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Background System based practice (SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless, structured assessment is required for training programs. We hypothesized that objective structured clinical examination (OSCE) would be an effective tool for assessment of SBP. Aim To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE. Methods For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twenty-six first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey. Results Survey response rate was 100%. The average composite score across SBP milestones for all cases were 6.22 (SBP1), 4.34 (SBP2), 3.35 (SBP3), and 6.42 (SBP4) out of 9. The lowest composite score was in SBP 3, which asks fellows to advocate for cost effective care. This highest score was in patient care 2, which asks fellows to develop comprehensive management plans. Discrepancies were identified between the fellows' perceived performance in their self-assessments and Standardized Patient checklist evaluations for each case. Eighty-seven percent of fellows agreed that OSCEs are an important component of their clinical training, and 83% stated that the cases were similar to actual clinical encounters. All participating fellows stated that the immediate feedback was "very useful." One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice. Conclusion OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.

Background We developed and implemented a structured clinical documentation support (SCDS) toolkit within the electronic medical record, to optimize patient care, facilitate documentation, and capture data at office visits in a sleep medicine/neurology clinic for patient care and research collaboration internally and with other centers. Methods To build our SCDS toolkit, physicians met frequently to develop content, define the cohort, select outcome measures, and delineate factors known to modify disease progression. We assigned tasks to the care team and mapped data elements to the progress note. Programmer analysts built and tested the SCDS toolkit, which included several score tests. Auto scored and interpreted tests included the Generalized Anxiety Disorder 7-item, Center for Epidemiological Studies Depression Scale, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Insomnia Severity Index, and the International Restless Legs Syndrome Study Group Rating Scale. The SCDS toolkits also provided clinical decision support (untreated anxiety or depression) and prompted enrollment of patients in a DNA biobank. Results The structured clinical documentation toolkit captures hundreds of fields of discrete data at each office visit. This data can be displayed in tables or graphical form. Best practice advisories within the toolkit alert physicians when a quality improvement opportunity exists. As of May 1, 2019, we have used the toolkit to evaluate 18,105 sleep patients at initial visit. We are also collecting longitudinal data on patients who return for annual visits using the standardized toolkits. We provide a description of our development process and screenshots of our toolkits. Conclusions The electronic medical record can be structured to standardize Sleep Medicine office visits, capture data, and support multicenter quality improvement and practice-based research initiatives for sleep patients at the point of care.

Background MedicineInsight is a database containing de-identified electronic health records (EHRs) from over 700 Australian general practices. To support the trust placed in analyses of MedicineInsight data, additional evidence regarding the accuracy of the data is needed. Methods This study measures the validity of algorithms available in MedicineInsight that identify patients with depression, anxiety, asthma, type 2 diabetes and osteoporosis. Fifty practices met eligibility criteria regarding patient load and location, five were randomly selected and four agreed to participate. Within each practice, 250 patients aged ≥ 40 years were randomly selected. This age restriction increased the prevalence of the evaluated conditions, thereby optimising statistical power. Trained staff review the full EHR for these patients, including progress notes and correspondence, which are not available in MedicineInsight because they may contain identifiable information. Results With data collection almost complete, the target sample size will not be attainable. Power calculations indicate the current sample of 479 should provide adequate precision. For each condition of interest, the sensitivity, specificity, positive predictive value and negative predictive value of the algorithm is calculated. The full EHR review is the gold standard against which the algorithms are benchmarked. Conclusions The findings will indicate whether these algorithms demonstrate adequate accuracy to be used for research and decision-making. Key messages This additional understanding regarding the accuracy of MedicineInsight data will facilitate the interpretation of analyses of MedicineInsight data and guide improvements to the algorithms.

n the not too distant past, illegible handwriting was considered to be the biggest problem with medical record keeping. Now the primary problem with medical records is that they are disorganized, and usually undigested, data dumps. A solution to at least part of this problem lies in utilizing the principles of the problem-oriented record. When one contemplates the optimal format for progress notes, it is worth considering the purposes of progress notes. While progress notes do, of course, play a role in billing, the primary purposes of a progress note should be to provide efficient and effective communication with all who are caring for that patient and to facilitate efficient and effective contemplation of the condition of and the plans for that patient. Although it is beyond the scope of this treatise on creating progress notes, it is also worth pointing out that all patient care notes will also occasionally have legal implications and lawyers reading clinical notes will pay far more attention to assessments and plans than they will to data and results recorded in progress notes that are always easily available elsewhere in the patient record. In other words, lawyers reviewing medical records want to know what the clinicians caring for a patient were thinking, in addition to what those clinicians actually did for that patient. While all of these issues must be kept in mind, we will focus primarily on the role of clinical notes in providing optimal patient care, particularly in the realm of cardiothoracic surgery, though the principles to be enunciated can apply to most disciplines and to most clinical environments.

Objective To evaluate the prevalence of delayed traumatic brain injury (TBI) diagnosis and cause of injury that resulted in a TBI diagnosis after military deployment. Design Medical record notes were reviewed in 2016 from a random sample of 1150 US military service members who had their first-time deployment in 2011 and likely sustained a TBI. Location and cause of the injury were extracted from the progress note for analysis. Participants and setting Active-duty US military service members who received an International Classification of Diseases, Ninth Revision code for a TBI diagnosis in a military facility. Main outcome measures Presence of TBI, location of injury, cause of injury, and time of diagnosis with respect to deployment. Results The odds of being diagnosed with a deployment-related TBI were 8 times higher during the first 4 weeks upon return from deployment than the subsequent 32 weeks. The likelihood of diagnosing a deployment-sustained TBI during weeks 5 to 32 was 2 times higher than during 33 to 76 weeks following return from deployment. The proportion of deployment-related TBI diagnoses decreased with time following return from deployment but remained above 40% during weeks 33 to 76. Service branch, gender, race, occupation, and time between TBI diagnosis and return from deployment were significant predictors of deployment-related TBIs. Moving motor vehicle, sports, parachute, and being struck by objects were the top causes of injury in garrison (nondeployed setting), whereas blast produced the majority (66%) of all causes of injuries that resulted in a TBI in the deployed setting. Conclusion The increased incidence rate of a TBI diagnosis following deployment can be attributed to delayed diagnosis of TBI sustained from injuries during deployment. TBIs sustained during deployment can be diagnosed beyond the initial 4 weeks after return from deployment and may continue up to 76 weeks following return from deployment.

OBJECTIVES:Physicians increasingly share ambulatory visit notes with patients to meet new federal requirements, and evidence suggests patient experiences improve without overburdening physicians. Whether sharing inpatient notes with parents of hospitalized children yields similar outcomes is unknown. In this pilot study, we evaluated parent and physician perceptions of sharing notes with parents during hospitalization.METHODS:Parents of children aged RESULTS:In all, 25 parents and their children’s discharging attending and intern physicians participated. Parents agreed that the information in notes was useful and helped them remember their child’s care plan (100%), prepare for rounds (96%), and feel in control (91%). Although many physicians (34%) expressed concern that notes would confuse parents, no parent reported that notes were confusing. Some physicians perceived that they spent more time writing and/or editing notes (28%) or that their job was more difficult (15%). Satisfaction with sharing was highest among parents (100%), followed by attendings (81%) and interns (35%).CONCLUSIONS:Parents all valued having access to physicians’ notes during their child’s hospital stay; however, some physicians remained concerned about the potential negative consequences of sharing. Comparative effectiveness studies are needed to evaluate the effect of note sharing on outcomes for hospitalized children, families, and staff.

OBJECTIVES: Progress notes communicate providers’ assessments of patients’ diagnoses, progress, and treatment plans; however, providers perceive that note quality has degraded since the introduction of electronic health records. In this study, we aimed to (1) develop a tool to evaluate progress note assessments and plans with high interrater reliability and (2) assess whether a bundled intervention was associated with improved intern note quality without delaying note file time. METHODS: An 8-member stakeholder team developed a 19-item progress note assessment and plan evaluation (PNAPE) tool and bundled intervention consisting of a new note template and intern training curriculum. Interrater reliability was evaluated by calculating the intraclass correlation coefficient. Blinded assessors then used PNAPE to evaluate assessment and plan quality in pre- and postintervention notes (fall 2017 and 2018). RESULTS: PNAPE revealed high internal interrater reliability between assessors (intraclass correlation coefficient = 0.86; 95% confidence interval: 0.66–0.95). Total median PNAPE score increased from 13 (interquartile range [IQR]: 12–15) to 15 (IQR: 14–17; P = .008), and median file time decreased from 4:30 pm (IQR: 2:33 pm–6:20 pm) to 1:13 pm (IQR: 12:05 pm–3:59 pm; P < .001) in pre- and postintervention notes. In the postintervention period, a higher proportion of assessments and plans indicated the primary problem requiring ongoing hospitalization and progress of this problem (P = .0016 and P < .001, respectively). CONCLUSIONS: The PNAPE tool revealed high reliability between assessors, and the bundled intervention may be associated with improved intern note assessment and plan quality without delaying file time. Future studies are needed to evaluate whether these improvements can be sustained throughout residency and reproduced in future intern cohorts and other inpatient settings.

Seven hours into her overnight shift, Dr Carter opens the computer to complete her sixth admission of the evening. “BEEP! BEEP! BEEP!” her pager interrupts with “Sepsis Alert,” the fourth in the past 48 hours for a 12-year-old boy with metabolic disease, technology dependence, and paroxysmal sympathetic hyperactivity who was admitted 1 week ago for dehydration and increased storming. She leaves her computer to attend the mandatory bedside huddle. The result is the same as the 3 previous ones: storming caused his fever and tachycardia, not sepsis; no change to management. As Dr Carter writes a progress note documenting the huddle, her pager erupts again, requesting orders for her other patient. Pediatric severe sepsis in the United States costs $7.3 billion annually, one-fifth of pediatric hospitalization costs.1 Over the past 2 decades, professional organizations have built awareness, developed guidelines, and driven efforts to recognize sepsis and intervene early in its course.2,3 Early initiatives began in emergency departments (EDs), although state legal mandates and national quality improvement collaboratives have led to implementation hospital-wide, including in general inpatient units.4,5 Most guidelines frame their recommendations around sepsis response systems that incorporate clinical decision support tools (hereinafter referred to as sepsis scores) to identify suspected sepsis and trigger time-sensitive bundles of laboratory evaluation, intravenous fluid resuscitation, …

Background and objectives Type 2 diabetes mellitus (T2DM) is a complex disease that can lead to complications. Electronic decision support in the electronic medical record (EMR) aids management. There is no study demonstrating the effectiveness of electronic decision support in assisting medical student providers in student-run free clinics. Methods There were 71 T2DM patients seen by medical students. Twenty-three encounters used a Diabetes Progress Note (DPN) that was created from consensus, opinion-based guidelines. Each note received a total composite score based on an eight-point scale for adherence to guidelines. Statistical comparisons between mean composite scores were performed using independent t-tests. Results The mean total composite score of DPN users was significantly greater than DPN non-users (5.35 vs. 4.23, p = 0.008), with a significant difference in the physical exam component (1.70 vs. 1.31, p = 0.002). Conclusions In this exploratory study, medical student providers at an attending-supervised, student-run free clinic that used electronic decision support during T2DM patient visits improved adherence to screening for diabetic complications and standard of care.

Effective communication both verbally and documentation among the health care team will improve patient safety. Nurses in carrying out the documentation starting from assessment until evaluation that must be complete within the first 24 hours since patients admitted to the inpatient ward. After 24 hours of treatment, patient progress was recorded in an integrated documentation form known as the “Integrated Nursing Progress Note”. This study aims to evaluate nursing documentation inpatient records according to the integrated nursing progress notes. It involved 141 nursing documentations systematically observed from 12 inpatient wards of Zainoel Abidin hospital was performed using a validated audit instrument. The instrument was used to assess the integrated nursing progress note of 6 steps: 4 steps focusing on the nursing documentation and two steps on time and the nurse’s identity. The study shows that the majority of the integrated nursing progress note was a complete category (79.4%). The most correctly documented items were the time (100%), subjective data (100%), objective data (100%), planning (100%) and nurse’s identity (100%), whereas the least documented items were analysis (85.3%). The researchers suggest that the hospital should conducted training of documentation regularly for the nurses to have a better understanding of integrated nursing progress note for an improvement of patient safety in the hospital ward.

Objective To document the outcome of radioiodine therapy (RIT) in differentiated thyroid cancer (DTC) patients with recent contrasted computed tomography (CCT). Methods Eighteen patients with DTC and recent thyroidectomy who underwent RIT within 90 days after a CCT were included. Disease status following RIT and whether the expected response to RIT was achieved were documented. Disease status was classified into one of three categories based on the patient's thyroglobuline level, radioiodine scan (RIS), and other imaging modalities: no evidence of disease (NED), microscopic residual disease (MRD), or gross residual disease (GRD). Expected response to RIT was based on the overall interpretation of the referring physicians of follow up thyroglobuline values, RIS findings and clinical assessment as reflected in progress notes. Follow-up stimulated thyroglobuline and (or) RIS was performed on average 10.8 months after RIT (median 12 months). The last progress note reviewed was on average 33.3 months after RIT (median 31 months). Results There were 12 patients with NED, two with MRD and four with GRD. Expected response to RIT was achieved in 17 patients. In one patient, the effectiveness of RIT could not be determined. Conclusion RIT in postthyroidectomy setting can be successfully performed within 90 days after CCT. Further research is needed to confirm our findings.

Objective To use the electronic medical record (EMR) to optimize patient care, facilitate documentation, and support quality improvement and practice-based research, in a headache specialty clinic. Background Many physicians enter data into the EMR as unstructured free text and not as discrete data. This makes it challenging to use data for quality improvement or research initiatives. Methods We describe the process of building a customized structured clinical documentation support toolkit, specific for patients seen in a headache specialty clinic. The content was developed through frequent physician meetings to reach consensus on elements that define clinical Best Practices. Tasks were assigned to the care team and data mapped to the progress note. Results The toolkit collects hundreds of fields of discrete, standardized data. Auto scored and interpreted score tests include the Generalized Anxiety Disorder 7-item, Center for Epidemiology Studies Depression Scale, Migraine Disability Assessment questionnaire, Insomnia Sleep Index, and Migraine-Specific Quality of Life. We have developed Best Practice Advisories (BPA) and other clinical documentation support tools that alert physicians, when appropriate. As of April 1, 2018, we have used the toolkits at 4346 initial patient visits. We provide screenshots of our toolkits, details of data fields collected, and diagnoses of patients at the initial visit. Conclusions The EMR can be used to effectively structure and standardize headache clinic visits for quality improvement and practice-based research. We are sharing our proprietary toolkit with other clinics as part of the Neurology Practice-Based Research Network. These tools are also facilitating clinical research enrollment and a pragmatic trial of comparative effectiveness at the point-of-care among migraine patients.

Purpose The development and implementation of a clinical decision support system (CDSS) for pharmacists to use for identification of and intervention on patients with Staphylococcus aureus bacteremia (SAB) are described. Summary A project team consisting of 3 informatics pharmacists and 2 infectious diseases (ID) pharmacists was formed to develop the CDSS. The primary CDSS component was a scoring system that generates a score in real time for a patient with a positive blood culture for S. aureus. In addition, 4 tools were configured in the CDSS to facilitate pharmacists’ workflow and documentation tasks: a patient list, a patient list report, a handoff note, and a standardized progress note. Pharmacists are required to evaluate the patient list at least once per shift to identify newly listed patients with a blood culture positive for S. aureus and provide recommendations if necessary. The CDSS was implemented over a period of 2.5 months, with a pharmacy informatics resident dedicating approximately 200 hours in total. An audit showed that the standardized progress note was completed for 100% of the patients, with a mean time to completion of 8.5 hours. Importantly, this initiative can be implemented in hospitals without specialty-trained ID pharmacists. This study provides a framework for future antimicrobial stewardship program initiatives to incorporate pharmacists into the process of providing real-time recommendations. Conclusion A pharmacist-driven patient scoring system was successfully used to improve adherence to quality performance measures for management of SAB. A pharmacist-driven CDSS can be utilized to assist in the management of SAB.

Introduction Health care institutes are cooperative areas where multiple health care services come together and work closely; physician, nurses and paramedics etc,. These multidisciplinary teams usually communicate with each other by documentation. Therefore, accurate documentation in health care organization is considered one of the vital processes. To make the documentation useful, it needs to be accurate, relevant, complete and confidential. Objectives The aim of this paper is to demonstrate the effect of the collaborative work in the Department of Pediatrics on improving the quality of inpatient clinical documentation over 5 years. Methods Improving clinical documentations went through several collaborative approaches, these include: Departmental Administration involvement, establishment of quality management team, regular departmental collaborative meeting as a monitoring and motivating tool, establishment of the residents quality team, Integration of quality projects into the new residents annual orientation, considering it as a part of the trainee personal evaluation, sending reminders to the consultants and residents on the adherence for admission note initiating and 24 h's verification, utilization of standardized template of admission note and progress note and emphasizing on the adherence to the approved medical abbreviation list only for any abbreviation to be used. Results During the period between the first quarter of 2012 to the fourth quarter of 2017; a significant improvement was noticed in the overall in-patient clinical documentation compliance rate, as it was ranging from lower 50% in 2012 and 2013, and increased gradually to reach upper 80% in the last quarters of 2016 and 2017. These figures are based on an independent audit that being done by the hospital quality management department and received by the department in a quarterly basis. Conclusion Despite multiple challenges for improving the compliance for clinical documentations, major improvement can be achieved when the collaboration and efforts among all stakeholders being shared and set as a common goal.

Objective We describe our experience with routinely capturing and analyzing Mediterranean diet data via structured clinical documentation support tools built into the electronic medical record and describe adherence to the Mediterranean diet in patients at risk for either stroke or dementia in a US neurology clinical practice. Patients and Methods The Mediterranean diet is associated with a reduced risk of stroke and dementia. The Department of Neurology at NorthShore University HealthSystem routinely evaluates patients at initial and annual outpatient visits using structured clinical documentation support (SCDS) tools built into the electronic medical record (EMR). For patient evaluations in our Vascular Neurology and Brain Health subspecialty clinics, SCDS tools in the EMR include the validated 14-item questionnaire for Mediterranean diet adherence (PREvencion con DIeta MEDiterranea [PREDIMED]) that autoscores, auto-interprets, writes to the progress note, and electronically captures data. Our study population includes patients seen at these clinics from July 1, 2015, through November 29, 2017. Results At their initial office visit, 25.5% (95/373) of Brain Health patients scored 10 or more points ("strongly adherent") on the PREDIMED (median, 8; range, 0-14) whereas 6.7% (55/829) of Vascular Neurology patients achieved a score of 10 or more points (median, 6; range, 0-12). By contrast, 34.7% (2586/7447) of individuals in the original PREDIMED cohort were strongly adherent to the Mediterranean diet. Conclusion PREDIMED scores can be electronically captured to tailor nutrition interventions by assessing baseline adherence at the time of their initial neurology clinic visit. Patients in our Midwestern US clinics were weakly adherent to the Mediterranean diet. This suggests a major opportunity for nutrition intervention and education in US neurology clinical practices, toward preserving and improving brain health.

Background United States hospitals have widely adopted electronic health records (EHRs). Despite the potential for EHRs to increase efficiency, there is concern that documentation quality has suffered. Objective To examine the impact of an educational session bundled with a progress note template on note quality, length, and timeliness. Design A multicenter, nonrandomized prospective trial. Setting Four academic hospitals across the United States. Participants Intern physicians on inpatient internal medicine rotations at participating hospitals. Intervention A task force delivered a lecture on current issues with documentation and suggested that interns use a newly designed best practice progress note template when writing daily progress notes. Measurements Note quality was rated using a tool designed by the task force comprising a general impression score, the validated Physician Documentation Quality Instrument, 9-item version (PDQI-9), and a competency questionnaire. Reviewers documented number of lines per note and time signed. Results Two hundred preintervention and 199 postintervention notes were collected. Seventy percent of postintervention notes used the template. Significant improvements were seen in the general impression score, all domains of the PDQI-9, and multiple competency items, including documentation of only relevant data, discussion of a discharge plan, and being concise while adequately complete. Notes had approximately 25% fewer lines and were signed on average 1.3 hours earlier in the day. Conclusions The bundled intervention for progress notes significantly improved the quality, decreased the length, and resulted in earlier note completion across 4 academic medical centers.

Background: Syphilis is common and resurgences predominantly occurs among men who have sex with men (MSM ). Objective: The aim of the study was to describe the epidemiology, clinical and serological aspects of patients with syphilis diagnosed at Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Methods: A retrospective study was conducted whereby patients with serologically confirmed syphilis cases between January 2010 and December 2012 were included. The epidemiological and clinical data were gathered from the patient’s progress note. Results: A total of 67 patients were selected in this research (41 males, 26 females). The mean age was 48.97 ± 17.45, where majority were from 20 to 39 years old (37.3%). Most patients were diagnosed at latent stage (65.7%). Identified risk factors for syphilis infection included sexual promiscuity either homosexual or heterosexual, intravenous drug user and partner diagnosed as syphilis. Penicillin is the antibiotic of choice for the treated cases. Conclusions: This study managed to provide an epidemiological and serological data of syphilis infection in our medical center where syphilis was diagnosed predominantly in male especially in young adults. Bangladesh Journal of Medical Science Vol.17(1) 2018 p.62-66

OBJECTIVE Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service. METHODS At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a “system-based” progress note template was changed to a “problem-based” progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention. RESULTS The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002). CONCLUSIONS Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.

Background The transfer of information in a medical summary letter is a key aspect of the transition of adolescent patients with IBD from pediatric to adult care. The existing template from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) is nearly 20 years old, and the many intervening changes to the care of children with IBD necessitate a new template to reflect modern care. Aims We developed a standardized medical summary template based on the feedback of adult and pediatric IBD health care providers. Methods We purposively sampled gastroenterologists (GIs) or nurse practitioners (NPs) caring for patients with IBD in Montreal, Ottawa, Toronto or Vancouver and invited them to take part in focus group discussions. Gastroenterologists caring for Results Content areas of importance (see Table) were: patient/disease characteristics, therapeutics history, clinical history and current status, noteworthy investigations, history of complications, family history, immunization history, and psychosocial history. In addition, the template addressed health system process factors (i.e., urgency of transfer, mode of delivery, confidentiality) to ensure a seamless transfer to adult care. Conclusions The standardized medical summary template should be used by pediatric providers to ensure that essential information is sent to the receiving adult provider. Funding Agencies Transition des patients avec Crohn et colite (TRACC) program

Background The outpatient parenteral antimicrobial therapy (OPAT) plan has frequently been omitted or incompletely communicated during transitions of care at our institution. Better communication of the OPAT plan at discharge has the potential to improve patient outcomes. Methods A standardized OPAT documentation tool (SmartForm) was developed in our electronic health record system for use by our inpatient Infectious Disease (ID) consult service. This intervention was part of an ongoing quality improvement project to improve communication of the OPAT plan at discharge. Outcomes were assessed prospectively during the post-intervention time period (11/18/2019 - 4/13/2020) and compared to the pre-intervention time period (10/14/2019 - 11/11/2019). Patients were included if discharged on IV antibiotics with follow up by a University of Utah Health ID provider. Patients discharged to long-term acute care facilities were excluded. Results Three hundred five patients were included: 231 in the post-intervention period and 74 in the pre-intervention period. Demographic characteristics were similar between time periods with the exception of older age (mean 60 vs 56 years), a greater percentage of patients receiving OPAT via an infusion center (19% vs 9%), and fewer patients receiving OPAT via home health (54% vs 64%) in the pre-intervention cohort. Documentation of an OPAT progress note occurred more frequently (94% vs 85%, p = 0.02) and patients were more likely to be enrolled in our OPAT program (77% vs 51%, p < 0.0001) after implementation of the OPAT SmartForm. Outpatient laboratory monitoring occurred with similar frequency during the pre- and post-intervention time periods (85% vs 82% of expected laboratory encounters completed, p = 0.31). Sixty-day unplanned hospital readmissions were reduced after implementation of the SmartForm (22% vs 35%, p = 0.02). Multivariable logistic regression identified Charlson comorbidity index (OR 1.10, 95% CI: 1.02–1.18) and the pre-intervention time period (OR 1.78, 95% CI: 0.99–3.18) as variables independently associated with readmission. Conclusion Implementation of an OPAT SmartForm was associated with improved documentation of the OPAT plan, increased enrollment in the OPAT program, and reduction in hospital readmissions. Disclosures Russell J. Benefield, PharmD, Merck and Co (Grant/Research Support)Paratek Pharmaceuticals (Grant/Research Support)Rempex Pharmaceuticals (Grant/Research Support)

Using sequence alignment to compare more than 12,000 pairs of progress notes, we find that progress notes were, on average, 74.5% redundant with the prior progress note written for the same patient.

OBJECTIVE: To compare the catheter-associated urinary tract infections (CAUTI) standardized infection rate (SIR) before and after implementation of a multimodal intervention approach in a rural tertiary hospital. DESIGN: Before–after analysis of a multimodal intervention to evaluate primary outcomes of the incidence of inpatient CAUTI, the SIR for CAUTI, and number of urinary catheter days. SETTING: All inpatient departments of a rural 504-bed tertiary care facility in the Midwest. PARTICIPANTS: Patients admitted for in-patient care. INTERVENTIONS: A multimodal intervention composed of: (a) physician and nurse education, (b) modification of progress note templates and daily provider reminders for the clinical necessity of catheters, (c) implementing established best practices for eliminating CAUTIs, (d) advocating for alternative toileting options, and (e) promoting aseptic techniques for insertion and removal of catheters. SIR, CAUTI, and the number of urinary catheter days were obtained before and after implementation of the multimodal intervention in 2015 and 2017, respectively. RESULTS: After a one-year timeframe of intervention, CAUTI event rates decreased, and SIR for CAUTI was reduced by 60.2% (from 1.524 to 0.607) with P value

Procalcitonin (PCT) is a biomarker that has shown promise to identify bacterial etiology in acute infections, including bacterial lower respiratory tract infection (LRTI). In 2017, the United States Food and Drug Administration (FDA) approved the use of PCT as a diagnostic aid to guide the decisions around antibiotic therapy in acute LRTI.1 Although most of the data supporting the use of PCT for LRTI stems from adult studies, the high disease burden, predominance of viral etiologies, and frequent diagnostic uncertainty resulting in antibiotic overuse make pediatric LRTI an ideal target for the use of PCT as a diagnostic aid. This review evaluates and summarizes the current evidence regarding the role of PCT in the clinical care of pediatric LRTI, including its use in guiding antibiotic use and prognosticating disease severity.

We suggest changes in the electronic health record (EHR) in hospitalized patients to increase EHR usability by optimizing the physician’s ability to approach the patient in a problem-oriented fashion and by reducing physician data entry and chart navigation. The framework for these changes is a Physician’s Daily Hospital Progress Note organized into 3 sections: Subjective, Objective, and a combined Assessment and Plan section, subdivided by problem titles. The EHR would consolidate information for each problem by: 1) juxtaposing to each problem title relevant medications, key durable results, and limitations; 2) entering in the running lists under Assessment and Plan the most relevant information for that day, including abbreviated versions of relevant reports; and 3) generating a flow sheet in a problem’s progress note for any key results tracked daily. To reduce physician EHR navigation, the EHR would place in the Objective section abbreviated versions of notes of other physicians, nurses, and allied health professionals as well as recent orders. The physician would enter only the analysis and plan and new information not included in the EHR. The consolidation of information for each problem would facilitate physician communication at points of transition of care including generation of a problem-oriented discharge summary.

Background Padua linear model is widely used for the risk assessment of venous thromboembolism (VTE), a common but preventable complication for inpatients. However, genetic and environmental differences between Western and Chinese population limit the validity of Padua model in Chinese patients. Medical records which contain rich information about disease progression, are useful in mining new risk factors related to Chinese VTE patients. Furthermore, machine learning (ML) methods provide new opportunities to build precise risk prediction model by automatic selection of risk factors based on original medical records. Methods Medical records of 3,106 inpatients including 224 VTE patients were collected and various types of ontologies were integrated to parse unstructured text. A workflow of ontology-based VTE risk prediction model, that combines natural language processing (NLP) and machine learning (ML) technologies, was proposed. Firstly ontology terms were extracted from medical records, then sorted according to their calculated weights. Next importance of each term in the unit of section was evaluated and finally a ML model was built based on a subset of terms. Four ML methods were tested, and the best model was decided by comparing area under the receiver operating characteristic curve (AUROC). Results Medical records were first split into different sections and subsequently, terms from each section were sorted by their weights calculated by multiple types of information. Greedy selection algorithm was used to obtain significant sections and terms. Top terms in each section were selected to construct patients’ distributed representations by word embedding technique. Using top 300 terms of two important sections, namely the ‘Progress Note’ section and ‘Admitting Diagnosis’ section, the model showed relatively better predictive performance. Then ML model which utilizes a subset of terms from two sections, about 110 terms, achieved the best AUC score, of 0.973 ± 0.006, which was significantly better compared to the Padua’s performance of 0.791 ± 0.022. Terms found by the model showed their potential to help clinicians explore new risk factors. Conclusions In this study, a new VTE risk assessment model based on ontologies extraction from raw medical records is developed and its performance is verified on real clinical dataset. Results of selected terms can help clinicians to discover meaningful risk factors.

Objective: The objective of this study was to evaluate the impact of pharmacist's interventions through a collaborative ambulatory care pharmacy practice (CAPP) model in patients with type 2 diabetes mellitus (T2DM) among the underrepresented population. Methods: Eligible patients were 18 years and older with a diagnosis of T2DM with or without comorbid cardiovascular disease risk factors. Patients were enrolled through routine primary care provider referrals. During a one-on-one, face-to-face scheduled clinic visit, the pharmacist provided a comprehensive medication management by reviewing vital signs and laboratory values, provided medication reconciliation and management, followed by medication counseling through a CAPP approach in a primary care setting. The pharmacist worked in close collaboration with the primary care provider to intervene on medication therapy through recommendations to initiate, adjust, modify, or discontinue drug therapy and order laboratory tests and drug concentration levels as appropriate. Each visit was documented as a “PharmD Progress Note” in the patient's electronic medical record. Follow-up visits were scheduled until patients' targeted treatment goals were achieved. Primary and secondary outcome data were collected and then analyzed. Findings: A pharmacist saw 47 patients over 12 months. Sixty-four percent of the participating patients were able to achieve targeted treatment goals. A statistically significant decrease in the mean change in hemoglobin A1c, diastolic blood pressure, fasting blood glucose, and triglyceride levels was observed from the baseline which was −2.3%, −7.75 mmHg, −76.1 mg/dL, and −55.5 mg/dL, respectively. No significant changes in other clinical outcomes were observed. Conclusion: The CAPP model demonstrated a significant reduction in clinical endpoints in patients with T2DM among the high-risk underrepresented population.