Significant Increase In Documentation Research Articles

The Impact of a Web-Based Preintubation Preparation Module on the Knowledge, Confidence, and Behavior of Critical Care Fellows: A Single-Center Pilot Study.

The objectives of this study were to standardize airway management among critical care fellows and to evaluate whether the completion of a web-based preintubation airway preparation module improves their knowledge and behaviors in the identification and preparation of difficult airways. Critical care experts used international guidelines to develop the module, which contained mandatory readings, brief lectures, and a case-based activity. We measured learner satisfaction, improvements in fellows' preintubation preparation knowledge, and safety-oriented behavior. The paired t-test was used to compare knowledge assessment scores and the chi-square test was used to compare the categorical variables in the evaluation of the behavior construct. All trainees (N = 14) completed the module and were satisfied with its contents and structure. Fellows logged 114 intubations during the study period. The mean score on the knowledge test increased (pre 79% vs post 90%, P = .02) postmodule and there was a significant increase in documentation of airway risk stratification in fellows' procedure notes (65.9% vs 72.9%, P = .049). All respondents were confident that they would be able to apply what they learned in the module into clinical practice and that their patients would likely benefit from their new knowledge. The implementation of an asynchronous web-based module on airway assessment and intubation preparation was feasible. The module was engaging, enhanced the knowledge of our trainees, and improved procedural documentation.

AN EMR INTERVENTION TO IMPROVE EARLY INTRODUCTION OF PEANUTS IN INFANTS AT COMMUNITY-BASED HEALTH CLINICS

<h3>Introduction</h3> Infant peanut introduction is a recommended childhood feeding practice, following the landmark LEAP study showing that early introduction of peanut dramatically reduced rates of peanut allergy in high-risk infants. However, counselling about early introduction at infant well visits may not be happening systematically in all primary care settings. <h3>Methods</h3> In April 2019, we introduced an EMR screening tool in our general pediatrics clinics to discuss peanut allergy risk factors and early peanut introduction at well visits between 4-11 months. A retrospective chart review was undertaken, comparing all infants seen for 4-11 month old well visits in the year following the intervention (April 2019-March 2020) versus the year prior to the intervention (April 2018-March 2019). <h3>Results</h3> A total of 379 charts were screened, 179 pre-intervention and 200 post-intervention. There were no statistically significant differences in baseline characteristics in the pre-intervention and post-intervention groups, including age, sex, and comorbid egg allergy and eczema. Post-intervention, there was a statistically significant increase in discussion of early peanut introduction. 7 infants were screened pre-intervention, while 56 were screened after (p<0.001). There was a statistically significant increase in documentation of peanut in the diet by 12 months, with 5 documented pre-intervention and 23 post-intervention (p=0.001). <h3>Conclusion</h3> While introduction of the EMR screening tool increased discussion of early peanut introduction in community-based clinics, most infants still didn't have documentation of counselling on early peanut introduction in their medical records. Further interventions to improve rates of early peanut introduction are necessary to minimize development of peanut allergy.

An initiative to improve adherence to guidelines for thromboprophylaxis among high-risk gynecologic oncology patients receiving outpatient chemotherapy (293)

Objectives: Pharmacologic thromboprophylaxis is recommended for high-risk gynecologic oncology patients with a Khorana score (KS) ≥ 2 receiving outpatient chemotherapy. Our objective was to evaluate the impact of a quality improvement (QI) project designed to increase KS calculation and documentation of thromboprophylaxis eligibility for patients initiating outpatient chemotherapy. Methods: In January 2021, the Society of Gynecologic Oncology endorsed guidelines recommending thromboprophylaxis for gynecologic oncology patients with a KS ≥ 2 receiving outpatient chemotherapy. The primary barriers to the implementation of these guidelines at the author’s institution included provider awareness, KS calculation, and documentation of eligibility. Starting June 2021, a KS calculator and associated thromboprophylaxis algorithm were incorporated into outpatient documentation templates. Eligible patients included those with gynecologic malignancies initiating a new chemotherapy regimen from January to September 2021. The percentages of patients for whom KS and thromboprophylaxis eligibility were documented at the start of the first cycle pre- and post-QI initiative were compared using the Chi-square test. The percentages of eligible patients who were offered and initiated thromboprophylaxis (apixaban 2.5 mg twice daily) in accordance with the algorithm were also assessed. Results: There were 119 total new chemotherapy cases identified in the study time frame: 61 pre-QI (51.3%) and 58 post-QI (48.7%). Of these, 34.4% (21/61) and 34.5% (20/58) were eligible for thromboprophylaxis pre- and post-QI, respectively. Table 1 demonstrates percentages of patients for whom KS calculation and thromboprophylaxis eligibility were documented prior to cycle 1 initiation. There was a statistically significant increase in documentation following QI initiation (pre-QI: 8/61 [13.1%], post-QI: 38/58 [65.5%]; p < 0.001). Of those who were eligible, 9.5% were offered thromboprophylaxis pre-QI (2/21) and 65% post-QI (13/20) (p < 0.001). Table 1 describes the percentages of eligible patients initiating thromboprophylaxis in accordance with the recommendations. There were no new venous thromboembolic events among eligible patients’ pre-QI and one post-QI. Conclusions: Over one-third of gynecologic cancer patients starting outpatient chemotherapy met eligibility criteria for pharmacologic thromboprophylaxis. Following the implementation of our QI initiative, there was an increase in KS calculation, documentation, and appropriate prescription of thromboprophylaxis among eligible patients. Studies are ongoing to measure patient adherence to pharmacologic thromboprophylaxis and to determine if adherence to thromboprophylaxis guidelines improves outcomes in this population. Objectives: Pharmacologic thromboprophylaxis is recommended for high-risk gynecologic oncology patients with a Khorana score (KS) ≥ 2 receiving outpatient chemotherapy. Our objective was to evaluate the impact of a quality improvement (QI) project designed to increase KS calculation and documentation of thromboprophylaxis eligibility for patients initiating outpatient chemotherapy. Methods: In January 2021, the Society of Gynecologic Oncology endorsed guidelines recommending thromboprophylaxis for gynecologic oncology patients with a KS ≥ 2 receiving outpatient chemotherapy. The primary barriers to the implementation of these guidelines at the author’s institution included provider awareness, KS calculation, and documentation of eligibility. Starting June 2021, a KS calculator and associated thromboprophylaxis algorithm were incorporated into outpatient documentation templates. Eligible patients included those with gynecologic malignancies initiating a new chemotherapy regimen from January to September 2021. The percentages of patients for whom KS and thromboprophylaxis eligibility were documented at the start of the first cycle pre- and post-QI initiative were compared using the Chi-square test. The percentages of eligible patients who were offered and initiated thromboprophylaxis (apixaban 2.5 mg twice daily) in accordance with the algorithm were also assessed. Results: There were 119 total new chemotherapy cases identified in the study time frame: 61 pre-QI (51.3%) and 58 post-QI (48.7%). Of these, 34.4% (21/61) and 34.5% (20/58) were eligible for thromboprophylaxis pre- and post-QI, respectively. Table 1 demonstrates percentages of patients for whom KS calculation and thromboprophylaxis eligibility were documented prior to cycle 1 initiation. There was a statistically significant increase in documentation following QI initiation (pre-QI: 8/61 [13.1%], post-QI: 38/58 [65.5%]; p < 0.001). Of those who were eligible, 9.5% were offered thromboprophylaxis pre-QI (2/21) and 65% post-QI (13/20) (p < 0.001). Table 1 describes the percentages of eligible patients initiating thromboprophylaxis in accordance with the recommendations. There were no new venous thromboembolic events among eligible patients’ pre-QI and one post-QI. Conclusions: Over one-third of gynecologic cancer patients starting outpatient chemotherapy met eligibility criteria for pharmacologic thromboprophylaxis. Following the implementation of our QI initiative, there was an increase in KS calculation, documentation, and appropriate prescription of thromboprophylaxis among eligible patients. Studies are ongoing to measure patient adherence to pharmacologic thromboprophylaxis and to determine if adherence to thromboprophylaxis guidelines improves outcomes in this population.

Point prevalence survey of antimicrobial consumption and resistance: 2015-2018 longitudinal survey results from Nigeria

Background: Nigeria joined the global community in monitoring antimicrobial prescribing practices since 2015. Results of individual hospital Global Point Prevalence Survey (Global-PPS) have stimulated efforts at instituting hospital-based antimicrobial stewardship (AMS) programmes. We report the trends of antimicrobial prescribing rates and quality indicators for 3 surveillance periods; 2015, 2017 and 2018.Methodology: The web-based Global-PPS for surveillance of antimicrobial use in hospitals (www.globalpps.com) was completed by each participating hospital site for all inpatients receiving antimicrobials on a selected day in 2015, 2017 and 2018. Data included details on antimicrobial agents, reasons and indications for treatment and a set of quality prescribing indicators. Data were validated by the web-based data management system of University of Antwerp, exported into Microsoft Excel and analyzed with EPI INFO version 7.2.Results: Thirteen hospitals participated in the survey involving a total of 5,174 inpatients. Mean weighted overall antimicrobial prescribing prevalence was 70.7% which declined over the years from 71.7% in 2015 to 59.1% in 2018 (p&lt;0.001). The rate of documentation of date for post prescription review improved from 27.9% in 2015 to 48.5% in 2018 (p&lt;0.001) while the rates of targeted treatment declined from 12.0% in 2015 to 5.2% in 2018 (p&lt;0.001). There was no significant change in the choice of parenteral drug administration (64.5% in 2015, 65.1% in 2017 and 62.6% in 2018; p=0.6803), and but there was significant increase in documentation of reasons for prescription in case notes (62.2% in 2015, 74.5% in 2017, and 70.9% in 2018; p=0.008). Overall, the main indications for therapeutic prescribing were skin and soft tissue infections (20.8%), sepsis (15.9%) and pneumonia (11.6%). The top three antibiotics for therapeutic use were ceftriaxone (18.2%), metronidazole (15.3%) and ciprofloxacin (10.4%).Conclusions: The survey showed reduction in the overall antimicrobial prescribing rate especially in hospitals that had introduced AMS programmes. Among the quality prescribing indicators, documentation of post prescription review date showed improvement. The Global-PPS serves as a cost effective, flexible and userfriendly tool in instituting AMS programmes in hospitals.&#x0D; Keywords: antimicrobial prescribing, hospital, global-point prevalence survey, quality indicators

130 Improving Documentation of Bowel Movement on Geriatric Wards

Abstract Introduction Constipation is a widely prevalent issue in older adults that may result in complications such as urinary retention, delirium and bowel obstruction. Previous studies have indicated that while stool charts are well completed by nursing staff, they are infrequently monitored by doctors. This project aimed to improve the documentation of bowel movement by doctors on ward rounds to 85%, by the end of a 3-month period. Methods Formulation of the project was achieved using group work and a fishbone diagram which focussed on how doctors can improve on documenting bowel movements. Baseline data were collected from inpatient notes on weekdays over a three-week period on a geriatric ward in Northern General Hospital, Sheffield. Interventions of posters and stickers of the poo emoji were placed on walls and in inpatient notes respectively as a reminder. Post-intervention data were collected on weekdays over two weeks, and then repeated a month later to assess for a sustained change. Results The data on bowel activity documentation were collected from 28 patients. The baseline data showed that bowel activity was monitored daily on the ward 56.25% of the time. There was a significant increase in documentation of 85.75% following the interventions. The sustainability study showed that bowel activity was documented on the ward 59.09% of the time. Conclusions This study shows how a strong effect on behavioural change can be accomplished through simple interventions such as stickers and posters. As most wards currently still use paper notes, this is a generalisable model that other wards can trial. However, this study also shows the difficulty in maintaining behavioural change over extended periods of time. Further PDSA cycles should examine the reasons behind the difficulty sustaining the change and implement new changes that aim to overcome them.

Documenting New Ways of Delivering Care Under Oregon's Alternative Payment and Advanced Care Model.

The fee-for-service reimbursement system that dominates health care throughout the United States links payment to a billable office visit with a physician or advanced practice provider. Under Oregon's Alternative Payment and Advanced Care Model (APCM), initiated in 2013, participating community health centers (CHCs) received per-member-per-month payments for empaneled Medicaid patients in lieu of standard fee-for-service Medicaid payments. With Medicaid revenue under APCM no longer tied solely to the volume of visits, the Oregon Health Authority needed a way to document the full range of care and services that CHCs were providing to their patients, including nontraditional patient encounters taking place outside of traditional face-to-face visits with a billable provider. Toward this end, program leadership defined 18 visit and nonvisit-based care activities-"Care Services That Engage Patients" (Care STEPs)-that APCM CHCs were asked to document in the electronic health record to demonstrate continued empanelment. To describe trends in rates of traditional face-to-face office visits and Care STEPs documentation among CHCs involved in the first 3 phases of APCM implementation. The study population included the 9 CHCs involved in the first 3 phases of APCM implementation. Using data from the electronic health record, quarterly summary rates for office visits and Care STEPs were calculated for the first 18 quarters of implementation (March 1, 2013 to June 30, 2017). Among participating CHCs, the mean rate of face-to-face visits with billable providers declined from 635 ± 128 to 461 ± 109 visits/1000 patients/quarter (mean difference, -174; 95% CI, -255, -94). Care STEPs documentation increased from 831 ± 174 to 1017 ± 369 Care Steps/1000 patients/quarter, but the difference was not statistically significant. Care STEPs within the category of New Visit Types were documented most frequently. There were significant increases in documentation of Patient Care Coordination and Integration and a small, albeit significant, increase in Reducing Barriers to Health. There was a significant decline in the documentation of Care STEPs by physicians and advanced practice providers an increase in documentation by ancillary staff. These findings suggest that APCM is increasing CHCs' capacity to experiment with new ways of providing care beyond the traditional face-to-face office visit with a physician or advanced practice provider. However, CHCs may choose different ways to change the delivery of care and some CHCs have implemented these changes more quickly than others. Future mixed-methods research is needed to understand barriers and facilitators to changing the delivery of care after APCM implementation.

Use of a cesarean delivery checklist in an African maternity ward to improve management and reduce length of hospital stay†.

To create, implement, and evaluate the effectiveness of a cesarean delivery checklist on maternal and neonatal outcomes in a rural African hospital. Based on input from local authorities, WHO's Safe Surgical Checklist was modified for cesarean delivery and adapted for use in low-resource settings. Retrospective chart review between April and August 2013 in Kibogora Hospital, Nyamasheke, Rwanda, included the first 100 women undergoing cesarean after checklist implementation and the last 100 women undergoing cesarean before implementation. Checklist utilization was determined and degree of completeness assessed. Outcomes were compared between patients for whom the checklist was utilized and patients for whom the checklist was not utilized, in both pre and post-implementation groups. Checklist utilization rate was 83.0% (83/100). Checklist utilization was associated with significant increases in documentation of estimated blood loss (91.6% [76/83] vs 0.9% [1/117], P<0.001) and antibiotic administration before incision (96.4% [80/83] vs 30.8% [36/117], P<0.001). It was also associated with decreased rates of hospitalization longer than the standard 4days (19.3% [16/83] vs 70.1% [82/117], P<0.001). Implementation of a cesarean delivery checklist via a culturally specific and resource-specific strategy resulted in high utilization rates and improved performance in key best practices by healthcare providers.

A Quality Improvement Project to Improve Documentation and Awareness of Limitations of Life-Sustaining Therapies.

Poor documentation and understanding of the limitations of life-sustaining therapies upon admission to the pediatric intensive care unit (PICU) can result in moral distress for both providers and families. Limitations of life-sustaining treatments are often not documented and/or understood by members of the health care team. We performed a quality improvement initiative to improve the care teams' understanding and paper documentation of the limitations of life-sustaining therapies in the PICU of a quaternary children's hospital from January 2018 to March 2019. We implemented a series of plan-do-study-act cycles, including initiation of an updated rounding tool that included limitations of interventions, in-person and electronic information sessions, and implementation of a visual bedside tool to remind providers when limitations were present. Pre- and postintervention surveys were administered. Nursing paper documentation of limitations of life-sustaining therapies increased sequentially from 0% to 88% during plan-do-study-act cycles. Creating a specific area to document limitations on the nursing sheet resulted in the most significant increase in documentation (36.6 points). Nurses reported that they "always" document limitations, which increased from 10% to 38%. The percentage of nurses who understood patients' intervention limitations increased from 28% to 33%. Limitations of life-sustaining therapies in the PICU are nuanced and involve multiple stakeholders. Nursing education and designation of a section of intervention limitations in nursing daily goal paper documentation can increase comfort with therapeutic limitations in the PICU. Future studies should explore impacts on patient care and serve as a framework for the ultimate goal of improving documentation of care limitations and code status in the electronic medical record.

Impact of the Oncology Care Model (OCM) on pain management: A retrospective cohort analysis.

86 Background: Pain is a common symptom among patients with cancer and impacts performance status and quality of life. The OCM was implemented at Rutgers Cancer Institute of New Jersey (RCINJ) in July 2016 with the goal of improving many quality metrics in cancer care including documentation of pain and a plan of care for pain. Hypothesis: Documentation of pain and a plan of care for pain improved after implementation of the OCM at RCINJ. Improved documentation would correlate with a decrease in reported quantitative pain scores. Methods: Data from patients enrolled in OCM during its first year of implementation (post OCM) was compared to data from a control cohort the preceding year (pre OCM). The initial progress note and EMR flowsheet in each year were reviewed to determine pain documentation. For patients reporting a pain score ≥ 1 on a 0-10 scale, the association between documentation of a plan of care and improvement in quantitative pain score on a subsequent visit was analyzed using Chi square testing. Results: A total of 260 patient charts were analyzed. A quantitative pain score was documented in 99% of patients in the pre OCM group and 100% in the post OCM group. For those with a pain score ≥ 1, documentation of a plan of care increased from 43% to 55% after OCM implementation. Patients whose charts contained documented plans of care for pain were less likely to have decreased pain scores at a subsequent visit (51% vs 76%). Conclusions: (1) Documentation of a quantitative pain score was completed in nearly all patients before and after the implementation of OCM. (2) There was a non-statistically significant increase in documentation of plan of care for pain after OCM implementation. (3) Documentation of a plan of care was not associated with a decreased pain score at a subsequent visit. This may be the result of small sample size or related to progressive cancer-related pain or inadequate pain intervention. [Table: see text]

Complementary and alternative therapy use in a regional radiation oncology treatment centre: Can staff knowledge, views, confidence and documentation be improved?

IntroductionComplementary and alternative therapies (CATs) are widely used by cancer patients but are infrequently disclosed and documented. This study aimed to improve radiation therapy staff knowledge, confidence, views and documentation of radiation oncology patients' use of CATs.MethodParticipants completed a baseline questionnaire regarding their knowledge, confidence, views and documentation relating to patients' CAT use. An intervention was undertaken whereby participants attended an educational session and a CAT screening tool was implemented simultaneously. Participants immediately completed a post‐intervention questionnaire and later a 6‐month follow‐up questionnaire. A patient record audit was conducted to measure the documentation of CAT use pre‐ and post‐intervention.ResultsFrom baseline to post‐intervention, there was a statistically significant shift in staff knowledge and confidence (P = 0.001–0.01). The observed shift was sustained over a 6‐month period, (P = 0.453–1.00). Participants' perceived views of CATs did not change as a result of the intervention (P = 0.261–1.000). The post‐intervention audit compared to the baseline audit yielded a statistically significant increase in documentation. There was an increase in CAT use mentioned in patient records from 14% (15/108) to 40% (35/88) (P < 0.001).ConclusionsThe implementation of a screening tool and staff education increased radiation therapy staff knowledge of CATs and increased staff confidence when discussing CAT use with patients. Documentation of CATs in the patient record increased post‐intervention. These changes positively affected radiation therapy staff understanding the use of CATs by cancer patients.

Using Best Practice Advisory alert to increase early advanced care planning discussion and palliative care referral in advanced cancer patients.

320 Background: Patients with advanced cancer can benefit from early initiation of palliative care (PC) and advanced care planning (ACP). In theory, the Medical Order for Life-Sustaining Treatments (MOLST), which provides a vehicle for end-of-life discussion, could lead to improved uptake of ACP and PC. In order for MOLST forms to influence these care process outcomes, methods are needed to help clinicians introduce the forms to patients in a compassionate manner. The objective of this study is to develop a best practice advisory (BPA) alert in the electronic medical record (EMR) to help oncologists identify appropriate patients for ACP and PC referral and evaluate its impact on improving MOLST form and palliative referral order documentation in EMR for these patients. Methods: BPA alert criteria included Lung and GI cancer patients with stage IV disease or undergoing treatment with palliative intent. The oncologists could act on the alert by either acknowledging it with action statement (I have already discussed ACP, I intend to discuss ACP in this or next visit, Patient unlikely to die in next 12 months, other) or dismiss it. We examined the rates of MOLST form and PC referral orders in the EMR 12-months before and after the BPA was implemented in 03/2018. Results: The BPA fired in 424 patients who met the criteria over a period of 9 weeks. It was acknowledged in 409 and cancelled in 15 patients. Following the alert, 40 (9%) patients had a MOLST form added to the chart compared to only 9 (2%) patients before the alert and 17 (4%) patients had palliative care referral order placed vs. 10 (2%) patients before the alert. Physicians acknowledged discussing ACP in 145 patients, most of whom (25/30) initiated these conversations after the BPA was implemented. Data collection is ongoing to capture BPA effect for longer follow-up. Conclusions: The BPA alert intervention resulted in significant increase in documentation of ACP and palliative referral order suggesting the potential of this tool in improving adherence to national guidelines calling for early initiation of palliative care and advance care planning in patients with advanced cancers.

Completeness in clerking: The surgical admissions proforma.

BackgroundThe accessibility of surgical patient data is a key safety concern, and relies on efficient clerking and handovers. This project assessed whether the introduction of a surgical clerking proforma improved the recording of patient information in the surgical admissions unit (SAU) at Northwick Park Hospital.Materials and methodsExisting patient notes were assessed on content and ease of access, using two independent surveys conducted over a 5-day period. The first survey audited patient notes before (n = 28) and after (n = 23) the introduction of the proforma. It assessed whether key patient details were documented, in line with the 17 criteria set out in the Guidelines for Clinicians on Medical Records and Notes by The Royal College of Surgeons in England. The second survey questioned healthcare professionals before (n = 25) and after (n = 17) proforma implementation on the accessibility of patient data and coherency of patient notes.Results5 of the 17 criteria showed significant differences post proforma implementation. Of these differences, the recording of height and occupation was most notable (p < 0.01). Medication history, weight and investigations also showed significant increases in documentation (p < 0.05). In all 3 questions asked to healthcare professionals, fewer healthcare professionals were required to revisit archived notes following proforma implementation (p < 0.05).ConclusionOur study illustrates that a comprehensive surgical clerking proforma improves patient data documentation and saves healthcare professionals' time compared to the freehand clerking method. The implications of such work are far reaching, and if well implemented could allow a new reliable platform for further clinical audits.

The effect of an automated point of care tool on diagnosis and management of childhood obesity in primary care.

Childhood obesity is underdiagnosed in primary care practices. Our study aimed to compare rates of documentation of diagnosis of obesity and counselling for nutrition and physical activity at an academic primary care practice prior to and following implementation of a body mass index (BMI)-based electronic point of care clinical reminder tool. We performed a retrospective record review of children aged 2-18 years undergoing well child visits during any of three calendar years (2009, 2011 and 2013). The electronic clinical reminder tool was implemented in September 2010. Records of children with BMI > 95th percentile were electronically searched for terms of documentation of diagnosis of obesity and nutrition and physical activity counselling. Multivariable logistic regression models were used to adjust for potential patient and provider confounders. Among those with BMI ≥ 95th percentile, there was a statistically significant increase in documentation of diagnosis of obesity (45.5% in 2009 vs. 52.4% in 2011; P < 0.001; adjusted odds ratio 1.36; 95% CI 1.13-1.65) and in counselling for physical activity and nutrition (66.8% in 2009 vs. 75.2% in 2011; P < 0.001; adjusted odds ratio 1.33; 95% CI 1.06-1.66) following implementation of the tool. Compared with 2011, there was no statistically significant increase in documentation of obesity (50.4%) or nutrition and physical activity counselling (77.9%) in 2013. The implementation of a point of care clinical reminder tool was associated with improvement in documentation of diagnosis of obesity and counselling for nutrition and physical activity. Further studies are needed to determine the impact of these automated tools on weight outcomes in children.

Patient care outcomes of a tobacco use registry in an academic family practice.

While the potential benefit of a chronic disease registry for tobacco use is great, outcome reports have not been generated. We examined the effect of implementing a tobacco use registry, including a decision support tool, on treatment outcomes within an academic family medicine clinic. A chart review of 200 patients who smoked and attended the clinic before and after registry implementation assessed the number of patients with clinic notes documenting (1) counseling for tobacco use, (2) recommendations for cessation medication, (3) a set quit date, (4) referrals to the on-site Nicotine Dependence Program (NDP) and/or QuitlineNC, and (5) pneumococcal vaccine. Data from the NDP, QuitlineNC, and clinic billing records before and after implementation compared the number of clinic-generated QuitlineNC fax referrals, new scheduled appointments for the NDP, and visits coded for tobacco counseling reimbursement. Significant increases in documentation occurred across most chart review variables. Significant increases in the number of clinic-generated fax referrals to QuitlineNC (from 27 to 96), initial scheduled appointments for the NDP (from 84 to 148), and coding for tobacco counseling (from 101 to 287) also occurred when compared with total patient visits during the same time periods. Patient attendance at the NDP (52%) and acceptance of QuitlineNC services (31%) remained constant. The tobacco use registry's decision support tool increased evidenced-based tobacco use treatment (referrals, medications, and counseling) for patients at an academic family medicine clinic. This novel tool offers standardized care for all patients who use tobacco, ensuring improved access to effective tobacco use counseling and medication treatments.

Baseline metabolic monitoring of atypical antipsychotics in an inpatient setting

Background: Atypical antipsychotic agents serve an important role in the treatment of many psychiatric disorders but have the potential to cause adverse effects, notably metabolic disturbances. These agents are known to cause increases in obesity, glucose intolerance, dyslipidemia and hypertension. In 2004, the American Diabetes Association (ADA) and the American Psychiatric Association (APA), in collaboration with other organizations, acknowledged the association between the use of atypical antipsychotics and the development of metabolic abnormalities and provided monitoring recommendations for the use of these agents. Despite these recommendations, rates of monitoring remain low. Objective: The purpose of this study is to assess whether a pharmacist recommendation form is effective in improving baseline metabolic monitoring for patients admitted to an acute inpatient psychiatry unit who are ordered a scheduled atypical antipsychotic. Methods: A pharmacist recommendation form with metabolic monitoring parameters was placed on the charts of patients ordered a scheduled atypical antipsychotic during a two month period. A retrospective chart review was conducted to compare the percentage of baseline monitoring ordered pre-intervention versus the intervention period. Patients ages 18 years or older who were ordered a scheduled atypical antipsychotic were included. Results: During the intervention period, there was a significant increase in documentation for presence or absence of diabetes (p = 0.018) and cardiovascular disease (p &amp;lt; 0.001). A significant difference in the number of orders for hemoglobin A1c (p = 0.007) and lipid panels (p &amp;lt; 0.001) were noted. No other significant differences were found. Conclusion: A pharmacist recommendation form was effective in improving the baseline monitoring of personal history of diabetes and cardiovascular disease and monitoring of hemoglobin A1c and lipid panels, but rates of other baseline monitoring parameters did not improve.

Continuous intrapartum electronic fetal monitoring – impact of the introduction of new practices

BackgroundElectronic fetal monitoring (EFM) is recommended in high risk pregnancies during labour, aiming to improve perinatal outcome. Previous studies indicate poor interpretation is associated with significant perinatal complications. To reduce...

Documentation of Nonroutine Communications of Critical or Significant Radiology Results: A Multiyear Experience at a Tertiary Hospital

The aim of this study was to determine the frequency of radiology reports that contain nonroutine communications of results and categorize the urgency of such communications. A rule-based text-query algorithm was applied to a database of 2.3 million radiology reports, which has an accuracy of 98% for classifying reports containing documentation of communications. The frequency of such communications by year, modality, and study type was then determined. Finally, 200 random reports selected by the algorithm were analyzed, and reports containing critical results were categorized according to ascending levels of urgency. Critical or noncritical results to health care providers were present in 5.09% of radiology reports (116,184 of 2,282,923). For common modalities, documentation of communications were most frequent in CT (14.34% [57,537 of 402,060]), followed by ultrasound (9.55% [17,814 of 186,626]), MRI (5.50% [13,697 of 248,833]), and chest radiography (1.57% [19,840 of 1,262,925]). From 1997 to 2005, there was an increase in reports containing such communications (3.04% in 1997, 6.82% in 2005). More reports contained nonroutine communications in single-view chest radiography (1.29% [5,533 of 428,377]) than frontal/lateral chest radiography (0.80% [1,815 of 226,837]), diagnostic mammography (9.42% [3,662 of 38,877]) than screening mammography (0.47% [289 of 61,114]), and head CT (26.21% [20,963 of 79,985]) than abdominal CT (15.05% [19,871 of 132,034]) or chest CT (5.33% [3,017 of 56,613]). All of these results were statistically significant (P < .00001). Of 200 random radiology reports indicating nonroutine communications, 155 (78%) had critical and 45 (22%) had noncritical results. Regarding level of urgency, 94 of 155 reports (60.6%) with critical results were categorized as high urgency, 31 (20.0%) as low urgency, 26 (16.8%) as medium urgency, and 4 (2.6%) as discrepant. From 1997 to 2005, there was a significant increase in documentation of nonroutine communications, which may be due to increasing compliance with ACR guidelines. Most reports with nonroutine communications contain critical findings.

163: Improving Prenatal Counseling In the Nation's Capital

163: Improving Prenatal Counseling In the Nation's Capital

Microcytosis and possible early iron deficiency in paediatric inpatients: a retrospective audit

BackgroundIron deficiency anaemia is a common paediatric problem worldwide, with significant neurodevelopmental morbidity if left untreated. A decrease in the mean corpuscular volume (MCV) can be used as a surrogate marker for detecting early iron deficiency prior to definitive investigation and treatment. An audit cycle was therefore undertaken to evaluate and improve the identification, follow-up and treatment of abnormally low MCV results amongst the paediatric inpatients in an English district general hospital.MethodsThe audit cycle was performed retrospectively over two three-month periods (February to April 2006; September to November 2006), amongst patients aged between one month and 16 years that had full blood counts performed whilst admitted on the paediatric ward. Patients with at least one abnormally low MCV result were identified, and their notes reviewed. We looked for any underlying explanation for the result, adequate documentation of the result as abnormal, and instigation of follow-up or treatment. In-between the two audit periods, the results of the first audit period were presented to the medical staff and suggestions were made for improvements in documentation and follow-up of abnormal results. The z-test was used to test for equality of proportions between the two audit samples.ResultsOut of 701 inpatients across both audit periods that had full blood counts, 61 (8.7%) had a low MCV result. Only 15% of patients in each audit period had an identifiable explanation for their low MCV values. Amongst the remaining 85% with either potentially explicable or inexplicable results, there was a significant increase in documentation of results as abnormal from 25% to 91% of cases between the first and second audit periods (p = 0.00 using z-test). However, there was no accompanying increase in the proportion of patients who received follow-up or treatment for their abnormal results.ConclusionAbnormal red cell indices that may indicate iron deficiency are frequently missed amongst paediatric inpatients. Medical staff education and the use of appropriate protocols or pathways could further improve detection and treatment rates in this setting.

Can written nursing practice standards improve documentation of initial assessment of ED patients?

Introduction There is wide variation in emergency nursing practice in terms of initial patient assessment and the interventions implemented in response to these patient assessment findings. It is hypothesised that written ED nursing practice standards will reduce variability in documentation standards related to initial patient assessment. Aim This study aimed to examine the effect of written ED nursing practice standards augmented by an in-service education programme on the documentation of the initial nursing assessment. Method A pre-test/post-test design was used. Initial patient assessment was assessed using the Emergency Department Observation Chart. All adult patients (>18 years) who presented with chest pain and who were triaged to the general adult cubicles were eligible for inclusion in the study. Random sampling was used to select the patients for the pre-test (n = 78) and post-test groups (n = 74). Results There was significant improvement in documentation of all aspects of symptom assessment except quality and historical variables: pre-hospital care, cardiac risk factors, and past medical history. Improvements in documentation of elements of primary survey assessment were variable. There were significant increases in documentation of respiratory effort, chest auscultation findings, capillary refill and conscious state. There was a significant 18.3% decrease in the frequency of documentation of respiratory rate and no significant changes in documentation of oxygen saturation, heart rate or blood pressure. Conclusion Written ED nursing practice standards were effective in improving the documentation of some elements of initial nursing assessment for patients with chest pain. Active implementation strategies are important to ensure effective uptake of written practice standards and the relationship between nursing documentation and actual clinical practice warrants further consideration using a naturalistic approach in real practice settings. There is wide variation in emergency nursing practice in terms of initial patient assessment and the interventions implemented in response to these patient assessment findings. It is hypothesised that written ED nursing practice standards will reduce variability in documentation standards related to initial patient assessment. This study aimed to examine the effect of written ED nursing practice standards augmented by an in-service education programme on the documentation of the initial nursing assessment. A pre-test/post-test design was used. Initial patient assessment was assessed using the Emergency Department Observation Chart. All adult patients (>18 years) who presented with chest pain and who were triaged to the general adult cubicles were eligible for inclusion in the study. Random sampling was used to select the patients for the pre-test (n = 78) and post-test groups (n = 74). There was significant improvement in documentation of all aspects of symptom assessment except quality and historical variables: pre-hospital care, cardiac risk factors, and past medical history. Improvements in documentation of elements of primary survey assessment were variable. There were significant increases in documentation of respiratory effort, chest auscultation findings, capillary refill and conscious state. There was a significant 18.3% decrease in the frequency of documentation of respiratory rate and no significant changes in documentation of oxygen saturation, heart rate or blood pressure. Written ED nursing practice standards were effective in improving the documentation of some elements of initial nursing assessment for patients with chest pain. Active implementation strategies are important to ensure effective uptake of written practice standards and the relationship between nursing documentation and actual clinical practice warrants further consideration using a naturalistic approach in real practice settings.