The role of copy and paste function in orthopedic trauma progress notes.

INTRODUCTION: The electronic medical record (EMR) is standard in institutions. While there is not concern for legibility of notes and access to charts, there is an ease of copy and paste for daily notes. This may not lead to accurate portrayal of patient's status. Our purpose was to evaluate the use of copy and paste functions in daily notes of patients with injuries at high risk for complications. METHODS: IRB approval was obtained for a retrospective review. Inclusion criteria included patients aged 18 and older treated at our Level 1 Trauma Center after implementation of Epic Systems Corporation, Verona, WI, USA. Those who were surgically treated for bicondylar tibial plateau fracture, or open tibial shaft fracture type I or II were included. Manual comparison of daily progress to the previous day's note was carried out. Comparisons were made by evaluating the subjective, objective, and plan portions of the notes, coded nominally using 1 for a change 0 for remaining the same. RESULTS: 38 patients' charts were reviewed during a 10-month (July 2012-April 2013) period, and the average length of stay was 12 days (range: 2-35). A total of 418 notes were compared. The overall average of copied data was 85% daily. In the subjective portion, 85-97% of the data was copied on a daily basis and 71-92% of the data was copied within the objective portion of the notes. There were 15 medical complications necessitating intervention. Of these medical complications, the note the day after the complication reflected the event in 10 out of 15, or 70%, of the complications. Thus 5, or 30%, of the patients did not have notes reflecting the complication (p < 0.05). There were 7 complications related to the injuries: 4 cases of compartment syndrome, 1 case of foot drop, representing a change in neurologic status, an amputation, and a wound infection treated with antibiotics. Four of the 7 complications (57%) were not reflected in the notes the following day after the complication (p < 0.05). There were 54 planned returns to the operating room for procedures, yet 30 of the 54 (56%) notes regarding planned surgical procedures notes did not accurately report the plan for surgery (p < 0.05). There were 4 patients with unplanned trips to the operating room and 3 of the notes (75%) did not reflect this (p < 0.05). Twelve patients (32%) did not have notes accurately reflecting discharge plans and/or destination (p < 0.05). DISCUSSION/CONCLUSION: Our results demonstrated widespread use of copy and paste function. We encourage evaluation of the charts by comparing notes to check and a plan to minimize this practice. There needs to be consistent note writing guidelines and appropriate templates used. This will decrease the inaccuracies in the chart and provide a clear picture of the patient, their injuries, and current status.

Investigation of cell phones as a potential source of bacterial contamination in the operating room.

BACKGROUND: Cell phone use has become common in areas of the hospital, including the operating room. The purpose of this study was to document the frequency of bacterial contamination on the cell phones of orthopaedic surgeons in the operating room and to determine whether a standardized disinfecting protocol decreased the rate of bacterial contamination and the amount of organic material. METHODS: Orthopaedic attending and resident cell phones were swabbed on the front and back in the operating room with adenosine triphosphate bioluminescence to quantify organic material contamination and culture swabs to evaluate bacterial contamination. Adenosine triphosphate was quantified with use of relative light units. One photon of light was emitted for each molecule of adenosine triphosphate. Thresholds of 250 and 500 relative light units were used. The phones were cleaned with a cleaning wipe and were retested. One week later, a final set of studies was obtained. Fifty-three participants were enrolled in this study. Pathogenic bacteria were defined as those commonly causing surgical site infections. RESULTS: Of fifty-three cell phones, 83% (forty-four cell phones) had pathogenic bacteria at initial testing, 8% (four cell phones) had pathogenic bacteria after disinfection, and 75% (forty cell phones) had pathogenic bacteria one week later. The mean result (and standard deviation) at initial testing was 3488 ± 2998 relative light units, which reduced after disinfection to 200 ± 123 relative light units, indicating a cleaned surface, but increased one week later to 1825 ± 1699 relative light units, indicating a poorly cleaned surface. CONCLUSIONS: The cell phones of orthopaedic surgeons had a high rate of pathogenic bacteria and organic material contamination. Both were decreased after a single disinfecting process. However, recontamination occurred. It seems prudent to routinely disinfect them or avoid their use in the operating room. CLINICAL RELEVANCE: The current study investigates orthopaedic surgeons' cell phones as a potential source of nosocomial infection in the operating room. On the basis of the high percentage of cell phone contamination found, we would recommend periodic cell phone cleaning with either the wipes used in our study or similar ones. In addition, given that there was a high contamination rate one week after disinfection, we would recommend considering cell phone cleaning more frequently than once a week.

Predicting acute kidney injury among burn patients in the 21st century: a classification and regression tree analysis.

Historically, acute kidney injury (AKI) carried a deadly prognosis in the burn population. The aim of this study is to provide a modern description of AKI in the burn population and to develop a prediction tool for identifying patients at risk for late AKI. A large multi-institutional database, the Glue Grant's Trauma-Related Database, was used to characterize AKI in a cohort of critically ill burn patients. The authors defined AKI according to the RIFLE criteria and categorized AKI as early, late, or progressive. They then used Classification and Regression Tree (CART) analysis to create a decision tree with data obtained from the first 48 hours of admission to predict which subset of patients would develop late AKI. The accuracy of this decision tree was tested in a separate, single-institution cohort of burn patients who met the same criteria for entry into the Glue Grant study. Of the 220 total patients analyzed from the Glue Grant cohort, 49 (22.2%) developed early AKI, 39 (17.7%) developed late AKI, and 16 (7.2%) developed progressive AKI. The group with progressive AKI was statistically older, with more comorbidities and with the worst survival when compared with those with early or late AKI. Using CART analysis, a decision tree was developed with an overall accuracy of 80% for the development of late AKI for the Glue Grant dataset. The authors then tested this decision tree on a smaller dataset from our own institution to validate this tool and found it to be 73% accurate. AKI is common in severe burns with notable differences between early, late, and progressive AKI. In addition, CART analysis provided a predictive model for early identification of patients at highest risk for developing late AKI with proven clinical accuracy.