Lost in translation: Focused documentation improvement benefits trauma surgeons

IntroductionThere is a translational gap between physicians who document in the medical record and coders, who ultimately determine which codes are submitted. This gap exists because physicians are never formally educated about documentation strategies despite the fact that the quality of physician documentation directly affects revenue, outcomes and public profiling. We evaluated the effect of a formal model of focused documentation improvement (FDI) on the trauma/critical care division. We hypothesized that FDI would improve physician documentation, resulting in revenue recovery and a shift in the case mix index (CMI) to more accurately reflect the clinical complexity of trauma patients.MethodsFDI is defined as targeted physician education followed by concurrent inpatient chart review for documentation improvement opportunities by a clinical documentation specialist (CDS). All trauma surgeons (n = 9) at our Level 1 trauma center first completed three hours of mandatory training on documentation improvement. A CDS was subsequently assigned to the trauma service. They reviewed the charts of Medicare patients (n = 776) from January–December 2014 to identify opportunities for documentation improvement, participated in ICU rounds and provided ongoing education. Requests to clarify documentation (queries) were posted in the electronic medical record (EMR) and physicians were required to respond within 48 h. Data was collected on physician response rate, CMI and revenue recovery.Results411 of 776 (57%) charts were reviewed. Opportunities for FDI were identified in 177 (43%) cases. The physician response rate to queries was 100%. The CMI for reviewed cases increased (1.80 (SD 0.15) vs. 2.11 (SD 0.19); p < 0.001) after FDI. Overall revenue recovery was $1,132,581 with an average of $154,092 in revenue recovery/clinical full time equivalent. The total cost for administration of FDI was $353,265 resulting in a 220% return on investment (ROI).ConclusionFDI is an effective strategy to engage physicians in documentation improvement. It provides an infrastructure to assist physicians and yields a significant ROI.     

Agreement between medical record and administrative coding of common comorbidities in orthopaedic trauma patients

ObjectiveTo i) quantify the agreement between comorbidities documented within medical records and an orthopaedic trauma dataset; and ii) compare agreement between these sources before and after the introduction of new comorbidity coding rules in Australian hospitals.Study design and settingA random sample of adult (≥ 16 years) orthopaedic trauma patients (n = 400) were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Diagnoses of obesity, arthritis, diabetes and cardiac conditions documented within patients’ medical records were compared to ICD-10-AM comorbidity codes (provided by hospitals) for the same admission. Agreement was calculated (Cohen’s kappa) before and after the introduction of new coding rules.ResultsAll comorbidities had the same or higher prevalence in medical record data compared to coded data. Kappa values ranged from <0.001 (poor agreement) for coronary artery disease to 0.94 (excellent agreement) for type 2 diabetes. There was improvement in agreement between sources for most conditions following the introduction of new coding rules.ConclusionThere has been improvement in the coding of certain comorbidities since the introduction of new coding rules, suggesting that, since 2015, administrative data has improved capacity to capture patients’ comorbidity profiles. Consideration must be taken when using the ICD-10-AM data due to its limitations.     

A retrospective cohort study of the relationship between quality indicator measurement and patient outcomes in adult trauma centers in the United States

BackgroundImproving care is a key strategy for reducing the burden of injuries, but it is unknown whether the use of quality indicators (QI) is associated with patient outcomes. We sought to evaluate the association between the use of QIs by trauma centers and outcomes in adult injury patients.MethodsWe identified consecutive adult patients (n = 223,015) admitted to 233 verified trauma centers January 1, 2007 to December 31, 2010 that contributed data to the National Trauma Data Bank and participated in a survey of QI practices. Generalized Linear Mixed Models were employed to evaluate the association between the intensity (number of QIs) and nature (report cards, internal and external benchmarking) of QI use and survival to hospital discharge, adjusting for patient and hospital characteristics.ResultsThere were no significant differences in the odds of survival to trauma center discharge according to the number of QIs measured (quartiles; odds ratio{OR} [95% confidence interval{CI}] 1.00 vs. 1.08 [0.90–1.31] vs. 1.00 [0.82–1.22] vs. 1.21 [0.99–1.49]), or whether centers used reports cards (OR 1.07, 95%CI 0.94–1.23), internal (OR 1.06, 95%CI 0.89–1.26) or external (OR 1.09, 95%CI 0.92–1.31) benchmarking. The duration (geometric mean) of mechanical ventilation (4.0 days), ICU stay (4.6 days), hospital stay (7.7 days) and proportion of patients with a complication (13.6%) did not significantly differ according to the intensity or nature of QI use.ConclusionsThe intensity and nature of the QIs used by trauma centers was not associated with outcomes of patient care. Alternative quality improvement strategies may be needed.     

Low-dose external beam radiotherapy as a postoperative treatment for patients with diffuse pigmented villonodular synovitis of the knee

Background and purpose Pigmented villonodular synovitis (PVNS) is a rare proliferative disorder involving synovial membranes, and patients with PVNS have a variable prognosis. We retrospectively analyzed clinical outcomes after synovectomy plus low-dose external beam radiotherapy for diffuse PVNS of the knee.

Methods We reviewed the medical records of 23 patients who underwent postoperative radiotherapy between 1998 and 2007. 19 patients had primary disease and 4 had recurrent disease with an average of 2.5 prior surgeries. After synovectomy (17 arthroscopic surgeries; 6 open), all 23 patients received 4-MV or 6-MV external beam radiotherapy with a median dose of 20 (12–34) Gy in 10 fractions.

Results At a median follow-up of 9 (0.8–12) years, 4 patients had recurrent disease, with a median disease-free interval of 5 years. Of these 4 patients, 3 received salvage synovectomy and regained local control. Univariate analysis showed that age, sex, history of trauma, and total dose of radiation were not predictive of local control. 22 patients reported excellent or good joint function, and 1 who refused salvage synovectomy had poor joint function. None of the patients experienced grade 3 or higher radiation-related toxicity or radiation-induced secondary malignancies.

Interpretation Postoperative external beam radiotherapy is an effective and acceptable modality to prevent local recurrence and preserve joint function in patients with diffuse PVNS of the knee. Low-dose (20 Gy) radiotherapy appears to be as effective as moderate-dose treatment (around 35 Gy).     

Piloting a Medical Student Observational Experience With Hospital-Based Trauma Chaplains

IntroductionMedical students have typically received relatively modest training in approaches for engaging the concerns of patients and families facing life-threatening situations and terminal illnesses. We propose that medical students would perceive benefits to their communication skills, understanding of the role of the chaplain, and knowledge of emotional and spiritual needs of grieving patients and families after shadowing hospital-based trauma chaplains whose work focuses on emergency department traumas and intensive care units.MethodsThe authors developed a pilot program in which medical students shadowed a trauma chaplain during an on-call shift in an urban level 1 trauma center. Students subsequently completed an evaluative survey of their experience.ResultsOf 21 participants, 14 (67%) completed the questionnaire. Students observed an average of 1.50 traumas and 3.57 interactions with patients or families. One-third of the students witnessed a death. More than 90% of respondents agreed or strongly agreed that (1) the program provided them with a greater understanding of how to engage patients and families in difficult conversations; (2) they learned about the chaplain’s role in the hospital; and (3) the experience was useful for their medical education, careers, and personal development. About two-thirds (9/14) perceived that they learned how to discuss spirituality with patients and families. All recommended the experience be part of the medical school curriculum.DiscussionObservational experiences with hospital-based trauma chaplains might be an effective nondidactic approach for teaching medical students effective communication with patients and families, collaboration with chaplains, and spirituality in patient care.     

Strategic air medical evacuation of critically ill patients involving an intensive care physician: A retrospective analysis of 16 years of mission data

BackgroundStrategic medical evacuation (MEDEVAC) allows airborne repatriation of soldiers injured or sick on missions to their national territory. The aim of this study was to describe the epidemiology of strategic MEDEVAC performed by intensive care physicians (ICP) and to analyze the role of the ICP in the management of critical care situations in flight.MethodsAll soldiers who had high or medium dependency conditions and who benefited from a strategic MEDEVAC with an ICP on board between 1 January 2001 and 30 November 2017 were included in this epidemiological retrospective study.ResultsA total of 452 soldiers were repatriated; the causes of repatriation were either trauma (n = 245; 54%) or medical pathologies (n = 207; 46%). Two hundred and seventy-six (61%) evacuations were performed within 48 h. The median annual number of strategic MEDEVAC with an ICP was 26 [20–32]. One hundred and fifty-five (34%) patients were mechanically ventilated and 103 (23%) received catecholamines. The median SAPS II score was 13 [8–24]. One hundred and seventy-eight adverse events were identified, of which 123 (69%) related to a worsening of the patient's clinical condition and 30 (20%) related to a technical problem. Forty-seven (20%) patients who initially appeared stable worsened during the flight. No deaths occurred on board, however, and no flights had to be diverted due to an uncontrolled care situation.ConclusionThe results suggested that the presence of an ICP ensured a continued high-level care for patients with serious trauma and medical injuries, due to the medical and aeronautical expertise that resulted from the theoretical and practical training of the personnel on board. Based on these results, lessons regarding future MEDEVAC flights could be learned in order to continue to improve patient outcome.     

A critical review of patient safety indicators attributed to trauma surgeons

BackgroundThe Agency for Health Care Research and Quality (AHRQ) developed patient safety indicators (PSIs) to identify events with a high likelihood of representing medical error. The purpose of this study was to validate PSIs attributed to trauma surgeons and compare validated PSIs to performance improvement (PI) and morbidity and mortality (M&M) data. We hypothesized that PSIs are not an indicator of quality of care in trauma.MethodsPSI’s attributed to trauma surgeons (n = 9) at our institution were reviewed (Jan–Dec 2015). An initial review was conducted to ensure they met inclusion and exclusion criteria (valid). “Valid” PSIs were distributed to the trauma division for secondary review.Results48 PSIs were identified (17.2 per 1000 cases) during the study period. 19 were false positives yielding a positive predictive value of 60% (95% CI 45–74%). False positive PSIs were the result of coding error (78%), present on admission status (17%) and documentation error (5%). Valid PSIs (n = 29) were further analyzed. The most common were post-op PE/DVT (n = 14), failure to rescue (n = 6) and accidental puncture/laceration (n = 3). 60% of patients with a post-op PE/DVT were started on chemoprophylaxis on admission and 40% had significant intracranial hemorrhage; all were deemed non-preventable through trauma PI. All deaths considered failure to rescue were classified as expected mortalities during M&M review. Although not clinically significant, all cases of accidental puncture/laceration (10% of valid PSIs) represented opportunities for improvement.ConclusionOverall, PSIs have low validity and do not reflect quality of care in trauma.     

Patient safety indicators from a spine surgery perspective: the importance of a specialty specific clinician working with the documentation team and the impact to your hospital

BACKGROUND CONTEXTThe Hospital Acquired Conditions (HAC) Reduction Program supports the Centers for Medicare and Medicaid Services (CMS) effort to prevent harm to patients by providing a financial incentive to reduce HACs. HAC scores are impacted by Patient Safety Indicators (PSIs), potentially preventable hospital-related events associated with harmful patient outcomes. PSIs are identified using International Classification of Diseases (ICD) coding; however, ICD coding does not always reflect the patient's true medical course.PURPOSETo evaluate the efficacy of and costs savings associated with a clinical documentation review process in tandem with clinician collaboration in identifying incorrectly generated PSIs.STUDY DESIGNRetrospective chart review.PATIENT SAMPLEAll patients undergoing spine surgery at a single multi-surgeon tertiary spine center.OUTCOME MEASURESOccurrence of PSI.METHODSOver two 11-month periods, all PSIs attributable to spine surgery were determined. The number and type of spine related PSIs were compared before (Control) and after the implementation of a specialty specific clinical review (Intervention) to identify incorrectly generated PSIs. The financial impact of this intervention was calculated in the form of an annual cost savings to our hospital system.RESULTSDuring the Control phase, 61 PSIs were reported in 3368 spine cases, representing a total of 3.6 PSIs/month. During Intervention phase, 26 PSIs in 4,482 spine cases, resulting in a statistically significant decrease of 1.5 PSIs per month. The percentage of PSIs across all surgical cases attributable to spine surgery had a statistically significant decrease during the Intervention period compared to the Control period (16% vs. 10%, p=.034), resulting in the avoidance of a 1% CMS cost reduction, an annual cost saving of approximately $3–4 million dollars per year.CONCLUSIONSThe implementation of a clinical documentation review process with clinician collaboration to ensure ICD-10 coding accurately reflects the patient's medical course leads to more accurate PSI reporting, with the potential for substantial cost-savings for hospitals from CMS reimbursement.     

Major influence of interobserver reliability on polytrauma identification with the Injury Severity Score (ISS): Time for a centralised coding in trauma registries?

ObjectiveThe Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) find increasingly widespread use to assess trauma burden and to perform interhospital benchmarking through trauma registries. Since 2015, public resource allocation in Switzerland shall even be derived from such data. As every trauma centre is responsible for its own coding and data input, this study aims at evaluating interobserver reliability of AIS and ISS coding.MethodsInterobserver reliability of the AIS and ISS is analysed from a cohort of 50 consecutive severely injured patients treated in 2012 at our institution, coded retrospectively by 3 independent and specifically trained observers.ResultsConsidering a cutoff ISS ≥ 16, only 38/50 patients (76%) were uniformly identified as polytraumatised or not. Increasing the cut off to ≥20, this increased to 41/50 patients (82%). A difference in the AIS of ≥ 1 was present in 261 (16%) of possible codes. Excluding the vast majority of uninjured body regions, uniformly identical AIS severity values were attributed in 67/193 (35%) body regions, or 318/579 (55%) possible observer pairings.ConclusionInjury severity all too often is neither identified correctly nor consistently when using the AIS. This leads to wrong identification of severely injured patients using the ISS. Improving consistency of coding through centralisation is recommended before scores based on the AIS are to be used for interhospital benchmarking and resource allocation in the treatment of severely injured patients.     

Simulation-based multidisciplinary team training decreases time to critical operations for trauma patients

BackgroundSimulation has been promoted as a platform for training trauma teams. However, it is not clear if this training has an impact on health service delivery and patient outcomes. This study evaluates the association between implementation of a simulation based multidisciplinary trauma team training program at a metropolitan trauma centre and subsequent patient outcomes.MethodThis was a retrospective review of trauma registry data collected at an 850-bed Level 1 Adult Trauma Centre in Sydney, Australia. Two concurrent four-year periods, before and after implementation of a simulation based multidisciplinary trauma team training program were compared for differences in time to critical operations, Emergency Department (ED) length of stay (LOS) and patient mortality.ResultsThere were 2389 major trauma patients admitted to the hospital during the study, 1116 in the four years preceding trauma team training (the PREgroup) and 1273 in the subsequent 4 years (the POST group). There were no differences between the groups with respect to gender, body region injured, incidence of polytrauma, and pattern of arrival to ED. The POST group was older (median age 54 versus 43 years, p < 0.001) and had a higher incidence of falls and assaults (p < 0.001). There was a reduction in time to critical operation, from 2.63 h (IQR 1.23–5.12) in the PRE-group to 0.55 h (IQR 0.22–1.27) in the POST-group, p < 0.001. The overall ED LOS increased, and there was no reduction in mortality. Post-hoc analysis found LOS in ED was reduced in the cohort requiring critical operations, p < 0.001.ConclusionThe implementation of trauma team training was associated with a reduction in time to critical operation while overall ED length of stay increased. Simulation is promoted as a platform for training teams; but the complexity of trauma care challenges efforts to demonstrate direct links between multidisciplinary team training and improved outcomes. There remain considerable gaps in knowledge as to how team training impacts health service delivery and patient outcomes.Level of evidenceRetrospective comparative therapeutic/care management study, Level III evidence.     

Assessing teamwork in the trauma bay: introduction of a modified "NOTECHS" scale for trauma

BackgroundA modified nontechnical skills (NOTECHS) scale for trauma (T-NOTECHS) was developed to teach and assess teamwork skills of multidisciplinary trauma resuscitation teams. In this study, T-NOTECHS was evaluated for reliability and correlation with clinical performance.MethodsInterrater reliability (intraclass correlation coefficient) and correlation with the speed and completeness of resuscitation tasks were assessed during simulation-based teamwork training and during actual trauma resuscitations.ResultsFor T-NOTECHS ratings done in real time, intraclass correlation coefficients were .44 for simulated and .48 for actual resuscitations. Reliability was higher (intraclass correlation coefficient = .71) for video review of resuscitations. Better T-NOTECHS scores were correlated with better performance during simulations, evidenced by a greater number of completed resuscitation tasks (r = .50, P < .01) and faster time to completion (r = ?.38, P < .05) In actual resuscitations, T-NOTECHS ratings improved after teamwork training (P < .001). Higher T-NOTECHS scores were correlated with better clinical performance, evidenced by faster resuscitation (r = ?.13, P < .05) and fewer unreported resuscitation tasks (r = ?.16, P < .05).ConclusionsImprovement in T-NOTECHS scores after teamwork training, and correlation with clinical parameters in simulated and actual trauma resuscitations, suggest its clinical relevance. Further evaluation, aiming to improve reliability, may be warranted.     

Peripheral intravenous catheter infiltration: anesthesia providers do not adhere to their own ideas of best practice

Study ObjectiveTo survey anesthesia providers for their opinion on “best practice” in perioperative peripheral intravenous catheter (PIV) management, and to determine if they follow those opinions.DesignSurvey instrument.SettingAcademic medical center.Subjects266 United States (U.S.) anesthesia provider respondents (attending anesthesiologists, anesthesiology residents, anesthesia assistants, certified registered nurse-anesthetists and student registered nurse-anesthetists).MeasurementsBetween May 2009 and October 2010 a national survey was distributed to individuals who provide intraoperative anesthesia care to patients. Results were gathered via the SurveyMonkey database.Main Results266 anesthesia providers from across the U.S. took part in the survey. The majority (70%) had less than 5 years’ experience. Nearly 90% of respondents cared for a patient with an intravenous catheter infiltration at some point during their training; 7% of these patients required medical intervention. Intravenous assessment and documentation practices showed great variability. Management and documentation of PIVs was more aggressive and vigilant when respondents were asked about “best practice" than about actual management.ConclusionThere is no commonly accepted standard for management and documentation of PIVs in the operating room. From our survey, what providers think is “best practice" in the management and documentation of PIVs is not what is being done.     

Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on

IntroductionTrauma quality improvement (QI) programs have been shown to improve outcomes and decrease cost. These are high priorities in low- and middle-income countries (LMICs), where 2,000,000 deaths due to survivable injuries occur each year. We sought to define areas for improvement in trauma QI programs in four LMICs.MethodsWe conducted a survey among trauma care providers in four Andean middle-income countries: Bolivia, Colombia, Ecuador, and Peru.Results336 physicians, medical students, nurses, administrators and paramedical professionals responded to the cross-sectional survey with a response rate greater than 90% in all included countries except Bolivia, where the response rate was 14%. Eighty-seven percent of respondents reported morbidity and mortality (M&M) conferences occur at their hospital. Conferences were often reported as infrequent – 45% occurred less than every three months and poorly attended – 63% had five or fewer staff physicians present. Only 23% of conferences had standardized selection criteria, most lacked documentation – notes were taken at only 35% of conferences. Importantly, only 13% of participants indicated that discussions were routinely followed-up with any sort of corrective action. Multivariable analysis revealed the presence of standardized case selection criteria (OR 3.48, 95% CI 1.16–10.46), written documentation of the M&M conferences (OR 5.73, 95% CI 1.73–19.06), and a clear plan for follow-up (OR 4.80, 95% CI 1.59–14.50) to be associated with effective M&M conferences. Twenty-two percent of respondents worked at hospitals with a trauma registry. Fifty-two percent worked at institutions where autopsies were conducted, but only 32% of those reported the autopsy results to ever be used to improve hospital practice.ConclusionsM&M conferences are frequently practiced in the Andean region of Latin America but often lack methodologic rigor and thus effectiveness. Next steps in the maturation of QI programs include optimizing use of data from autopsies and registries, and systematic follow-up of M&M conferences with corrective action to ensure that these activities result in appreciable changes in clinical care.     

Introduction of a mobile device based tertiary survey application reduces missed injuries: A multi-center prospective study

BackgroundMissed injuries during the initial assessment are a major cause of morbidity after trauma. The tertiary survey is a head-to-toe exam designed to identify any injuries missed after initial resuscitation. We designed a novel mobile device application (Physician Assist Trauma Software [PATS]) to standardize performance and documentation of the tertiary survey. This study was undertaken to assess the feasibility of introducing PATS into routine clinical practice, as well as its capacity to reduce missed injuries.MethodsPrior to implementation of PATS, the missed injury rates at a higher-volume and a medium-volume level I trauma center were assessed. The PATS program was implemented simultaneously at both centers. Missed injuries were tracked during the study period. Compliance and tertiary survey completion rates were evaluated as a marker of feasibility.ResultsAt the higher-volume trauma center, the missed injury rated decreased from 1% to 0% with the introduction of the PATS program (p = 0.04). At the medium-volume trauma center, the missed injury rate decreased from 9% to 1% (p < 0.001). Compliance and documentation increased from 68% to 100%, and from no formal documentation to 60% compliance at the higher- and medium-volume centers respectively.ConclusionsThe implementation of a mobile tertiary survey application significantly reduced missed injuries at both a higher- and medium-volume trauma center. The use of this application resulted in a significant improvement in compliance with documentation of the tertiary survey.     

Stop the Bleed Training empowers learners to act to prevent unnecessary hemorrhagic death

BackgroundUncontrolled bleeding is a leading cause of preventable death from trauma. With the rise in mass casualty events, training of laypersons can be life-saving. “Stop the Bleed” is a campaign to teach the public techniques of bleeding control. We believe that training in these techniques will increase participants' willingness and preparedness to intervene and increase knowledge of trauma/hemorrhage control.MethodsWe created a “Stop the Bleed” training program. School nurses, medical students, researchers, and community members participated in the program. Pre- and post-training questionnaires assessed participants' willingness/preparedness to intervene in a casualty event and knowledge of trauma/hemorrhage control.ResultsThere was a significant change in attitudes after receiving training (p < 0.05). There was also an improvement in knowledge regarding bleeding control techniques.Conclusions“Stop the Bleed” training empowers participants with the confidence and knowledge to aid others in preventable hemorrhagic death.