaster call light response time was associated with lower total fall and injurious fall rates. Units with a higher call light use rate had lower total fall and injurious fall rates. A higher percentage of productive nursing hours provided by registered nurses was associated with lower total fall and injurious fall rates. A higher percentage of patients with altered mental status was associated with a higher total fall rate but not a higher injurious fall rate. Units with a higher percentage of patients aged 65 years or older had lower injurious fall rates.ConclusionsFaster call light response time appeared to contribute to lower total fall and injurious fall rates, after controlling for the covariates. For practical relevance, hospital and nursing executives should consider strategizing fall and injurious fall prevention efforts by aiming for a decrease in staff response time to call lights. Monitoring call light response time on a regular basis is recommended and could be incorporated into evidence-based practice guidelines for fall prevention.

Physical restraint use rate and total fall and injurious fall rates: An exploratory study in two US acute care hospitals

This exploratory study used archived hospital data to investigate the relationships between the percentage of patients with physical restraints and the total fall rate as well as the injurious fall rate per 1000 patient-days. The two tested research questions were 1) What is the relationship between the restraint use rate and the total fall rate? 2) What is the relationship between the restraint use rate and the injurious fall rate? The results showed that a higher restraint use rate was associated with a higher total fall rate, yet a lower injurious fall rate in adult inpatient acute care settings. In efforts for fall and injurious fall prevention, front-line managers need to balance the frequency and appropriateness of physical restraint use with optimizing patients’ physical activity. Future research should explore the cause–effect relationship between physical restraint use and consequent injurious fall incidents.

Acupuncture in the Inpatient Acute Care Setting: A Pragmatic, Randomized Control Trial

Purpose. To evaluate the acceptance and effectiveness of acupuncture in a hospital setting. Methods. This 18-month pragmatic randomized controlled trial used a two-tiered consent process for all patients admitted to the acute care unit by study physician groups. The primary study comparison was between those randomized (using biased-coin randomization after initial consent) to be offered acupuncture or not. The primary outcome was length of stay (LOS). Other measures include costs, self-reported anxiety, depression, health status, and patient satisfaction. Results. Of the 383 patients consented to the study, 253 were randomized to be offered acupuncture, and 130 were not offered acupuncture. Of those offered acupuncture, 173 (69%) accepted and received daily acupuncture. On average, patients offered acupuncture had longer LOSs (4.9 versus 4.1 days) than those not offered acupuncture (P = .047). Adjustment for diagnosis and severity mix reduced this difference and its significance (P = .108). No other significant differences in outcomes were found. Patients who were more anxious (P = .000) or depressed (P = .017) at admission tended to more often accept acupuncture when offered. Conclusion. Acupuncture is accepted by a majority of hospitalized acute care patients. However, it did not reduce LOS in this already short-stay population.

Patient Safety Beyond the Hospital

The focus of studies and much of the data about patient safety is predominantly in inpatient acute care settings, even though more episodes of care are provided in the ambulatory setting. Research to inform safety in the non-inpatient environment is required as a critical part of delivering better/safer care and providing a means to document safety issues.

Usability Testing of a Falls Prevention Toolkit for an Inpatient Acute Care Setting

Efforts to prevent falls in the hospital setting involves identifying patients at risk of falling and implementing fall prevention strategies. This poster describes the method and results of Performance Usability Testing on a web-based Fall Prevention Tool Kit (FPTK) developed as part of a research study, (Falls TIPS-Tailoring Interventions for Patient Safety) funded by The Robert Wood Johnson Foundation.

Patient falls: acute care nurses’ experiences

To describe the findings from a qualitative study exploring acute care nurses' experiences with patient falls. Patient falls continue to be a problem in acute care settings for nurses at the point of care. Despite the growing body of knowledge related to risk factors and interventions for fall prevention, minimal attention has been given to nurses' perspectives of patient falls. A qualitative descriptive design was used. Focus group discussions were conducted with nurses working on a cross-section of inpatient acute care settings. Audio-taped sessions were transcribed and analysed thematically. Nurses described their experience of falls as 'knowing the patient as safe', an ongoing affirmation that the patient was free from harm. In this focused, narrowly defined and highly specific knowing, nurses employed the key strategies of assessment, monitoring and communicating. Variable conditions influenced whether these strategies were effective in giving nurses the knowledge they needed to keep the patient safe. When strategies failed to provide nurses with knowledge of their patients as safe and patients fell, this created considerable stress for nurses and prompted them to use a range of coping strategies. Knowing the patient as safe has the potential to resolve the tension between patient safety and independence. The critical, often taken for granted, activities used by nurses in this knowing must be expanded to include the meaning falls have for patients and attend to factors beyond nurses control such as environmental redesign and staffing. Nurses play an important role in fall prevention through knowing the patient as safe but must be supported through the use of a multi-faceted approach extending from the individual nurse to the institutional level.

Difficult Discharge: Lessons from the Oncology Setting

As Swidler et al. (2007) point out, a variety of difficulties can arise when discharging patients from an inpatient acute care setting. We have encountered similar problems at our own institution, ...

Use of the levels of cognitive functioning assessment scale (LOCFAS) by acute care nurses

W ITH MORE than 1.5 million traumatic brain-injured (TBI) persons hospitalized annually for extended periods, nurses in acute care settings have the opportunity to make a difference in the rehabilitation of these patients' cognitive functioning (National Institute of Neurological and Communicative Disorder and Stroke, 1989). Although nurses are at the bedsides of patients with brain injuries and have the greatest opportunity for ongoing direct observation, nurses generally do not assess the cognitive level of these patients in the acute care setting. The data routinely collected as the basis for nursing care provide the necessary baseline to make such an assessment, but nurses who are not rehabilitative specialists may not know how to interpret these data to make a cognitive level diagnosis. The assessment of cognitive functioning for rehabilitation programming is more routinely done by neuropsychologists. For this type of evaluation to be administered, the patient must be able to comprehend, cooperate, and participate. Many weeks may elapse after trauma before the patient reaches this level. Because early intervention provides greater success for the patient's achieving maximum potential than later intervention, nurses caring for the TBI patient at an early stage of recovery are in a position to evaluate the patient's level of cognitive functioning and initiate rehabilitative measures before the patient is at the level appropriate for a neuropsychological evaluation (Hagen, 1982; Miller, 1984). The Levels of Cognitive Functioning Assessment Scale (LOCFAS) was developed from the Rancho Los Amigos Levels by author Jeanne Flannery using only Levels I through V of the eight original levels (Malkmus, Booth, & Kodimer, 1980). These selected levels include behaviors more commonly seen in the earliest stages of recovery, when the TBI patient is more likely to be in an inpatient acute care setting. For example, a Level I patient is in the deepest possible stage of coma. Six behaviors are assessed in the LOCFAS for this level and include items such as unresponsive to auditory, tactile, and painful stimuli. In contrast, a Level V patient is no longer comatose but remains disoriented to time and place. The patient can respond to simple commands but is unable to learn new tasks. Ten behaviors are included at this level to assess the TBI patient. For more detailed information or a copy of the instrument, please contact Dr. Jeanne Flannery. On the LOCFAS, a grid beside each behavior allows the nurse simply to make a check to indicate the presence of that behavior. Once completed, a summary grid allows the nurse to designate the cognitive level in which most behaviors were observed. The outcome shows the patient's maximum capacity at the time of each observation. Repeated use of the instrument also provides a common interdisciplinary language to describe a patient's progress in recovery. More important, by identifying the patient's current level of cognitive functioning, the tool can serve as a basis for the development of an appropriate plan of care to facilitate cognitive recovery. Initial psychometric data with the LOCFAS was reported by Flannery (1993). Construct and content validity were established by expert opinion. Three reliability studies were conducted using five written vignettes developed to represent each of the five LOCFAS levels. Interrater reliability, with raters experienced in assessing cognitive functioning for care-planning purposes, was supported with high agreement among cognitive levels (coefficient kappa = 1.00) and individual items (M coefficient kappa = .871). A second interrater re-