Are we failing to document adequate smoking histories? A brief review 1999-2009.

BACKGROUND: Documenting a detailed smoking history is of obvious importance. Failure to adequately document the smoking history may result in the misdiagnosis and management of asthma, and may be associated with a deficiency of care in patients with cardiovascular disease and several other common diseases. SCOPE: The purpose of this article is to review the evidence over the past decade that demonstrates inadequate documentation of smoking history. A literature search of English language journals from 1999 to 2009 was completed using several databases, including PubMed, MEDLINE, EMBASE, and SCOPUS. FINDINGS: Fourteen studies demonstrated inadequate documentation of smoking histories by primary care clinicians, specialists, residents, and medical students. Failure to document smoking histories was observed in patients with conditions such as heart failure, coronary artery disease, and asthma. Electronic decision support systems and simple medical record reminders were effective in improving the documentation of smoking histories. CONCLUSIONS: Failure to adequately document the smoking history appears to be common. Strategies such as electronic decision support systems are needed to correct this problem in order for patients to receive optimal therapy for their appropriate diagnoses.

Inadequate documentation of asthma management in hospitalized adult patients.

Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two cardiovascular diseases. This study was designed to evaluate the documentation of asthma management in the MR to determine if it is consistent with the NIH asthma guidelines. We performed a retrospective chart review of patients (ages 18-49) admitted to the hospital with an ICD-9 code for a primary diagnosis of asthma between January 2004 and May 2007. Patients admitted with a hospitalization for >24 hours and had <10 pack per year smoking history were included. We assessed medication regimens, documentation of asthma education, asthma action plans, referrals, and exacerbating factors. There were 233 admissions for 144 unique patients analyzed. At discharge, 85% of patients lacked documentation of asthma education, 97% lacked documentation of a written asthma action plan being given, and 79% did not have referral to an asthma specialist. Respiratory infection was the most common factor associated with admission; 58% of admissions were lacking documentation of the exacerbating factor. Only 47% of patients were receiving inhaled corticosteroids (ICS) prior to admission; 25% of patients did not have ICS prescribed for maintenance therapy upon discharge. Documentation of asthma management, specifically asthma education in the MR, is insufficient and may reflect a deficiency in care. Additionally, an inadequate number of patients were receiving ICS for maintenance therapy. Based on these findings, mechanisms are needed to ensure appropriate documentation and optimal care.

Evaluation of glycemic control following discontinuation of an intensive insulin protocol.

BACKGROUND: Intensive insulin protocols (IIPs) have been demonstrated to reduce morbidity and mortality in critically ill patients. Currently, there are no published studies evaluating glycemic control after discontinuation of an IIP. OBJECTIVE: The purpose of this study was to compare blood glucose (BG) control during an IIP and for 5 days following its discontinuation (follow-up period). METHODS: The study was a retrospective review of intensive care unit patients who received an IIP for >or=24 hours. Data were collected during the last 12 hours of the IIP and subsequent follow-up period. RESULTS: For all 65 included patients, the mean +/- standard deviation for BG on the IIP was 123 +/- 26 mg/dL versus 168 +/- 50 mg/dL following discontinuation of the IIP (P < 0.001). The median (interquartile range) insulin that was administered decreased from 40 (22-65) units on the IIP to 8 (0-18) units after the IIP was stopped (P < 0.001). The mean daily BG during the follow-up period was significantly higher than that during the IIP (P < 0.001). Additionally, an insulin requirement of >20 units during the last 12 hours of the IIP was identified as a risk factor for poor glycemic control during the follow-up period (odds ratio: 4.62; 95% confidence interval: 1.17-18.17). CONCLUSIONS: This study demonstrates a significant increase in BG following discontinuation of an IIP. Higher insulin requirements during the last 12 hours of an IIP were identified as an independent risk factor for poor glycemic control following the IIP. A standardized insulin transition protocol may help better control BG after discontinuation of an IIP.

Blood pressure management in acute hypertensive emergency.

PURPOSE: The frequency with which patients coming to an emergency room with hypertensive emergency received excessive or inadequate blood-pressure reduction was studied. METHODS: A retrospective chart review was conducted for all patients who were treated for hypertensive emergency at a 696-bed university teaching hospital between November 2003 and April 2004. Patients who received a continuous i.v. infusion of an antihypertensive agent for >30 minutes in the emergency department or the intensive care unit were included in the study. The primary outcomes measured were number of patients treated appropriately, number of patients treated excessively (reduction in mean arterial pressure [MAP] beyond 25% at the end of the two-hour acute-phase treatment window), and number of treatment failures within the two-hour window. RESULTS: A total of 427 patients with hypertensive emergency were identified, of whom 47 met the study criteria. Fifteen patients (32%) were appropriately treated, 27 (57%) were excessively treated, and 5 (11%) had treatment failures during the two-hour acute-phase treatment period. Only 6 patients (13%) had been appropriately treated at six hours. Patients who were given nicardipine had a greater risk of an excessive MAP reduction at two hours than all other patients. One or more treatment-related adverse events occurred in 44 patients (94%). CONCLUSION: Excessive reduction of MAP was common among patients who came to an emergency department with hypertensive emergency.