Development and initiation of computer generated documentation for burn patient care.

Burn care is costly, complex, and poorly reimbursed. Capturing evaluation and management codes is an essential step in obtaining reimbursement for services rendered. For surgeons used to billing on the basis of Current Procedural Terminology codes, this represents a significant paradigm shift. In an effort to document the care provided and increase compliance with billing standards, we created computerized history and physical examination notes and progress notes specifically for burn patients. Drop down menus are included to answer directed queries, which allows the majority of the documentation to be completed with a point and click of the mouse. The note is completed by the house staff except for the "assessment and plan," which are entered by the attending physician who reviews and then electronically signs the note. A log of electronically signed notes is generated weekly for billing purposes. The use of these computerized documents has been reviewed and approved by the coding and quality assurance specialists within our billing organization. We believe these tools maximize the efficiency of documenting burn patient care, while minimizing the effort necessary to comply with evaluation and management guidelines. The aim of this study was to test the new computerized method at our institution to see whether it would improve documentation for evaluation and management services provided to burn patients. The results prove that this new system accomplished the goal we had set.

Gene therapy in transplantation: pathological consequences of unavoidable plasmid contamination with lipopolysaccharide.

Experimental studies evaluated the responses of murine cardiac graft recipients to high and low levels of lipopolysaccharide (LPS) contaminating plasmid DNA preparations. Immediately prior to transplantation, graft recipients were transfected by injecting the quadriceps muscles with plasmids that encoded the murine interleukin (IL)-4 gene and beta-galactosidase (beta-gal) gene. Graft recipients transfected with plasmids encoding only the beta-gal gene served as negative plasmid controls. Three groups of mice were transfected with plasmids containing high levels of contaminating LPS: (a) nontransplanted C57B1/6 mice, (b) C57B1/6 cardiac isograft recipients, (c) DBA/2 (H-2d)-->C57BL/6 (H-2b) cardiac allograft recipients. Unexpectedly, graft failure within 24 h was observed in IL-4 transfected isograft and allograft recipients, but not in mice transfected with the beta-gal gene alone. However, histopathological findings, for example, vascular cell adhesion moelcule-1 (VCAM-1) expression in cardiac grafts and mononuclear lung infiltration, were remarkably similar for both treatment groups and consistent with LPS-induced pathology. LPS assays were used to evaluate four different methods of plasmid purification for degree of LPS contamination. A successful strategy for reducing levels of LPS contamination was identified and transfection experiments repeated in cardiac allograft recipients receiving LPS inoculum that were minimized and standardized (6.4 EU/mouse) for all treatment groups. Despite receiving substantially lower levels of LPS, in all treatment groups there was persistent cardiac graft endothelial cell activation manifested by VCAM-1 expression and persistent, albeit less severe, lung pathology. We found that plasmid contamination with LPS was unavoidable and that even very low levels can alter immune responses in transplant recipients confounding data interpretation. Thus, it is imperative to account for LPS contamination in experiments utilizing plasmid DNA for gene transfer, especially in experimental models of immunity and inflammation.