Development, Evaluation and Implementation of Chief Complaint Groupings to Activate Data Collection: A Multi-Center Study of Clinical Decision Support for Children with Head Trauma.

BACKGROUND: Overuse of cranial computed tomography scans in children with blunt head trauma unnecessarily exposes them to radiation. The Pediatric Emergency Care Applied Research Network (PECARN) blunt head trauma prediction rules identify children who do not require a computed tomography scan. Electronic health record (EHR) based clinical decision support (CDS) may effectively implement these rules but must only be provided for appropriate patients in order to minimize excessive alerts. OBJECTIVES: To develop, implement and evaluate site-specific groupings of chief complaints (CC) that accurately identify children with head trauma, in order to activate data collection in an EHR. METHODS: As part of a 13 site clinical trial comparing cranial computed tomography use before and after implementation of CDS, four PECARN sites centrally developed and locally implemented CC groupings to trigger a clinical trial alert (CTA) to facilitate the completion of an emergency department head trauma data collection template. We tested and chose CC groupings to attain high sensitivity while maintaining at least moderate specificity. RESULTS: Due to variability in CCs available, identical groupings across sites were not possible. We noted substantial variability in the sensitivity and specificity of seemingly similar CC groupings between sites. The implemented CC groupings had sensitivities greater than 90% with specificities between 75-89%. During the trial, formal testing and provider feedback led to tailoring of the CC groupings at some sites. CONCLUSIONS: CC groupings can be successfully developed and implemented across multiple sites to accurately identify patients who should have a CTA triggered to facilitate EHR data collection. However, CC groupings will necessarily vary in order to attain high sensitivity and moderate-to-high specificity. In future trials, the balance between sensitivity and specificity should be considered based on the nature of the clinical condition, including prevalence and morbidity, in addition to the goals of the intervention being considered.

Concurrent increases in the storage and release of mucin-like molecules by rat airway epithelial cells in response to bacterial endotoxin.

Mucus hypersecretion is a prominent response of the airways to bacterial infections. Recent findings showed that bacterial endotoxin, a lipopolysaccharide complex released from the bacterial cell wall, was able to induce at least one component of the hypersecretory response, i.e., an increase in the amount of stored epithelial mucosubstances (1, 2). The goal of the present study was to determine whether endotoxin also was capable of increasing mucosubstance release from cells. Based on evidence that human mucin antibodies A10G5 and B6E8 cross-reacted with rat mucin-like molecules, we used the antibodies in enzyme-linked immunosorbent assays (ELISA) to compare mucin concentrations in bronchoalveolar lavage (BAL) fluid from endotoxin-treated and control rats. Results showed that endotoxin treatment increased the amount of released mucin over that in controls 1.5-fold at 96 h and 2.5-fold at 168 h after instillation. Thus, these studies have defined the previously detected mucosubstances as mucin-like molecules and showed that endotoxin increases their release from, as well as their storage in, rat airway epithelium. Concurrent increases in storage and release suggest that endotoxin also stimulates mucin synthesis and/or stability.