Optimizing Neurology Inpatient Documentation: A Pilot Study of a Novel Discharge Documentation EHR Tool.

Background and Purpose: Clinical documentation of patient acuity is a major determinant of payer reimbursement. This project aimed to improve case mix index (CMI) by incorporating a novel electronic health record (EHR) discharge documentation tool into the inpatient general neurology service at the University of California, Los Angeles (UCLA) Medical Center. Methods: We used data from Vizient AMC Hospital: Risk Model Summary for Clinical Data Base (CBD) 2017 to create a discharge diagnosis documentation tool consisting of dropdown menus to better capture relevant secondary diagnoses and comorbidities. After implementation of this tool, we compared pre- (July 2017-June 2019) and post-intervention (July 2019-June 2021) time periods on mean expected length of stay (LOS) and mean CMI with two sample T-tests and the percentage of encounters classified as having Major Complications/Comorbidities (MCC), with Complication/Comorbidity (CC), and without CC/MCC with tests of proportions. Results: Mean CMI increased significantly from 1.2 pre-intervention to 1.4 post-intervention implementation (P < .01). There was a pattern of increased MCC percentages for "Bacterial infections," "Other Disorders of Nervous System", "Multiple Sclerosis," and "Nervous System Neoplasms" diagnosis related groups post-intervention. Conclusions: This pilot study describes the creation of an innovative EHR discharge diagnosis documentation tool in collaboration with neurology healthcare providers, the clinical documentation improvement team, and neuro-informaticists. This novel discharge diagnosis documentation tool demonstrates promise in increasing CMI, shifting diagnosis related groups to a greater proportion of those with MCC, and improving the quality of clinical documentation.

Using a Clinical Triggers System to Improve Early Recognition of Clinical Changes.

PURPOSE: A medical-surgical telemetry unit implemented a clinical triggers system for early recognition of clinical deterioration and bedside management between nurses and providers. The goal was to decrease cardiopulmonary arrest events. DESCRIPTION OF THE PROJECT: A clinical triggers system was developed to help nurses to identify clinical markers early and advocate for prompt bedside assessment and interventions. When clinical triggers were identified, the nurse notified the provider, who performed a bedside assessment within 15 minutes. If the provider did not respond promptly, the rapid response team was activated. OUTCOMES: Before intervention, the unit experienced 14 cardiopulmonary arrest events (rate of 1.37 per 1000 patient days). Incidences decreased annually to 5, 4, and 3 events (rates of 0.49, 0.39, and 0.3 per 1000 patient days) during the 3-year implementation period. CONCLUSIONS: The clinical triggers system was successful in achieving the project objective of decreasing unit cardiopulmonary arrest events through early recognition and response to patient deterioration during the implementation period. The clinical nurse specialist helped nurses to use the clinical triggers system to detect and respond to clinical changes. Nurses were empowered to address concerns and promote patient safety.

Evaluation of antibiotic escalation in response to nurse-driven inpatient sepsis screen.

Objective: To determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution. Design: Retrospective cohort study. Setting: Two affiliated academic medical centers in Los Angeles, California. Patients: Hospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards. Methods: We described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation. Results: Of the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91-4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28-3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34-0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22-0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria. Conclusions: Inpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.

Adherence to the SEP-1 Sepsis Bundle in Hospital-Onset v. Community-Onset Sepsis: a Multicenter Retrospective Cohort Study.

BACKGROUND: Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis. OBJECTIVE: To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis. DESIGN: Retrospective cohort study using multivariable analysis of clinical data. PARTICIPANTS: A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection. SETTING: Four university hospitals in California between 2014 and 2016. MAIN OUTCOMES AND MEASURES: The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen. KEY RESULTS: Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p < 0.001). With the exception of vasopressors (RR 1.11, p = 0.002), each component of SEP-1 evaluated-blood cultures (RR 0.76, p < 0.001), serum lactate (RR 0.51, p < 0001), broad-spectrum antibiotics (RR 0.62, p < 0.001), intravenous fluids (0.47, p < 0.001), and follow-up lactate (RR 0.71, p < 0.001)-was less likely to be performed within the recommended time frame in hospital-onset sepsis. Within the hospital, cases of hospital-onset sepsis arising on the ward were less likely to receive SEP-1-adherent care than were cases arising in the intensive care unit (RR 0.68, p = 0.004). CONCLUSIONS: Inpatients with hospital-onset sepsis receive different management than individuals with community-onset sepsis. It remains to be determined whether system-level factors, provider-level factors, or factors related to measurement explain the observed variation in care or whether variation in care affects outcomes.

Global payment contract attitudes and comprehension among internal medicine physicians.

OBJECTIVES: Global payment contracts (GPCs) are increasingly common agreements between insurance payers and healthcare providers that incorporate aspects of risk adjustment, capitation, and pay-for-performance. Physicians are often viewed as potential barriers to implementation of organizational change, but little is known about internist opinion on GPC involvement or specific internist attributes that might predict GPC support. We aimed to investigate internist and internal medicine subspecialist support of GPC involvement, and to identify associations among physician attributes, GPC knowledge, and GPC support. STUDY DESIGN: Cross-sectional. METHODS: General medicine and internal medicine subspecialist physicians within the Beth Israel Deaconess Department of Medicine in Boston, Massachusetts, were surveyed 4 years after care organization entry into a GPC. Measurements collected included reported support for GPC involvement, reason for support, and demonstrated comprehension of key GPC details. RESULTS: Of the 281 respondents (49% response rate), 85% reported supporting involvement in a GPC. In a multivariate ordinal logistic regression model, exposure to prior information about GPCs, demonstrated comprehension of key GPC details, longer time since completion of residency, and lower clinical time commitment were all independently associated with higher levels of GPC involvement support. CONCLUSIONS: Four years since first engaging in a global payment contract, a majority of internal medicine physician respondents support this decision. Understanding predictors of physician support for GPC involvement within our care organization may help other health systems to approach organizational change. Health system leaders debating GPC involvement should consider engaging physicians via educational interventions geared toward improving GPC support.