Donor Limb Functional Restoration via a Novel Clinical Care Pathway following Fibula Free Flap Harvest for Head and Neck Reconstruction.

Patients undergoing head and neck skeletal reconstruction (HNR) often require free tissue transfer from the extremities to ensure proper restoration of form and function. This requires a team-based, highly reliable medical system centered around the patient needs. Surgical intervention across multiple sites and harvesting of donor tissue results in short- and long-term physical impairments. There is a paucity of research objectively measuring impairments resulting from the graft donor site. There is a lack of research that objectively measures impairments and protocols for the management of these patients postoperatively. Patients undergo little, if any, formal approach to dealing with the vast impairments, which are sequelae to this surgery. This leads to large discrepancies in proposed functional progressions, return to duty timelines, and utilization of rehabilitative resources. At a major military medical center, an innovative clinical care pathway for patients undergoing HNR using free tissue transfer was implemented using a multidisciplinary model that focuses on early engagement with rehabilitation. This model, paired with a single surgery, will attempt to return service members to duty months earlier than the traditional approach. This report describes the conceptual framework and implementation of a new criteria-based, multidisciplinary clinical care pathway for HNR patients. The collaboration amongst the multidisciplinary care team has optimized the holistic health of the patient and communication with their support network, yielding faster return to normalization of daily life activities. The long-term goal is to further develop and formalize this pathway to best serve this patient population.

The new face of war: Craniofacial injuries from Operation Inherent Resolve.

BACKGROUND: During the last 20 years of conflict in the Middle East, improvements in body armor and the use of improvised explosive devices have resulted in an increased incidence of complex craniofacial trauma (CFT). Currently, CFT comprises up to 40% of all casualties. We present new data from the recent conflict in Iraq and Syria during Operation Inherent Resolve. METHODS: Data were collected for patients treated at role 1, role 2, and role 3 facilities in Iraq and Syria over a 1-year period. During this time, a specialized head & neck surgical augmentation team was deployed and colocated with the central role 3 facility. Data included for this cross-sectional study are as follows: injury type and mechanism, triage category, initial managing facility and subsequent levels of care, and procedures performed. RESULTS: Ninety-six patients sustained CFT over the study period. The most common injuries were soft tissue (57%), followed by cranial (44%) and orbital/facial (31%). Associated truncal and/or extremity injuries were seen in 46 patients (48%). There were marked differences in incidence and pattern of injuries between mechanisms (all p < 0.05). While improvised explosive devices had the highest rate of cranial and truncal injuries, gunshot wounds and blunt mechanisms had higher incidences of orbital/facial and neck injuries. Overall, 45% required operative interventions including complex facial reconstruction, craniotomy, and open globe repair. Mortality was 6% with 83% due to associated severe brain injury. Most patients were local nationals (70%) who required discharge or transfer to the local health care system. CONCLUSION: Complex craniofacial trauma is increasingly seen by deployed surgeons, regardless of subspecialty training or location. Deployment of a centrally located head and neck team greatly enhances the capabilities for forward deployed management of CFT, with excellent outcomes for both US and local national patients. LEVEL OF EVIDENCE: Therapeutic/care management; Level V.

Plastic Surgery at War: A Scoping Review of Current Conflicts.

INTRODUCTION: The scope of military plastic surgery and location where care is provided has evolved with each major conflict. To help inform plastic surgeon utilization in future conflicts, we conducted a review of military plastic surgery-related studies to characterize plastic surgeon contributions during recent military operations. MATERIALS AND METHODS: Using a scoping review design, we searched electronic databases to identify articles published since September 1, 2001 related to military plastic surgery according to a defined search criterion. Next, we screened all abstracts for appropriateness based on pre-established inclusion/exclusion criteria. Finally, we reviewed the remaining full-text articles to describe the nature of care provided and the operational level at which care was delivered. RESULTS: The final sample included 55 studies with most originating in the United States (54.5%) between 2005 and 2019 and were either retrospective cohort studies (81.8%) or case series (10.9%). The breadth of care included management of significant upper/lower extremity injuries (40%), general reconstructive and wound care (36.4%), and craniofacial surgery (16.4%). Microsurgical reconstruction was a primary focus in 40.0% of published articles. When specified, most care was described at Role 3 (25.5%) or Roles 4/5 facilities (62.8%) with temporizing measures more common at Role 3 and definite reconstruction at Roles 4/5. Several lessons learned were identified that held commonality across plastic surgery domain. CONCLUSIONS: Plastic surgeons continue to play a critical role in the management of wounded service members, particularly for complex extremity reconstruction, craniofacial trauma, and general expertise on wound management. Future efforts should evaluate mechanisms to maintain these skill sets among military plastic surgeons.

First Do No Harm: Predicting Surgical Morbidity During Humanitarian Medical Missions.

BACKGROUND: Despite good intentions, humanitarian surgical missions are unavoidably linked to some degree of complication. We hypothesized that the American College of Surgeons Surgical Risk Calculator (ACS-SRC) could estimate the risk of complications of procedures performed during the US Navy's Pacific Partnership 2015 (PP15) mission. METHODS: Patient information and surgical details recorded during PP15 were entered into the ACS-SRC. Risks of complications for each procedure were calculated. Receiver operating characteristics and Brier scores were calculated to compare the predicted outcomes to the observed complications. RESULTS: Of the 174 unique procedures performed during PP15 (representing 465 patients), 99 were found in the ACS-SRC (representing 256 patients). Risk calculations for PP15 were: 1.5% risk (IQR 0.9, 2.4) of "serious" complications and 2.0% risk (IQR 1.3, 2.8) of "any" complication. ACS-SRC specific risks were calculated as follows: pneumonia 0.1%, cardiac 0.0%, surgical site infection (SSI) 0.6%, urinary tract infection 0.2%, venous thromboembolism 0.1%, renal failure 0.0%, OR return 0.9%, and death 0.0%. The only specific ACS-SRC complication observed was "OR return" (0.35%) and SSI (0.35%). The observed PP15 rates for "serious" or "any" complications (ACS-SRC definition) were 0.70% (2/285) each. Receiver operating characteristics for ACS-SRC for predicting "serious" or "any" complication were 0.743 (p = 0.118) and 0.654 (p = 0.227), respectively. CONCLUSIONS: Although the ACS-SRC over-predicted risk compared to observed outcomes, it may offer a good starting point for humanitarian surgery risk calculation. Observed outcomes may be limited by loss-to-follow-up bias. Emphasis should be placed on establishing patient follow-up as part of humanitarian surgical mission planning and execution.

Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients.

BACKGROUND: Clinical assessments and rehabilitation in athletic groin pain (AGP) have focused on specific anatomical structures and uniplanar impairments rather than whole body movement. OBJECTIVE: To examine the effectiveness of rehabilitation that targeted intersegmental control in patients with AGP and to investigate post rehabilitation changes in cutting biomechanics. METHODS: Two hundred and five patients with AGP were rehabilitated focusing on clinical assessment of intersegmental control, linear running and change of direction mechanics in this prospective case series. Hip and Groin Outcome Score (HAGOS) was the primary outcome measure. Secondary measures included pain-free return to play rates and times, pain provocation on squeeze tests and three-dimensional (3D) biomechanical analysis during a 110° cutting manoeuvre. RESULTS: Following rehabilitation, patients demonstrated clinically relevant improvements in HAGOS scores (effect size (ES): 0.6-1.7). 73% of patients returned to play pain-free at a mean of 9.9 weeks (±3.5). Squeeze test values also improved (ES: 0.49-0.68). Repeat 3D analysis of the cutting movement demonstrated reductions in ipsilateral trunk side flexion (ES: 0.79) and increased pelvic rotation in the direction of travel (ES: 0.76). Changes to variables associated with improved cutting performance: greater centre of mass translation in the direction of travel relative to centre of pressure (ES: 0.4), reduced knee flexion angle (ES: 0.3) and increased ankle plantar flexor moment (ES: 0.48) were also noted. CONCLUSIONS: Rehabilitation focused on intersegmental control was associated with improved HAGOS scores, high rates of pain-free return to sporting participation and biomechanical changes associated with improved cutting performance across a range of anatomical diagnoses seen in AGP.

Ablative Fractional Laser Resurfacing: A Promising Adjunct to Surgical Reconstruction.

Ablative fractional laser resurfacing (AFLR) is emerging as a safe and effective treatment option for the mitigation of cosmetic and functional deficits resulting from traumatic scars and scar contractures. Military centers of excellence engaged in the multidisciplinary rehabilitation of wounded warriors have been instrumental in the widening acceptance of the technique in both the military and civilian realms. Despite the end of large-scale combat operations, AFLR remains a promising complement to surgical reconstruction and a novel option in challenging clinical situations that defy resolution with traditional methods. Herein, we present the case of a man in his 50s who underwent extensive genital and perineal debridement related to Fournier's gangrene. Despite successful reconstruction including extensive skin grafting, the patient suffered from intractable discomfort related to developing scar contractures that responded rapidly to a course of AFLR. This case serves to highlight the potential benefits of AFLR for postoperative wound management, and the importance of a multidisciplinary approach for the care of complex injuries.

Secondary Neck Lift and the Importance of Midline Platysmaplasty: Review of 101 Cases.

BACKGROUND: The authors believe that open access to the submental region, platysmaplasty, and wide skin undermining provide the most long-lasting results in neck rejuvenation, and sought to evaluate this hypothesis by reviewing their neck-lift patients. METHODS: The authors performed a retrospective chart review of their experience with neck-lift procedures and patients who underwent a secondary procedure. Patient age, sex, initial technique, visible neck deformities, and reasons for revision were assessed. Photographs were used to assess the features of persistent or recurrent neck-lift deformity and techniques to correct them. RESULTS: Of 1089 neck lifts reviewed, 101 patients underwent secondary or revision procedures (approximately 10 percent of total). The average patient age was 57.4 years, 95 percent were women, and secondary procedures were performed 10.3 years after the first procedure. Seventy percent of the revisions were of the authors' own primary neck lifts, and all of these after 10 years. The most common aesthetic deformities--recurrent platysmal bands (87 percent), persistent/recurrent jowling (48 percent), fat malposition/irregularities (10 percent), and vertical band deformity (8 percent)--were most often corrected with open platysmaplasty and medial or lateral plication and skin redraping. All patients had their submental region opened in the secondary procedure. All secondary operations were performed at least 10 years after primary surgery. CONCLUSIONS: The authors believe their technique of open submental neck access and platysmal approximation in patients with medial bands provides long-lasting results. The authors use precise preoperative evaluation, recontouring of neck fat irregularities, opening of the submental region with platysmaplasty, drains, and strict hemostasis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Role of the Superwet Technique in Face Lift: An Analysis of 1089 Patients over 23 Years.

BACKGROUND: The use of superwet technique of infiltration and autologous tissue sealants during rhytidectomy has benefits of decreasing bleeding and edema, improving visualization, and easing dissection. The purpose of this study was to analyze whether these intraoperative strategies resulted in more consistent and reproducible outcomes and significantly decreased hematoma rates. METHODS: A retrospective review was performed on 1089 consecutive face lifts performed by a single surgeon. Fisher's exact test was used to determine significant differences in hematomas between those patients who received platelet-rich plasma and superwet technique and those who did not. Multivariate logistic regression was used to evaluate demographic variables and intraoperative interventions for risk of complication. RESULTS: Five hundred eighty-seven of 1089 face lifts received platelet-rich plasma and 926 of 1089 underwent a superwet technique. Ten hematomas were recorded, six in the group that did not receive platelet-rich plasma compared to four who did (p = 0.527). One hematoma was observed before implementation of the superwet technique and nine were in the group after (p = 1.00). Multivariate analysis showed male sex to be a significant factor for hematoma (p < 0.001). CONCLUSIONS: This analysis showed excellent outcomes with a hematoma rate of 0.9 percent. Although no significant differences were noted, the authors attribute their consistent and reproducible results to the use of the superwet technique and platelet-rich plasma. The superwet technique allows for improved safety and visualization with improved hemostasis. Platelet-rich plasma potentially decreases ecchymosis and edema. Prospective studies are needed to determine significant differences between these intraoperative interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Computed-tomography modeled polyether ether ketone (PEEK) implants in revision cranioplasty.

PURPOSE: Traditional cranioplasty methods focus on pre-operative or intraoperative hand molding. Recently, CT-guided polyether ether ketone (PEEK) plate reconstruction enables precise, time-saving reconstruction. This case series aims to show a single institution experience with use of PEEK cranioplasty as an effective, safe, precise, reusable, and time-saving cranioplasty technique in large, complex cranial defects. METHODS: We performed a 6-year retrospective review of cranioplasty procedures performed at our affiliated hospitals using PEEK implants. A total of nineteen patients underwent twenty-two cranioplasty procedures. Pre-operative, intra-operative, and post-operative data was collected. RESULTS: Nineteen patients underwent twenty-two procedures. Time interval from injury to loss of primary cranioplasty averaged 57.7 months (0-336 mo); 4.0 months (n=10, range 0-19) in cases of trauma. Time interval from primary cranioplasty loss to PEEK cranioplasty was 11.8 months for infection (n=11, range 6-25 mo), 12.2 months for trauma (n=5, range 2-27 mo), and 0.3 months for cosmetic or functional reconstructions (n=3, range 0-1). Similar surgical techniques were used in all patients. Drains were placed in 11/22 procedures. Varying techniques were used in skin closure, including adjacent tissue transfer (4/22) and free tissue transfer (1/22). The PEEK plate required modification in four procedures. Three patients had reoperation following PEEK plate reconstruction. CONCLUSION: Cranioplasty utilizing CT-guided PEEK plate allows easy inset, anatomic accuracy, mirror image aesthetics, simplification of complex 3D defects, and potential time savings. Additionally, it's easily manipulated in the operating room, and can be easily re-utilized in cases of intraoperative course changes or infection.

Comprehensive review of methicillin-resistant Staphylococcus aureus: screening and preventive recommendations for plastic surgeons and other surgical health care providers.

BACKGROUND: Up to 2.3 million people are colonized with methicillin-resistant Staphylococcus aureus in the United States, causing well-documented morbidity and mortality. Although the association of clinical outcomes with community and hospital carriage rates is increasingly defined, less is reported about asymptomatic colonization prevalence among physicians, and specifically plastic surgeons and the subsequent association with the incidence of patient surgical-site infection. METHODS: A review of the literature using the PubMed and Cochrane databases analyzing provider screening, transmission, and prevalence was undertaken. In addition, a search was completed for current screening and decontamination guidelines and outcomes. RESULTS: The methicillin-resistant S. aureus carriage prevalence of surgical staff is 4.5 percent. No prospective data exist regarding transmission and interventions for plastic surgeons. No studies were found specifically looking at prevalence or treatment of plastic surgeons. Current recommendations by national organizations focus on patient-oriented point-of-care testing and intervention, largely ignoring the role of the health care provider. Excellent guidelines exist regarding screening, transmission prevention, and treatment both in the workplace and in the community. No current such guidelines exist for plastic surgeons. CONCLUSIONS: No Level I or II evidence was found regarding physician screening, treatment, or transmission. Current expert opinion, however, indicates that plastic surgeons and their staff should be vigilant for methicillin-resistant S. aureus transmission, and once a sentinel cluster of skin and soft-tissue infections is identified, systematic screening and decontamination should be considered. If positive, topical decolonization therapy should be offered. In refractory cases, oral antibiotic therapy may be required, but this should not be used as a first-line strategy.

The platysma window: an anatomically safe, efficient, and easily reproducible approach to neck contour in the face lift.

BACKGROUND: The cornerstone of the face lift is neck contour. The pursuit of reliable and reproducible results has led plastic surgeons to investigate a multitude of different approaches. Unfortunately, addressing neck contour can lead to complications such as injury to the great auricular nerve. The purpose of this study was to describe an efficient, safe, and reproducible technique of improving face lifts: the platysma window. METHODS: The authors use a reference point located one fingerbreadth inferior to the angle of the mandible and one fingerbreadth anterior to the anterior border of the sternocleidomastoid muscle. A two-fingerbreadth incision is made on the muscle to open a small "window," approximately 2 cm of total vertical flap length. Two figure-of-eight 4-0 Mersilene sutures are placed from the window to the mastoid fascia, spanning the great auricular nerve at McKinney's point. RESULTS: The platysma window technique is designed to minimize the complications of neck lifts-especially the risk of injury to the great auricular nerve. Placing the window inferior and anterior to these structures ensures a safe area for executing platysma tightening. This maneuver can augment a myriad of face-lifting techniques. The authors have used the maneuver described in over 200 cases, with consistently repeatable and improved neck contour results. CONCLUSIONS: Patients demand expedient and safe procedures in addition to an excellent cosmetic outcome. Plastic surgeon should try to meet their patients' needs; the authors believe the platysma window can play a role in becoming a useful method available to surgeons when addressing neck contour in face lifting.

Infant botulism mimicking Hirschprung's disease.

We report a case of infant botulism presenting as primary colonic ileus--mimicking Hirschprung's megacolon. Infant botulism should be considered in any infant with constipation and neurologic abnormalities.

Preemptive craniectomy with craniotomy: what role in the management of severe traumatic brain injury?

BACKGROUND: Patients with severe traumatic brain injury (TBI) require aggressive management to prevent secondary brain injury. "Preemptive" craniectomy (CE)--craniectomy performed as a primary procedure in conjunction with craniotomy--has been used as prophylaxis for secondary injury, but the indications and outcomes of craniectomy used for this purpose are not well defined. METHODS: To evaluate the role of CE in the management of TBI, we retrospectively reviewed 62 consecutive patients who underwent CE in a 78-month period at our level I trauma center. A cohort of patients who underwent craniotomy only (CO) during this period was compared with the CE group for TBI patterns, indications for operation, and outcomes. Multivariable logistic regression and matched propensity score analysis were used to test the association between CE and survival. The rate of CE was determined by individual neurosurgeons. RESULTS: Of 197 patients with brain injuries who underwent craniotomy, 62 (31.5%) had CE and 135 (68.5%) had CO. Mean age for CE versus CO was 41 years versus 51 years (p < 0.01). Mean admission Glasgow Coma Score was lower in CE versus CO (7.6 vs. 11.8, p < 0.001); Injury Severity Score was higher (30.2 vs. 26.3, p < 0.01). The indication for operation for CE compared with CO was subdural hematoma in 41 (66.1%) versus 87 (64.4%, p = 0.82), epidural hematoma in 2 (3.2%) versus 26 (19.3%, p < 0.01), and cerebral contusion or hematoma in 15 (24.2%) versus 8 (5.9%, p < 0.001). Postoperative intracranial pressure was monitored in 48 (77.4%) CE and 44 (32.6%) CO patients (p < 0.001). Intracranial pressure <20 was maintained in 26 (54.2%) after CE and in 31 (70.5%) after CO (p = 0.12). In the CE group, 26 (42%) died compared with 31 (26%, p < 0.01) in the CO group. When adjusted for severity of injury, however, there was no significant difference in mortality between the two groups (p = 0.134). The CE rate obtained by a neurosurgeon varied from 8.6% to 75.0% (p < 0.001). CONCLUSION: CE was used in patients with more severe injuries, and particularly in those with more severe head injuries. When adjusted for injury severity, CE was not associated with worsened survival, and therefore may reasonably be included in the armamentarium of neurotrauma care. Use of CE by our neurosurgeons, however, varied significantly. These findings underscore the need for practice guidelines based on randomized trials to fully evaluate the role of CE in the management of TBI.

Small catheter tube thoracostomy: effective in managing chest trauma in stable patients.

BACKGROUND: Image-guided small catheter tube thoracostomy (SCTT) is not currently used as a first-line procedure in the management of patients with chest trauma. We adopted a practice recommendation to use SCTT as a less invasive alternative in the treatment of chest injuries. We reviewed our trauma registry to evaluate our change in practice and the effectiveness of SCTT. METHODS: Retrospective review of all tube thoracostomies (TT) performed in patients with chest injury at a level I trauma center from September 2002 through March 2006. Data collected included age, sex, indications and timing for TT, use of antibiotics, length of stay, complications, and outcomes. Large catheter tube thoracostomy (LCTT) not performed in the operating room or trauma room and all SCTT were deemed nonemergent. RESULTS: There were 565 TT performed in 359 patients. Emergent TT was performed in 252 (70%) and nonemergent TT in 157 (44%) patients, of which 63 (40%) received LCTT and 107 (68%) received SCTT. Although SCTT was performed later after injury than nonemergent LCTT (5.5 days vs. 2.3 days, p < 0.001), average duration of SCTT was shorter (5.5 days vs. 7 days, p < 0.05). Rates of hemothoraces were similarly low for SCTT versus nonemergent LCTT (6.1% vs. 4.2%, p = NS) and rates of residual/recurrent pneumothoraces were not significantly different (8% vs. 14%, p = NS). The rate of occurrence of fibrothorax, however, was significantly lower for SCTT compared with nonemergent LCTT (0% vs. 4.2%, p < 0.05). In patients receiving a single nonemergent TT, SCTT was performed in 55 (61%) and LCTT in 35 (39%). A comparison of these groups revealed that SCTT was performed in older patients (p < 0.05), and was associated with a lower Injury Severity Score (p < 0.05) and shorter length of stay (p = 0.05). SCTT was increasingly used in younger and more seriously injured patients as our experience grew. CONCLUSION: SCTT is effective in managing chest trauma. It is comparable with LCTT in stable trauma patients. This study supports adopting image-guided small catheter techniques in the management of chest trauma in stable patients.

Early intubation in the management of trauma patients: indications and outcomes in 1,000 consecutive patients.

BACKGROUND: The Eastern Association for the Surgery of Trauma Practice Management Guidelines identify indications (EI) for early intubation. However, EI have not been clinically validated. Many intubations are performed for other discretionary indications (DI). We evaluated early intubation to assess the incidence and outcomes of those performed for both EI and DI. METHODS: One thousand consecutive intubations performed in the first 2 hours after arrival at our Level I trauma center were reviewed. Indications, outcomes, and trauma surgeon (TS) intubation rates were evaluated. RESULTS: During a 56-month period, 1,000 (9.9%) of 10,137 trauma patients were intubated within 2 hours of arrival. DI were present in 444 (44.4%) and EI in 556 (55.6%). DI were combativeness or altered mental status in 375 (84.5%), airway or respiratory problems in 21 (4.7%), and preoperative management in 48 (10.8%). Injury Severity Score was 14.6 in DI patients and 22.7 in EI patients (p < 0.001). Predicted versus observed survival was 96.6% versus 95.9% in DI patients and 75.2% versus 75.0% in EI patients (p < 0.001). Head Abbreviated Injury Scale score of >or=3 occurred in 32.7% with DI and 52.0% with EI (p < 0.001). Seven (0.7%) surgical airways were performed; two for DI (0.2%). Eleven (1.1%) patients aspirated during intubation and five (0.5%) suffered oral trauma. There were no other significant complications of intubation for either DI or EI and complication rates were similar in the two groups. Delayed intubation (early intubation after leaving the trauma bay) was required in 67 (6.7%) patients and 59 (88.1%) were for combativeness, neurologic deterioration, or respiratory distress or airway problems. Intubation rates varied among TS from 7.6% to 15.3% (p < 0.001) and rates for DI ranged from 3.3% to 7.4% (p < 0.001). There was a statistically insignificant trend among TS with higher intubation rates to perform fewer delayed intubations. CONCLUSIONS: Early intubation for EI as well as DI was safe and effective. One third of the DI patients had significant head injury. Surgical airways were rarely needed and delayed intubations were uncommon. The intubation rates for EI and DI varied significantly among TSs. The Eastern Association for the Surgery of Trauma Guidelines may not identify all patients who would benefit from early intubation after injury.

Acute myeloid leukaemia secondary to treatment with capecitabine for metastatic colorectal cancer.

A 63-year-old woman was diagnosed with acute myelo-monocytic leukaemia, associated with MLL gene rearrangement, 16 months after completion of oral capecitabine for metastatic colon cancer. Capecitabine, recommended for use in metastatic breast and colon cancer and more recently as adjuvant treatment of colon cancer, has not previously been reported to be associated with secondary cancer.

The effect of point-of-care personal digital assistant use on resident documentation discrepancies.

BACKGROUND: We recently found documentation discrepancies in 60% of resident daily-progress notes with respect to patient weight, medications, or vascular lines. To what extent information systems can decrease such discrepancies is unknown. OBJECTIVE: To determine whether a point-of-care personal digital assistant (PDA)-based patient record and charting system could reduce the number of resident progress-note documentation discrepancies in a neonatal intensive care unit (NICU). DESIGN/METHODS: We conducted a before-and-after trial in an academic NICU. Our intervention was a PDA-based patient record and charting system used by all NICU resident physicians over the study period. We analyzed all resident daily-progress notes from 40 randomly selected days over 4 months in both the baseline and intervention periods. Using predefined reference standards, we determined the accuracy of recorded information for patient weights, medications, and vascular lines. Logistic and Poisson regression were used in analyses to control for potential confounding factors. RESULTS: A total of 339 progress notes in the baseline period and 432 progress notes in the intervention period were reviewed. When controlling for covariates in the regression, there were significantly fewer documentation discrepancies of patient weights in notes written by using the PDA system (14.4%-4.4% of notes; odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.15-0.56). When using the PDA system, there were no significant changes in the numbers of notes with documentation discrepancies of medications (27.7%-17.1% of notes; OR: 0.63; 95% CI: 0.35-1.13) or vascular lines (33.6%-36.1% of notes; OR: 1.11; 95% CI: 0.66-1.87). CONCLUSIONS: The use of our PDA-based point-of-care patient record and charting system showed a modest benefit in reducing the number of documentation discrepancies in resident daily-progress notes. Further study of PDAs in information systems is warranted before they are widely adopted.

Resident documentation discrepancies in a neonatal intensive care unit.

CONTEXT: Medical errors are common and potentially dangerous. Little is known about the role of documentation errors. OBJECTIVE: To determine the proportion of resident physician progress notes that contained discrepancies, and to identify predictors of such discrepancies. DESIGN/METHODS: We conducted a retrospective cross-sectional chart review of resident physician progress notes over 40 random days in a 4-month period in a neonatal intensive care unit. Using predetermined criteria, we compared resident documentation of patient weights, medications, and vascular lines to other sources of information and recorded the numbers of documentation discrepancies. RESULTS: There were discrepancies in 209 (61.7%) notes with respect to weight, vascular lines, or medications. Discrepancies occurred in the documentation of medications in 103 (27.7%) progress notes, of vascular lines in 119 (33.9%) progress notes, and of weights in 45 (13.3%) progress notes. Notes both omitted information regarding medications (18.2%) and vascular lines (13.9%) and documented inaccurate information regarding medications (18.6%) and vascular lines (30.1%). Patients with more medications or vascular lines, and with longer lengths of stay, were significantly more likely to have higher rates of documentation errors. CONCLUSIONS: Daily progress notes written by resident physicians in the neonatal intensive care unit often contain inaccurate, or omit pertinent, information. Alternative means or methods of documentation are warranted.