Surveillance of Health Care-Associated Violence Using Natural Language Processing.

BACKGROUND AND OBJECTIVES: Patient and family violent outbursts toward staff, caregivers, or through self-harm, have increased during the ongoing behavioral health crisis. These health care-associated violence (HAV) episodes are likely under-reported. We sought to assess the feasibility of using nursing notes to identify under-reported HAV episodes. METHODS: We extracted nursing notes across inpatient units at 2 hospitals for 2019: a pediatric tertiary care center and a community-based hospital. We used a workflow for narrative data processing using a natural language processing (NLP) assisted manual review process performed by domain experts (a nurse and a physician). We trained the NLP models on the tertiary care center data and validated it on the community hospital data. Finally, we applied these surveillance methods to real-time data for 2022 to assess reporting completeness of new cases. RESULTS: We used 70 981 notes from the tertiary care center for model building and internal validation and 19 332 notes from the community hospital for external validation. The final community hospital model sensitivity was 96.8% (95% CI 90.6% to 100%) and a specificity of 47.1% (39.6% to 54.6%) compared with manual review. We identified 31 HAV episodes in July to December 2022, of which 26 were reportable in accordance with the hospital internal criteria. Only 7 of 26 cases were reported by employees using the self-reporting system, all of which were identified by our surveillance process. CONCLUSIONS: NLP-assisted review is a feasible method for surveillance of under-reported HAV episodes, with implementation and usability that can be achieved even at a low information technology-resourced hospital setting.

Enhancing Pressure Injury Surveillance Using Natural Language Processing.

OBJECTIVE: This study assessed the feasibility of nursing handoff notes to identify underreported hospital-acquired pressure injury (HAPI) events. METHODS: We have established a natural language processing-assisted manual review process and workflow for data extraction from a corpus of nursing notes across all medical inpatient and intensive care units in a tertiary care pediatric center. This system is trained by 2 domain experts. Our workflow started with keywords around HAPI and treatments, then regular expressions, distributive semantics, and finally a document classifier. We generated 3 models: a tri-gram classifier, binary logistic regression model using the regular expressions as predictors, and a random forest model using both models together. Our final output presented to the event screener was generated using a random forest model validated using derivation and validation sets. RESULTS: Our initial corpus involved 70,981 notes during a 1-year period from 5484 unique admissions for 4220 patients. Our interrater human reviewer agreement on identifying HAPI was high ( κ = 0.67; 95% confidence interval [CI], 0.58-0.75). Our random forest model had 95% sensitivity (95% CI, 90.6%-99.3%), 71.2% specificity (95% CI, 65.1%-77.2%), and 78.7% accuracy (95% CI, 74.1%-83.2%). A total of 264 notes from 148 unique admissions (2.7% of all admissions) were identified describing likely HAPI. Sixty-one described new injuries, and 64 describe known yet possibly evolving injuries. Relative to the total patient population during our study period, HAPI incidence was 11.9 per 1000 discharges, and incidence rate was 1.2 per 1000 bed-days. CONCLUSIONS: Natural language processing-based surveillance is proven to be feasible and high yield using nursing handoff notes.

De-adopting low-value care: The missing step in evidence-based practice?

BACKGROUND: Low-value care provides little or no benefit to pediatric patients, has the potential to cause harm, waste healthcare resources, and increase healthcare costs. Nursing has a responsibility to identify and de-adopt low-value practices to help promote quality care. PURPOSE: 1) Describe the process of identifying and de-adopting low-value clinical practices guided by a conceptual model using a case study approach. 2) Identify facilitators and barriers to de-adoption practices, including levels of stakeholder engagement, organizational structures, and the quality of available scientific and non-scientific evidence. METHODOLOGY: An evidence-based practice (EBP) project investigating the efficacy of antihistamines in decreasing infusion reactions to infliximab identified a low-value practice within a pediatric infusion center. The Synthesis Model for the Process of De-adoption was then applied to guide the de-adoption of this low-value practice. Case study analysis highlighted facilitators and barriers to de-adoption efforts. CONCLUSIONS: The process for de-adopting care is an essential component of EBP and, as such, should be explicated through robust, standardized EBP processes and education. PRACTICE IMPLICATIONS: Nurses are best positioned to identify, assess and prioritize low-value practices and facilitate the de-adoption of low-value practice that impact pediatric patients and families. Models to support de-adoption and a focus on site-specific practices including a prepared nursing workforce, continuous evaluation of care processes and the use of resources to assess for contextual determinants facilitates success and sustainability of this essential EBP approach.

Electronic surveillance of patient safety events using natural language processing.

OBJECTIVE: We describe our approach to surveillance of reportable safety events captured in hospital data including free-text clinical notes. We hypothesize that a) some patient safety events are documented only in the clinical notes and not in any other accessible source; and b) large-scale abstraction of event data from clinical notes is feasible. MATERIALS AND METHODS: We use regular expressions to generate a training data set for a machine learning model and apply this model to the full set of clinical notes and conduct further review to identify safety events of interest. We demonstrate this approach on peripheral intravenous (PIV) infiltrations and extravasations (PIVIEs). RESULTS: During Phase 1, we collected 21,362 clinical notes, of which 2342 were reviewed. We identified 125 PIV events, of which 44 cases (35%) were not captured by other patient safety systems. During Phase 2, we collected 60,735 clinical notes and identified 440 infiltrate events. Our classifier demonstrated accuracy above 90%. CONCLUSION: Our method to identify safety events from the free text of clinical documentation offers a feasible and scalable approach to enhance existing patient safety systems. Expert reviewers, using a machine learning model, can conduct routine surveillance of patient safety events.

The Efficacy of Antihistamines in Preventing Reactions to Infliximab in Patients With Crohn Disease/Ulcerative Colitis: A Review of the Evidence.

Inflammatory bowel diseases, including Crohn disease and ulcerative colitis, are most often diagnosed during adolescence and young adulthood, with a rising incidence in pediatric populations. Infliximab is an effective treatment option for Crohn disease and ulcerative colitis. The most common adverse event with infliximab is an infusion reaction. Patients are often treated prophylactically with combinations of acetaminophen, intravenous steroid, and an antihistamine to prevent an infusion reaction. There is a high degree of practice variation regarding pretreatment for infliximab infusions, the efficacy of pretreatment with an antihistamine is unproven in preventing infusion-related reactions, and there is no national clinical standard. Unnecessary pretreatment in adolescence and young adulthood may be harmful, as this is a time to focus on developing self-care management skills. Antihistamine side effects including somnolence and dizziness may adversely affect adolescents and/or young adults' ability to complete schoolwork, drive, and transition toward autonomous management of their chronic illness. This report presents the findings of an evidence-based practice project reviewing the efficacy of pretreatment with an antihistamine in patients with Crohn disease and ulcerative colitis receiving infliximab. Practice implications are discussed.

Emergency department visits for dental problems associated with trauma in Alberta: A report between the years 2011 and 2017.

BACKGROUND/AIMS: Dental trauma represents a significant cause for concern in emergency department (ED). The aim of this study was to report on the prevalence of ED visits for dental problems associated with trauma (DPAT) in Alberta, Canada. The specific objectives were to provide up-to-date information regarding ED utilization for dental trauma concerning the demographics of users and distribution of ED visits across the Province of Alberta, allowing for an assessment of possible trends over the period of time observed. METHODS: Data for ED visits in Alberta between January 1, 2011, and December 31, 2017, were extracted from the National Ambulatory Care Reporting System (NACRS). Data elements pertinent to this analysis include patient demographics, administrative information, and diagnosis. Only the main or primary diagnosis of each ED visit was included in this analysis using the International Statistical Classification of Diseases (ICD-10-CA). RESULTS: There were 71 118 total ED visits for DPAT in this time period, with an average of 10 159 visits per year across Alberta. Children aged 1-4 years old represented the age-group in both genders with the largest number of ED visits, 22.1% of the total number of visits. The number of ED visits for DPAT by males 21 years or younger (22 384) was higher than the total number of ED visits among females in all age-groups (21 099). The ICD-10-CA code S01.5 referring to open wound of lip and oral cavity was by far the most prevalent diagnosis, representing 57.6% of the total visits during the period investigated. CONCLUSIONS: This population-based report quantifies the rates and frequency of ED utilization for DPAT in the province of Alberta, Canada. The information gathered is important to support injury prevention initiatives using a population-based approach targeting the high-risk groups of the population identified by this study.

Emergency department visits for dental problems not associated with trauma in Alberta, Canada.

OBJECTIVES: The objective of this report was to describe the frequency of emergency department (ED) visits for dental problems not associated with trauma (DPNAT) in Alberta, Canada, over a 5-year period. METHODS: In Alberta, ED visits for DPNAT between 1 January 2011 and 30 April 2016 were identified using the codes from the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA). The codes for DPNAT range from K00 to K14, described as diseases of the oral cavity, salivary glands and jaws. The data were gathered from the National Ambulatory Care Reporting System (NACRS) database and from the Alberta Real Time Syndromic Surveillance Net (ARTSSN). The information gathered on ED visits for DPNAT was related to the primary diagnosis of the discharge disposition of the visits. RESULTS: During the study period, there were a total of 147,357 ED visits for DPNAT in Alberta. The visits were made by 111,362 individuals, representing 1.3 visits per person. Among all ED visits, a prevalence of 1.2% of ED visits for DPNAT was observed. The most prevalent primary diagnosis of ED visits for DPNAT was for diseases of pulp and periapical tissues (K04), such as periapical abscess, representing 45.0% of all visits, followed by disorders of teeth and supporting structures (K08), such as toothache, representing 18.8% of all visits. The majority of the visits were made by patients from 20 to 44 years of age (52.2%). North and Calgary Alberta Health Service (AHS) Zones were those with the highest occurrence of ED visits (31.9% and 24.5%, respectively). ED visits for dental problems were more common than visits for other general health conditions, such as diabetes and asthma. CONCLUSION: The frequency of ED visits for DPNAT suggests barriers faced by the population in accessing dental care resources, especially for urgent dental needs. Policy efforts and political will are needed to provide alternative options for seeking emergency dental care.

Antibodies to infliximab are associated with lower infliximab levels and increased likelihood of surgery in pediatric IBD.

BACKGROUND: Adult studies suggest antibodies to infliximab (ATI) correlate with loss of response in inflammatory bowel disease but pediatric data are limited. METHODS: We conducted a cross-sectional study of trough infliximab levels and ATI in 134 pediatric and young adult patients receiving infliximab. At the time serum was obtained demographics, disease phenotype, duration of infliximab therapy, use of combination therapy (methotrexate or 6-mercaptopurine with infliximab), and surgery were recorded. RESULTS: Assays were performed on 134 subjects currently receiving infliximab (85 male; mean age, 17.3 ± 4.3 years; 114 Crohn's disease and 20 ulcerative colitis). Infliximab use ranged from 12 days to 12 years: median 2.0 (interquartile range [1.1-4.3]) years. Twenty-seven of 134 (20%) patients had ATI ≥5 U/mL. Of patients with ATI ≥5 U/mL, 59% had infliximab levels <5 µg/mL, compared with 14% of patients with ATI <5 U/mL (P < 0.001). Ten (7%) patients (9 Crohn's disease, 1 ulcerative colitis) underwent bowel resections after beginning infliximab infusions. Sixty percent who underwent surgery had ATI ≥12 U/mL; in contrast, only 8% of patients who did not undergo surgery had ATI ≥12 U/mL (P = 0.01). At the time of serum sampling, 50 (37%) patients were receiving combination therapy, compared with 84 (63%) on infliximab alone. Combination therapy at the time of serum sampling did not correlate with either increase infliximab levels or lower ATI compared with infliximab monotherapy. However, prior immunomodulator use was associated with lower antibody levels (P = 0.007). CONCLUSIONS: ATI correlates with reduction in infliximab level and a higher risk of surgery in patients with inflammatory bowel disease.