Patient-Friendly Discharge Summaries in Korea Based on ChatGPT: Software Development and Validation.

BACKGROUND: Although discharge summaries in patient-friendly language can enhance patient comprehension and satisfaction, they can also increase medical staff workload. Using a large language model, we developed and validated software that generates a patient-friendly discharge summary. METHODS: We developed and tested the software using 100 discharge summary documents, 50 for patients with myocardial infarction and 50 for patients treated in the Department of General Surgery. For each document, three new summaries were generated using three different prompting methods (Zero-shot, One-shot, and Few-shot) and graded using a 5-point Likert Scale regarding factuality, comprehensiveness, usability, ease, and fluency. We compared the effects of different prompting methods and assessed the relationship between input length and output quality. RESULTS: The mean overall scores differed across prompting methods (4.19 ± 0.36 in Few-shot, 4.11 ± 0.36 in One-shot, and 3.73 ± 0.44 in Zero-shot; P < 0.001). Post-hoc analysis indicated that the scores were higher with Few-shot and One-shot prompts than in zero-shot prompts, whereas there was no significant difference between Few-shot and One-shot prompts. The overall proportion of outputs that scored ≥ 4 was 77.0% (95% confidence interval: 68.8-85.3%), 70.0% (95% confidence interval [CI], 61.0-79.0%), and 32.0% (95% CI, 22.9-41.1%) with Few-shot, One-shot, and Zero-shot prompts, respectively. The mean factuality score was 4.19 ± 0.60 with Few-shot, 4.20 ± 0.55 with One-shot, and 3.82 ± 0.57 with Zero-shot prompts. Input length and the overall score showed negative correlations in the Zero-shot (r = -0.437, P < 0.001) and One-shot (r = -0.327, P < 0.001) tests but not in the Few-shot (r = -0.050, P = 0.625) tests. CONCLUSION: Large-language models utilizing Few-shot prompts generally produce acceptable discharge summaries without significant misinformation. Our research highlights the potential of such models in creating patient-friendly discharge summaries for Korean patients to support patient-centered care.

Improving Resident Hospital Discharge Communication by Changing Electronic Health Record Templates to Enhance Primary Care Provider Satisfaction.

BACKGROUND AND OBJECTIVES: Despite use of standardized electronic health record templates, the structure of discharge summaries may hinder communication from inpatient settings to primary care providers (PCPs). We developed an enhanced electronic discharge summary template to improve PCP satisfaction with written discharge summaries targeting diagnoses, medication reconciliation, laboratory test results, specialist follow-up, and recommendations. METHODS: Resident template usage was measured using statistical process control charts. PCP reviewers' discharge summary satisfaction was surveyed using 5-point Likert scales analyzed using the Mann-Whitney U test. Residents were surveyed for satisfaction. RESULTS: Resident template usage increased from 61% initially to 72% of discharge summaries at 6 months. The PCP reviewers reported increased satisfaction for summaries using the template compared with those without (4.3 vs 3.9, P = .003). Surveyed residents desired template inclusion in the default electronic discharge summary (93%). CONCLUSIONS: This system-level resident-initiated quality improvement initiative created a novel discharge summary template that achieved widespread usage among residents and significantly increased outpatient PCP satisfaction.

Prevalence and Risk Factors for Dangerous Abbreviations in Malaysian Electronic Clinical Notes.

Medical abbreviations can be misinterpreted and endanger patients' lives. This research is the first to investigate the prevalence of abbreviations in Malaysian electronic discharge summaries, where English is widely used, and elicit the risk factors associated with dangerous abbreviations. We randomly sampled and manually annotated 1102 electronic discharge summaries for abbreviations and their senses. Three medical doctors assigned a danger level to ambiguous abbreviations based on their potential to cause patient harm if misinterpreted. The predictors for dangerous abbreviations were determined using binary logistic regression. Abbreviations accounted for 19% (33,824) of total words; 22.6% (7640) of those abbreviations were ambiguous; and 52.3% (115) of the ambiguous abbreviations were labelled dangerous. Increased risk of danger occurs when abbreviations have more than two senses (OR = 2.991; 95% CI 1.586, 5.641), they are medication-related (OR = 6.240; 95% CI 2.674, 14.558), they are disorders (OR = 7.771; 95% CI 2.054, 29.409) and procedures (OR = 3.492; 95% CI 1.376, 8.860). Reduced risk of danger occurs when abbreviations are confined to a single discipline (OR = 0.519; 95% CI 0.278, 0.967). Managing abbreviations through awareness and implementing automated abbreviation detection and expansion would improve the quality of clinical documentation, patient safety, and the information extracted for secondary purposes.

Efficacy, cost-minimization, and budget impact of a personalized discharge letter for basal cell carcinoma patients to reduce low-value follow-up care.

BACKGROUND: The incidence of keratinocyte carcinomas is high and rapidly growing. Approximately 80% of keratinocyte carcinomas consist of basal cell carcinomas (BCC) with 50% of these being considered as low-risk tumors. Nevertheless, 83% of the low-risk BCC patients were found to receive more follow-up care than recommended according to the Dutch BCC guideline, which is one visit post-treatment for this group. More efficient management could reduce unnecessary follow-up care and related costs. OBJECTIVES: To study the efficacy, cost-utility, and budget impact of a personalized discharge letter for low-risk BCC patients compared with usual care (no personalized letter). METHODS: In a multi-center intervention study, a personalized discharge letter in addition to usual care was compared to usual care in first-time BCC patients. Model-based cost-utility and budget impact analyses were conducted, using individual patient data gathered via surveys. The outcome measures were number of follow-up visits, costs and quality adjusted life years (QALY) per patient. RESULTS: A total of 473 first-time BCC patients were recruited. The personalized discharge letter decreased the number of follow-up visits by 14.8% in the first year. The incremental costs after five years were -€24.45 per patient. The QALYs were 4.12 after five years and very similar in both groups. The national budget impact was -€2,7 million after five years. CONCLUSIONS: The distribution of a personalized discharge letter decreases the number of unnecessary follow-up visits and implementing the intervention in a large eligible population would results in substantial cost savings, contributing to restraining the growing BCC costs.

Cross-sectional analysis of hospital tasks handed over to general practitioners: workload delegation or dumping?

PURPOSE OF THE STUDY: New requirements for hospital clinicians to follow up and act on hospital-initiated investigations were introduced in 2016 in the National Health Service standard contract. We aimed to evaluate the tasks handed over from hospital clinicians to general practitioners (GPs). STUDY DESIGN: A retrospective observation of all tasks in a random sample of electronic discharge summaries at a university teaching hospital over a 1 month period was conducted. A single-best-answer questionnaire was circulated among hospital clinicians over 3 months to gain an understanding of their follow-up and referral practices. RESULTS: The total number of tasks found on discharge summaries (n=178) were 227, of which 39% were directed at GPs and 61% at the hospital team. Of 89 tasks delegated to GPs, 33% were inappropriate. Some tasks on discharge summaries were delegated more frequently to GPs such as blood tests (73%) and endoscopy requests (67%). While others were undertaken more often by hospitals clinicians including imaging requests (88%), follow-up appointments (87%) and onward referrals (71%). Surveyed doctors (n=72) admitted to asking GPs to follow up blood tests (52%), imaging and endoscopy (16%) and make onward referrals for related conditions (14%) and unrelated conditions (70%). CONCLUSION: The majority of outstanding tasks in the hospital setting were followed up by hospital clinicians. A considerable volume of tasks were delegated to GPs, of which a significant proportion were inappropriate. An increase in awareness and understanding among hospital clinicians of their responsibility to follow up hospital-initiated investigations is needed.

A retrospective analysis of discharge summaries from a tertiary care hospital medical oncology unit: To assess compliance with documentation of recommended discharge summary components.

BACKGROUND: Discharge summaries are essential for health transition between inpatient hospital teams and outpatient general practices. The patient's outcome is dependent on the quality and timeliness of discharge summaries. AIM: A retrospective analysis was carried out to assess the compliance with recommended documentation of 697 electronic discharge summaries (eDSs) of oncology inpatients discharged in 2018 from the Canberra Hospital according to the National Guidelines of On-Screen Presentation of Discharge Summaries. METHODS AND RESULTS: Individual medical records were identified and screened for the recommended eDS components according to the National Guidelines. Out of the 17 recommended components, nine components were included in all discharge summaries, two components in more than 99% and two components in 95-96% of discharge summaries. The most frequently omitted components include "information provided to the patient," "ceased medicine" and "procedures," and these were omitted in 8, 38 and 82% of discharge summaries, respectively. CONCLUSION: Overall, most discharge summaries adhered to the national guidelines quite well by including most of the recommended components. However, the discharge summary quality is still inadequate in some domains.

The Utility of the Modified Dionne's Egress Test as a Predictor of Falls in Adult Medical and Surgical Patients.

OBJECTIVE: The aim of this study was to compare the efficacy of a modified Dionne's Egress Test (Egress) as a predictor of falls with the Morse Fall Scale (MFS) in adult medical and surgical patients in an acute care setting. BACKGROUND: Nurses must identify fall risk while balancing fall prevention and early mobility in their care delivery. Fall risk screening tools alone are not enough to assist nurses in predicting patients at risk of falling. METHODS: A retrospective observational study design was used to compare the Egress as a predictor of falls to the MFS. The sample included data abstracted from 197 electronic health records and internal falls data. RESULTS: The Egress and the MFS are moderately and negatively correlated; however, only Egress was a significant predictor of falls. Passing the Egress, not being on benzodiazepines, and having a longer length of stay (LOS) results were associated with being less likely to fall. CONCLUSION: Egress is a better predictor of falls than MFS when benzodiazepines and LOS are controlled in the model.

Facilitating better postnatal care with women-held documents in The Gambia: a mixed-methods study.

BACKGROUND: Women-held documents are a basic component of continuity of maternity care. The use and completion of women-held documents following discharge could improve treatment and care for postnatal women. Using a mixed-methods study design, we aimed to assess the number, type, quality and completeness of women-held discharge documents, identify factors contributing to document completeness and facilitators or barriers for effective use of the documents. METHODS: Documents given to women at discharge from three hospitals in the Greater Banjul Area, The Gambia, were reviewed for content and quality. All women completed a questionnaire on the use of the documents. Poisson regression was used to estimate factors predicting document completion. Semi-structured interviews (n = 21) and focus groups (n = 2) were carried out with healthcare professionals (HCPs). RESULTS: Nearly all (n = 211/212; 99%) women were given a document to take home. The most complete document (maternal record) had on average 17/26 (65%) items completed and 10% of women held an illegible document. None of the women's sociodemographic or clinical characteristics predicted document completeness. The following facilitators for effective use of documents were identified from the women's responses to the questionnaire and interviews with HCPs: 94% of women thought written information is important, 99% plan to have postnatal check-ups and 67% plan to use their documents, HCPs understand the importance of the documents and were familiar with the document's use and content. The following barriers for effective use of documents were identified: HCPs had too many women-held documents to complete at discharge, there is no national protocol and HCPs think women do not understand the documents due to a lack of education and that women often lose or forget their documents. CONCLUSIONS: Women-held documents are well established in The Gambia; though quality and completeness needs improving. Future research should determine the impact of using only one document at discharge, protocols and training on completeness, among other outcomes, and on ways to ensure all women are using the documents for their postnatal care.

Assessing the Impact of Hospital Dismissal Summary Readability on Patient Outcomes Following Prostatectomy.

PURPOSE: To assess the impact of decreasing the reading level of hospital dismissal summary information on the number of unplanned patient contacts with providers following robot-assisted radical prostatectomy. METHODS: A multidisciplinary team revised the hospital dismissal summary given to patients following prostatectomy to decrease the reading level from a 13th grade to seventh grade level. We conducted a retrospective cohort study comparing 30-day outcome measures including: patient-initiated telephone calls and online messages, unplanned clinic visits, readmission rates, and emergency department visits pre- and post-intervention. Other perioperative practices remained unchanged between the cohorts. RESULTS: A total of 110 patients were included in the study (pre-intervention n=60, post-intervention n=50). Patient age (P =.72), race (P =.59), marital status (P =.39), and education level (P = 1.0) were similar between the groups. Pre-intervention, 11.7% of patients had a self-reported education lever lower than the 13th grade, compared to 2% of patients post-intervention with an education level at or below the seventh grade. Following revision of the dismissal information, the number of patient-initiated messages (per patient) significantly decreased (mean 2.3 vs 1.4; P =.02). Patients who received the new dismissal information were significantly less likely to have an emergency department visit (20% vs 4%;P = .02). There were no differences in 30-day unplanned office visits (P =.75) or readmissions (P = 1.0). CONCLUSION: Reducing grade level readability of hospital dismissal information was associated with significantly lower rates of patient-initiated messages and emergency department visits. This intervention represents a valuable opportunity for improving the quality of patient care and decreasing postoperative care burden on the healthcare system.

A section identification tool: Towards HL7 CDA/CCR standardization in Spanish discharge summaries.

BACKGROUND: Nowadays, with the digitalization of healthcare systems, huge amounts of clinical narratives are available. However, despite the wealth of information contained in them, interoperability and extraction of relevant information from documents remains a challenge. OBJECTIVE: This work presents an approach towards automatically standardizing Spanish Electronic Discharge Summaries (EDS) following the HL7 Clinical Document Architecture. We address the task of section annotation in EDSs written in Spanish, experimenting with three different approaches, with the aim of boosting interoperability across healthcare systems and hospitals. METHODS: The paper presents three different methods, ranging from a knowledge-based solution by means of manually constructed rules to supervised Machine Learning approaches, using state of the art algorithms like the Perceptron and transfer learning-based Neural Networks. RESULTS: The paper presents a detailed evaluation of the three approaches on two different hospitals. Overall, the best system obtains a 93.03% F-score for section identification. It is worth mentioning that this result is not completely homogeneous over all section types and hospitals, showing that cross-hospital variability in certain sections is bigger than in others. CONCLUSIONS: As a main result, this work proves the feasibility of accurate automatic detection and standardization of section blocks in clinical narratives, opening the way to interoperability and secondary use of clinical data.

Discharge Summary Completion Timeliness and the Association of 30-Day Readmission.

OBJECTIVE: This study aimed to review the association between timeliness to completion of a discharge summary to 30-day readmission to the hospital. METHODS: This was a retrospective chart review of 109 patients discharged from Mayo Clinic Hospital. RESULTS: Twenty-four of these patients were readmitted within 30 days. The time to completion of discharge summary was categorized for these readmissions to <72 hours: 15 (20%), between 72 hours and 7 days: 2 (11.1%), and >7 days: 7 (43.7%). There was no statistical significance for readmission for discharge summaries completed between 72 hours and 7 days compared with <72 hours (P = 0.44). There was statistical significance correlating readmission within 30 days to the discharge summary completed >7 days compared with <72 hours (P = 0.04). CONCLUSIONS: This study found that discharge summaries completed >7 days have an increased association with 30-day readmission rate.

Usability of Electronic Health Record-Generated Discharge Summaries: Heuristic Evaluation.

BACKGROUND: Obtaining accurate clinical information about recent acute care visits is extremely important for outpatient providers. However, documents used to communicate this information are often difficult to use. This puts patients at risk of adverse events. Elderly patients who are seen by more providers and have more care transitions are especially vulnerable. OBJECTIVE: This study aimed to (1) identify the information about elderly patients' recent acute care visits needed to coordinate their care, (2) use this information to assess discharge summaries, and (3) provide recommendations to help improve the quality of electronic health record (EHR)-generated discharge summaries, thereby increasing patient safety. METHODS: A literature review, clinician interviews, and a survey of outpatient providers were used to identify and categorize data needed to coordinate care for recently discharged elderly patients. Based upon those data, 2 guidelines for creating useful discharge summaries were created. The new guidelines, along with 17 previously developed medical documentation usability heuristics, were applied to assess 4 simulated elderly patient discharge summaries. RESULTS: The initial research effort yielded a list of 29 items that should always be included in elderly patient discharge summaries and a list of 7 "helpful, but not always necessary" items. Evaluation of 4 deidentified elderly patient discharge summaries revealed that none of the documents contained all 36 necessary items; between 14 and 18 were missing. The documents each had several other issues, and they differed significantly in organization, layout, and formatting. CONCLUSIONS: Variations in content and structure of discharge summaries in the United States make them unnecessarily difficult to use. Standardization would benefit both patients, by lowering the risk of care transition-related adverse events, and outpatient providers, by helping reduce frustration that can contribute to burnout. In the short term, acute care providers can help improve the quality of their discharge summaries by working with EHR vendors to follow recommendations based upon this study. Meanwhile, additional human factors work should determine the most effective way to organize and present information in discharge summaries, to facilitate effective standardization.

Effects of Hospital-Based Comprehensive Medication Reviews Including Postdischarge Follow-up on Older Patients' Use of Health Care: A Cluster Randomized Clinical Trial.

Importance: Suboptimal use of medications is a leading cause of health care-related harm. Medication reviews improve medication use, but evidence of the possible benefit of inpatient medication review for hard clinical outcomes after discharge is scarce. Objective: To study the effects of hospital-based comprehensive medication reviews (CMRs), including postdischarge follow-up of older patients' use of health care resources, compared with only hospital-based reviews and usual care. Design, Setting, and Participants: The Medication Reviews Bridging Healthcare trial is a cluster randomized crossover trial that was conducted in 8 wards with multiprofessional teams at 4 hospitals in Sweden from February 6, 2017, to October 19, 2018, with 12 months of follow-up completed December 6, 2019. The study was prespecified in the trial protocol. Outcome assessors were blinded to treatment allocation. In total, 2644 patients aged 65 years or older who had been admitted to 1 of the study wards for at least 1 day were included. Data from the modified intention-to-treat population were analyzed from December 10, 2019, to September 9, 2020. Interventions: Each ward participated in the trial for 6 consecutive 8-week periods. The wards were randomized to provide 1 of 3 treatments during each period: CMR, CMR plus postdischarge follow-up, and usual care without a clinical pharmacist. Main Outcomes and Measures: The primary outcome measure was the incidence of unplanned hospital visits (admissions plus emergency department visits) within 12 months. Secondary outcomes included medication-related admissions, visits with primary care clinicians, time to first unplanned hospital visit, mortality, and costs of hospital-based care. Results: Of the 2644 participants, 7 withdrew after inclusion, leaving 2637 for analysis (1357 female [51.5%]; median age, 81 [interquartile range, 74-87] years; median number of medications, 9 [interquartile range, 5-13]). In the modified intention-to-treat analysis, 922 patients received CMR, 823 received CMR plus postdischarge follow-up, and 892 received usual care. The crude incidence rate of unplanned hospital visits was 1.77 per patient-year in the total study population. The primary outcome did not differ between the intervention groups and usual care (adjusted rate ratio, 1.04 [95% CI, 0.89-1.22] for CMR and 1.15 [95% CI, 0.98-1.34] for CMR plus postdischarge follow-up). However, CMR plus postdischarge follow-up was associated with an increased incidence of emergency department visits within 12 months (adjusted rate ratio, 1.29; 95% CI, 1.05-1.59) compared with usual care. There were no differences between treatment groups regarding other secondary outcomes. Conclusions and Relevance: In this study of older hospitalized patients, CMR plus postdischarge follow-up did not decrease the incidence of unplanned hospital visits. The findings do not support the performance of hospital-based CMRs as conducted in this trial. Alternative forms of medication reviews that aim to improve older patients' health outcomes should be considered and subjected to randomized clinical trials. Trial Registration: ClinicalTrials.gov Identifier: NCT02986425.

Implementation, spread and impact of the Patient Oriented Discharge Summary (PODS) across Ontario hospitals: a mixed methods evaluation.

BACKGROUND: Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable a patient-centred process. METHODS: Twenty one acute-care and rehabilitation hospitals in Ontario, Canada engaged in a community of practice and worked over a period of 18 months to implement PODS. An effectiveness-implementation hybrid design using a triangulation approach was used with hospital-collected data, patient and provider surveys, and interviews of project teams. Key outcomes included: penetration and fidelity of the intervention, change in patient-centred processes, patient and provider satisfaction and experience, and healthcare utilization. Statistical methods included linear mixed effects models and generalized estimating equations. RESULTS: Of 65,221 discharges across hospitals, 41,884 patients (64%) received a PODS. There was variation in reach and implementation pattern between sites, though none of the between site covariates was significantly associated with implementation success. Both high participation in the community of practice and high fidelity were associated with higher penetration. PODS improved family involvement during discharge teaching (7% increase, p = 0.026), use of teach-back (11% increase, p < 0.001) and discussion of help needed (6% increase, p = 0.041). Although unscheduled healthcare utilization decreased with PODS implementation, it was not statistically significant. CONCLUSIONS: This project highlighted the system-wide adaptability and ease of implementing PODS across multiple patient groups and hospital settings. PODS demonstrated an improvement in patient-centred discharge processes linked to quality standards and health outcomes. A community of practice and high quality content may be needed for successful implementation.

SAFER Care: Improving Caregiver Comprehension of Discharge Instructions.

BACKGROUND: One in five pediatric patients suffers from adverse events related to hospital discharge. Current literature lacks evidence on effective interventions to improve caregiver comprehension (CC) of discharge instructions. We examined if a standardized framework for written and verbal discharge counseling was associated with increased CC of key discharge instructions after discharge from a general pediatric inpatient unit. METHODS: An interprofessional team created the SAFER Care framework to encourage standard, comprehensive discharge counseling. Plan-do-study-act cycles included electronic health record smartphrases, educational initiatives, data feedback, visual aids, and family outreach. Caregivers were surveyed by phone within 4 days of discharge. Our primary outcome was the proportion of caregivers correctly responding to all questions related to discharge care, comparing pre- and postintervention periods. Data were plotted on a statistical process control chart to assess the effectiveness of interventions. RESULTS: A total of 171 surveys were analyzed in the preintervention period, and 262 surveys were analyzed in the postintervention period. A total of 37% of caregivers correctly responded to all questions in the preintervention period, compared with 62% of caregivers in the postintervention period, meeting rules for special cause variation. CONCLUSIONS: Development of the SAFER Care framework and its use in written and verbal discharge counseling was associated with significantly improved CC of discharge instructions in a general pediatric inpatient unit. Further studies should be focused on expanding this to other populations, particularly limited-English-proficiency families.

Communicating deprescribing decisions made in hospital with general practitioners in the community.

BACKGROUND: Deprescribing, the supervised withdrawal of inappropriate medications, intends to manage polypharmacy, which is prevalent in older patients. AIMS: To examine general practitioner (GP) perceptions of communication processes between clinicians in hospital and GP in the community about deprescribing decisions made in hospital. METHODS: Focus groups and interviews were held with 15 GP, exploring deprescribing in hospitals, communication of deprescribing information and the format of communications. Sessions were audiotaped, transcribed and analysed using an inductive approach. RESULTS: GP stated that they should be involved in deprescribing decisions, especially for older complex patients, because of their good knowledge of their patients. Barriers to effective communication included the acute nature of hospital stays and lack of time. Facilitators included long-term relationships of GP with their patients and engaged patients. GP preferred communication of deprescribing decisions to be over the telephone while the patient was still in hospital, and with a concise, electronic discharge summary at the time of discharge. GP indicated that rationale for medication changes and recommended follow-up actions were crucial in a discharge summary to enable care post-discharge. CONCLUSIONS: GP welcome increased communication with hospital clinicians regarding deprescribing decisions made while patients are in hospital. Communication needs to be timely, transparent, succinct and accessible. Lack of time and difficulties contacting hospital clinicians challenge this process.

Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria.

RATIONALE AND OBJECTIVE: The discharge summary (DS) is one of the most important instruments to transmit information to the treating general physician (GP). The objective of this study was to analyse important components of DS, structural characteristics as well as medical and general abbreviations. METHOD: One hundred randomly selected DS from five different clinics were evaluated by five independent reviewers regarding content, structure, abbreviations and conformity to the Austrian Electronic Health Records (ELGA) using a structured case report form. Abbreviations of all 100 DS were extracted. All items were scored on a 4-point Likert-type scale ranging from "strongly agree" to "strongly disagree" (or "not relevant"). Subsequently, the results were discussed among reviewers to achieve a consensus decision. RESULTS: The mandatory fields, reason for admission and diagnosis at discharge were present in 80% and 98% of DS. The last medication was fully scored in 48% and the recommended medication in 94% of 100 DS. There were significant overall differences among clinics for nine mandatory items. In total, 750 unexplained abbreviations were found in 100 DS. CONCLUSIONS: In conclusion, DS are often lacking important items. Particularly important are a detailed medication history and recommendations for further medication that should always be listed in each DS. It is thus necessary to design and implement changes that improve the completeness of DS. An important quality improvement can be achieved by avoiding the use of ambiguous abbreviations.

The Free Fibula Flap for Lower Extremity Reconstruction.

Reconstruction of critical size bone defects in the lower extremity poses a significant risk to not only limb malfunction but also amputation. The reconstructive goal of free bone flaps is to provide vascularized bone that restores length and stability. This applies to the native limb and also in amputations when a vascularized length of bone is required to maintain level of amputation. Multiple anatomic regions of the lower extremity may be successfully reconstructed with the fibula free flap.

A prospective cross-sectional study examining the documented evaluation of patients at high risk for mild traumatic brain injury.

OBJECTIVES: Annually, the CDC reports that 2.5 million Emergency Department (ED) visits occur due to Traumatic Brain Injuries (TBI) with nearly 75% classified as mild TBI (mTBI). Generally, these injuries are thought to be under recognized. This study was done to determine the proportion of patients, who were considered high risk for an mTBI, that had documentation of an mTBI evaluation. METHODS: A prospective cross-section of patients was identified using a 3-question screen at the time of triage: did an injury occur; was the mechanism consistent with mTBI; and was there a period of altered mental status. Chart review was completed for these patients who were thought to meet a minimum threshold warranting an evaluation for mTBI. RESULTS: 38,621 patients were screened over 16 weeks, of whom 441 (1.14%) were identified as being high risk for having an mTBI and met inclusion criteria. Recommended portions of an mTBI evaluation occurred in fewer than 50% of patients. In total, 98 subjects were diagnosed with an mTBI, and 49 received mTBI discharge instructions. The odds ratio for the subgroup of patients who had documented criteria sufficient for diagnosis revealed that an isolated head injury increased a patient's odds of a documented diagnosis by 2.1 times (95%, 1.3-3.4). CONCLUSIONS: Many patients with a possible mTBI did not have significant portions of an mTBI evaluation documented, and roughly half of the patients with a documented mTBI diagnosis did not receive discharge education. Changes in clinicians' approach to mTBI must occur to ensure patients receive appropriate evaluations, management, and education.