Charge capture in the BICU: Increasing revenue by improving documentation behaviors.

Documentation by a healthcare provider is the key to capturing appropriate reimbursement for effort, expertize, and time given to patients. However, patient encounters are known to be under-coded; often describing a level of service that does not reflect the physician's labor. If there is deficient medical decision making (MDM) documentation, this will ultimately lead to a loss of revenue, as coders can only evaluate service levels from the documentation during the encounter. Physicians at the Timothy J. Harnar Regional Burn Center at Texas Tech University Health Sciences Center were experiencing below-average reimbursement for work performed in the burn center and theorized that deficiencies in documentation (particularly in the area of MDM) were the cause. They hypothesized that poor documentation by physicians was resulting in a substantial proportion of encounters being compulsorily coded at inadequate and imprecise levels of service. To improve the service levels of MDM in physician documentation at the Burn Center and consequently, increase the numbers and levels of billable encounters in the unit with an accompanying increase in revenue, two resources were created and employed with the purpose of providing increased documentation recall and thoroughness. These resources included a pocket card, designed to prevent missed details when documenting patient encounters, and a standardized EMR template that was mandated to be used by all BICU medical professionals rotating through the unit. After completion of the intervention period (July - October 2021), a comparison was made between the 4-month periods of July-October 2019 and 2021. Based on the encounters provided by residents and one fellow assigned to the BICU medical director, inpatient subsequent visit codes showed an average increase in billable encounters of 1500% amid the compared periods. Upon implementation of the intervention, subsequent visit codes 99231, 99232, and 99233 (higher-numbered codes indicating an increased level of service and accompanying reimbursement) raised by 142%, 2158%, and 2200%, respectively. An additional finding since the implementation of the pocket card and revised template, billable encounters have replaced the once-dominate global encounter, 99024 (associated with no reimbursement); realizing an increase in billable inpatient services due to complete and thorough documentation of non-global issues patients experienced throughout their hospital stays. Obtaining buy-in from physicians proved a significant challenge; consistent training and feedback allowed for an improved understanding of billing and coding processes within the BICU. The described findings indicate that a focused effort to improve documentation offers a promising method to yield potentially significant improvements in a unit's profitability.

Embedding 21st century employability into assessment and feedback practice through a student-staff partnership.

In-course assessments are an essential part of any coursework because they represent both a physical output of the skills and knowledge acquired at university, but also have the role of supporting student transitions into prospective careers. Therefore, assessments could be used as a conduit to encourage student awareness of the skills needed for the workplace and verify their attainment of these skills, particularly at foundation levels within a degree. Within a second-year Microbiology and Immunology course, students struggled to engage with standalone timetabled careers-related sessions, yet they showed enthusiasm when employability was embedded into assessments. A staff-student partnership project explored these issues, with the overall aim of understanding how to effectively embed employability skills into assessment and feedback and support students positioning themselves for the future. Through a focus group, this project investigated the reasons for low student engagement with timetabled employability sessions and used student views to develop digital initiatives and 21st-century competencies that could be applied more widely within assessment and feedback practice. These initiatives were then implemented as pre-session self-directed activities, with the objective of helping students to link course feedback with employment skills and future career planning, followed by a newly developed in-class reflective feedback session that allowed students time to consider what skills they have developed and make links with future careers. Project evaluation was conducted using a quantitative survey of the students involved.

Efficacy, Safety, and Pharmacodynamic Effects of the Bruton's Tyrosine Kinase Inhibitor Fenebrutinib (GDC-0853) in Systemic Lupus Erythematosus: Results of a Phase II, Randomized, Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: Fenebrutinib (GDC-0853) is a noncovalent, oral, and highly selective inhibitor of Bruton's tyrosine kinase (BTK). The efficacy, safety, and pharmacodynamics of fenebrutinib in systemic lupus erythematosus (SLE) were assessed in this phase II, multicenter, randomized, placebo-controlled study. METHODS: Patients who had moderately to severely active SLE while receiving background standard therapy were randomized to receive placebo, fenebrutinib 150 mg once daily, or fenebrutinib 200 mg twice daily. Glucocorticoid taper was recommended from weeks 0 to 12 and from weeks 24 to 36. The primary end point was the SLE Responder Index 4 (SRI-4) response at week 48. RESULTS: Patients (n = 260) were enrolled from 44 sites in 12 countries, with the majority from Latin America, the US, and Western Europe. The SRI-4 response rates at week 48 were 51% for fenebrutinib 150 mg once daily (P = 0.37 versus placebo), 52% for fenebrutinib 200 mg twice daily (P = 0.34 versus placebo), and 44% for placebo. British Isles Lupus Assessment Group-based Combined Lupus Assessment response rates at week 48 were 53% for fenebrutinib 150 mg once daily (P = 0.086 versus placebo), 42% for fenebrutinib 200 mg twice daily (P = 0.879 versus placebo), and 41% for placebo. Safety results were similar across all arms, although serious adverse events were more frequent with fenebrutinib 200 mg twice daily. By week 48, patients treated with fenebrutinib had reduced levels of a BTK-dependent plasmablast RNA signature, anti-double-stranded DNA autoantibodies, total IgG, and IgM, as well as increased complement C4 levels, all relative to placebo. CONCLUSION: While fenebrutinib had an acceptable safety profile, the primary end point, SRI-4 response, was not met despite evidence of strong pathway inhibition.

Inhaled JAK inhibitor GDC-0214 reduces exhaled nitric oxide in patients with mild asthma: A randomized, controlled, proof-of-activity trial.

BACKGROUND: The Janus kinase (JAK) pathway mediates the activity of many asthma-relevant cytokines, including IL-4 and IL-13. GDC-0214 is a potent, inhaled, small-molecule JAK inhibitor being developed for the treatment of asthma. OBJECTIVE: We sought to determine whether GDC-0214 reduces fractional exhaled nitric oxide (Feno), a JAK1-dependent biomarker of airway inflammation, in patients with mild asthma. METHODS: We conducted a double-blind, randomized, placebo-controlled, phase 1 proof-of-activity study in adults with mild asthma and Feno higher than 40 parts per billion (ppb). Subjects were randomized 2:1 (GDC-0214:placebo) into 4 sequential ascending-dose cohorts (1 mg once daily [QD], 4 mg QD, 15 mg QD, or 15 mg twice daily). All subjects received 4 days of blinded placebo, then 10 days of either active drug or placebo. The primary outcome was placebo-corrected percent reduction in Feno from baseline to day 14. Baseline was defined as the average Feno during the blinded placebo period. Pharmacokinetics, safety, and tolerability were also assessed. RESULTS: Thirty-six subjects (mean age, 28 years; 54% females) were enrolled. Mean Feno at baseline across all subjects was 93 ± 43 ppb. At day 14, placebo-corrected difference in Feno was -23% (95% CI, -37.3 to -9) for 15 mg QD and -42% (95% CI, -57 to -27.4) for 15 mg twice daily. Higher plasma exposure was associated with greater Feno reduction. No dose-limiting adverse events, serious adverse events, or treatment discontinuations occurred. There were no major imbalances in adverse events or laboratory findings, or evidence of systemic JAK inhibition. CONCLUSIONS: GDC-0214, an inhaled JAK inhibitor, caused dose-dependent reductions in Feno in mild asthma and was well tolerated without evidence of systemic toxicity.

Does Noise From Shipping and Boat Traffic Affect Predator Vigilance in the European Common Hermit Crab?

The effect of noise on predator vigilance in Pagurus bernhardus was explored in this study. Latency of the first response, emergence time, and response type were measured from hermit crabs during continuous and variable vessel noise and two controls. The mean (±SE) response latency was longer for the noise treatments (continuous, 18.19 ± 2.78 s; variable, 11.39 ± 1.48 s) than for the controls (ambient, 7.21 ± 0.82 s; silent, 6.66 ± 0.95 s). Response type and emergence time were not significantly affected but were more variable during the noise treatments than during the controls. Noisy conditions may increase predation risk, suggesting potential fitness consequences for invertebrates.

Effects of body condition on buoyancy in endangered North Atlantic right whales.

Buoyancy is an important consideration for diving marine animals, resulting in specific ecologically relevant adaptations. Marine mammals use blubber as an energy reserve, but because this tissue is also positively buoyant, nutritional demands have the potential to cause considerable variation in buoyancy. North Atlantic right whales Eubalaena glacialis are known to be positively buoyant as a result of their blubber, and the thickness of this layer varies considerably, but the effect of this variation on buoyancy has not been explored. This study compared the duration and rate of ascending and descending glides, recorded with an archival tag, with blubber thickness, measured with an ultrasound device, in free-swimming right whales. Ascending whales with thicker blubber had shorter portions of active propulsion and longer passive glides than whales with thinner blubber, suggesting that blubber thickness influences buoyancy because the buoyant force is acting in the same direction as the animal's movement during this phase. Whales with thinner layers also used similar body angles and velocities when traveling to and from depth, while those with thicker layers used shallower ascent angles but achieved higher ascent velocities. Such alterations in body angle may help to reduce the cost of transport when swimming against the force of buoyancy in a state of augmented positive buoyancy, which represents a dynamic response to reduce the energetic consequences of physiological changes. These results have considerable implications for any diving marine animal during periods of nutritional stress, such as during seasonal migrations and annual variations in prey availability.

Automatic identification of individual killer whales.

Following the successful use of HMM and GMM models for classification of a set of 75 calls of northern resident killer whales into call types [Brown, J. C., and Smaragdis, P., J. Acoust. Soc. Am. 125, 221-224 (2009)], the use of these same methods has been explored for the identification of vocalizations from the same call type N2 of four individual killer whales. With an average of 20 vocalizations from each of the individuals the pairwise comparisons have an extremely high success rate of 80 to 100% and the identifications within the entire group yield around 78%.