Disparities in Misclassification of Race and Ethnicity in Electronic Medical Records Among Patients with Traumatic Injury.

Systems-level barriers to self-reporting of race and ethnicity reduce the integrity of data entered into the medical record and trauma registry among patients with injuries, limiting research assessing the burden of racial disparities. We sought to characterize misclassification of self-identified versus hospital-recorded racial and ethnic identity data among 10,513 patients with traumatic injuries. American Indian/Alaska Native patients (59.9%) and Native Hawaiian/Pacific Islander patients (52.4%) were most likely to be misclassified. Most Hispanic/Latin(x) patients preferred to only be identified as Hispanic/Latin(x) (73.2%) rather than a separate race category (e.g., White). Incorrect identification of race/ethnicity also has substantial implications for the perceived demographics of patient population; according to the medical record, 82.3% of the population were White, although only 70.6% were self-identified as White. The frequency of misclassification of race and ethnicity for persons of color limits research validity on racial and ethnic injury disparities.

Closing the gap: Triangulation of surgeons' respectful behaviors perceived by medical students, residents, and patients.

BACKGROUND: Professionalism in academia requires surgical faculty to establish a safe clinical learning environment based on respectful behaviors that span the training and patient interface. National data reporting trainee mistreatment suggest that there are significant gaps between resident and medical student perceptions of attending behavior. It is unknown whether patient perceptions mirror those of surgical trainees. HYPOTHESIS: Based on triangulated ratings, patients, surgical residents, and medical students have similar perceptions of a surgeons' respectful behaviors. METHODS: Respect scores from end-of-rotation evaluations by surgical residents and rotating medical students were compared for 50 academic surgeons over the period of 2014 to 2018. Clinician and Group Consumer Assessment surveys were collected from patients of 36 of these surgeons and mined for respect and listening behavior ratings. Data were triangulated and analyzed for correlation and variability across the trainee and patient experiences. RESULTS: Resident respect ratings of faculty were consistently higher than those from medical students. Despite a wider variability, medical students still rated their surgical faculty as being respectful to themselves and others most often, almost always, and always 95% of the time. Patient scores were generally lower than trainee scores for an individual surgeon, particularly regarding listening skills. Triangulation of trainee data with patient data identified surgeons demonstrating strong respectful behaviors across the clinical environment as well as those with gaps in behavior toward trainees and patients. CONCLUSION: Triangulation of feedback from trainees and patients provides a unique opportunity to target interventions in professionalism across the clinical learning environment.

Using an electronic medical record tool to improve pneumococcal screening and vaccination rates for older patients admitted with community-acquired pneumonia.

An electronic medical record tool was developed that determines if a patient meets criteria for screening for the vaccine; it then poses a series of screening questions. Use of the tool has improved performance on pneumococcal vaccination from 44% to more than 90%, with an increase in vaccine units of 305%.

An electronic catheter-associated urinary tract infection surveillance tool.

OBJECTIVE: To develop and validate an electronic surveillance tool for catheter-associated urinary tract infections (CAUTIs). DESIGN: Retrospective cohort study. SETTING: 413-bed university-affiliated urban teaching hospital. METHODS: An electronic surveillance tool was developed for CAUTI and urinary catheter utilization based on the objective components of the National Healthcare Safety Network (NHSN) definitions including fever, urinalysis, and urine culture. Results were compared to manual chart review by an infection preventionist (IP). RESULTS: During January and February 2010, 204 positive urine cultures (≥10(3) colony-forming units/mL) were identified in 136 patients with indwelling urinary catheters during their hospitalization. The electronic surveillance tool detected 60 CAUTI cases and 7,098 catheter-days, yielding a CAUTI incidence rate of 8.5 per 1,000 catheter-days. Urinary catheter utilization ratios (Foley-days/patient-days) were: acute care units, 0.27 (3,637 of 13,229); intensive care units, 0.77 (3,461 of 4,469); and overall, 0.40 (7,098 of 17,698). In comparison, the IP identified 59 cases by manual review with a sensitivity of 51 of 59 (86.4%), specificity 136 of 145 (93.8%), and negative predictive value of 136 of 144 (94.4%). Fever was present in 54 of 59 (91.5%) of CAUTI cases identified manually, while subjective criteria were documented in only 6 of 59 (10.2%) infections. Agreement between the electronic surveillance and manual IP review was assessed as very good (κ, 0.80; 95% confidence interval, 0.71-0.89). CONCLUSIONS: We report an attempt at automating surveillance for CAUTI. With a high negative predictive value, the electronic tool allows for more efficient CAUTI surveillance and facilitates housewide trending of rates and catheter utilization. This approach should be validated in different patient populations.

Adherence to guideline-directed venous thromboembolism prophylaxis among medical and surgical inpatients at 33 academic medical centers in the United States.

This study's purpose was to describe compliance with established venous thromboembolism (VTE) prophylaxis guidelines in medical and surgical inpatients at US academic medical centers (AMCs). Data were collected for a 2007 University HealthSystem Consortium Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE) Benchmarking Project that explored VTE in AMCs. Prophylaxis was considered appropriate based on 2004 American College of Chest Physicians guidelines. A total of 33 AMCs from 30 states participated. In all, 48% of patients received guideline-directed prophylaxis-59% were medical and 41% were surgical patients. VTE history was more common among medical patients with guideline-directed prophylaxis. Surgical patients admitted from the emergency department and with higher illness severity were more likely to receive appropriate prophylaxis. Despite guidelines, VTE prophylaxis remains underutilized in these US AMCs, particularly among surgical patients. Because AMCs provide the majority of physician training and should reflect and set care standards, this appears to be an opportunity for practice and quality improvement and for education.

Validation of the "HAMP" mapping algorithm: a tool for long-term trauma research studies in the conversion of AIS 2005 to AIS 98.

BACKGROUND: There are significant changes in the abbreviated injury scale (AIS) 2005 system, which make it impractical to compare patients coded in AIS version 98 with patients coded in AIS version 2005. METHODS: Harborview Medical Center created a computer algorithm "Harborview AIS Mapping Program (HAMP)" to automatically convert AIS 2005 to AIS 98 injury codes. The mapping was validated using 6 months of double-coded patient injury records from a Level I Trauma Center. HAMP was used to determine how closely individual AIS and injury severity scores (ISS) were converted from AIS 2005 to AIS 98 versions. The kappa statistic was used to measure the agreement between manually determined codes and HAMP-derived codes. RESULTS: Seven hundred forty-nine patient records were used for validation. For the conversion of AIS codes, the measure of agreement between HAMP and manually determined codes was [kappa] = 0.84 (95% confidence interval, 0.82-0.86). The algorithm errors were smaller in magnitude than the manually determined coding errors. For the conversion of ISS, the agreement between HAMP versus manually determined ISS was [kappa] = 0.81 (95% confidence interval, 0.78-0.84). CONCLUSION: The HAMP algorithm successfully converted injuries coded in AIS 2005 to AIS 98. This algorithm will be useful when comparing trauma patient clinical data across populations coded in different versions, especially for longitudinal studies.

A descriptive case series of patients with end-stage liver disease hospitalized with variceal bleeding who received pharmacologic venous thromboembolism prophylaxis.

BACKGROUND: It is unknown whether venous thromboembolism prophylaxis (VTEP) should be utilized in hospitalized patients with end-stage liver disease (ESLD), particularly in those admitted with variceal bleeding. OBJECTIVE: We sought to describe a cohort of patients who received pharmacologic VTEP, specifically identifying the occurrence of rebleeding. DESIGN: Descriptive case series. SETTING/PATIENTS: All adult patients with ESLD admitted to an urban county teaching hospital over three years with variceal bleeding who received pharmacologic VTEP during hospitalization. RESULTS: A total of 22 patients with ESLD and variceal bleeding received pharmacologic VTEP. Only 1 patient rebled after initiation of VTEP; 2 patients were diagnosed with lower extremity deep venous thrombosis while on VTEP including the 1 patient who rebled. CONCLUSIONS: VTEP was associated with an unexpectedly low incidence of recurrent bleeding in patients with ESLD and variceal bleeding. Further study may be warranted.

Translating a multifactorial fall prevention intervention into practice: a controlled evaluation of a fall prevention clinic.

Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital-based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinic's first 6 months of operation were compared with outcomes for 86 age-, sex-, and race-matched controls; all persons included in analyses received primary care at the hospital's geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall-related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow-up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fall-related healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow-up; differences in fall-related healthcare use according to study group from baseline to follow-up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real-world clinical practice settings on key outcomes, including injurious falls, downstream fall-related healthcare use, and costs.

Improving insulin ordering safely: the development of an inpatient glycemic control program.

This report describes a Glycemic Control Program instituted at an academic regional level-one trauma center. Key interventions included: 1) development of a subcutaneous insulin physician order set, 2) use of a real-time data report to identify patients with out-of-range glucoses, and 3) implementation of a clinical intervention team. Over four years 18,087 patients admitted to non-critical care wards met our criteria as dysglycemic patients. In this population, glycemic control interventions were associated with increased basal and decreased sliding scale insulin ordering. No decrease was observed in the percent of patients experiencing hperglycemia. Hypoglycemia did decline after the interventions (4.3% to 3.6%; p = 0.003). Distinguishing characteristics of this Glycemic Control Program include the use of real-time data to identify patients with out-of-range glucoses and the employment of a single clinician to cover all non-critical care floors.

Ambient woodsmoke and associated respiratory emergency department visits in Spokane, Washington.

Three multivariate receptor algorithms were applied to seven years of chemical speciation data to apportion fine particulate matter to various sources in Spokane, Washington. Source marker compounds were used to assess the associations between atmospheric concentration of these compounds and daily cardiac hospital admissions and/or respiratory emergency department visits. Total carbon and arsenic had high correlations with two different vegetative burning sources and were selected as vegetative burning markers, while zinc and silicon were selected as markers for the motor vehicle and airborne soil sources, respectively. The rate of respiratory emergency department visits increased 2% for a 3.0 microg/m3 interquartile range change in a vegetative burning source marker (1.023, 95% CI 1.009-1.038) at a lag of one day. The other source markers studied were not associated with the health outcomes investigated. Results suggest vegetative burning is associated with acute respiratory events.