Improving Allergy Documentation: A Retrospective Electronic Health Record System-Wide Patient Safety Initiative.

OBJECTIVES: Documentation of allergies in a coded, non-free-text format in the electronic health record (EHR) triggers clinical decision support to prevent adverse events. Health system-wide patient safety initiatives to improve EHR allergy documentation by specifically decreasing free-text allergy entries have not been reported. The goal of this initiative was to systematically reduce free-text allergen entries in the EHR allergy module. METHODS: We assessed free-text allergy entries in a commercial EHR used at a multihospital integrated health care system in the greater Boston area. Using both manual and automated methods, a multidisciplinary consensus group prioritized high-risk and frequently used free-text allergens for conversion to coded entries, added new allergen entries, and deleted duplicate allergen entries. Environmental allergies were moved to the patient problem list. RESULTS: We identified 242,330 free-text entries, which included a variety of environmental allergies (42%), food allergies (18%), contrast media allergies (13%), "no known allergy" (12%), drug allergies (2%), and "no contrast allergy" (2%). Most free-text entries were entered by medical assistants in ambulatory settings (34%) and registered nurses in perioperative settings (20%). We remediated a total of 52,206 free-text entries with automated methods and 79,578 free-text entries with manual methods. CONCLUSIONS: Through this multidisciplinary intervention, we identified and remediated 131,784 free-text entries in our EHR to improve clinical decision support and patient safety. Additional strategies are required to completely eliminate free-text allergy entry, and establish systematic, consistent, and safe guidelines for documenting allergies.

Complete tracheal transection following blunt trauma in a pediatric patient.

Tracheal injury from blunt trauma is a rare, life-threatening condition in pediatric patients. Rapid assessment and identification of the severity of the injury will increase the likelihood of survival. Subcutaneous emphysema, pneumomediastinum, and persistent pneumothoraces after chest tube placement should be considered in the index of suspicion for tracheal injury. Treatment for a complete tracheal transection includes rapid airway securement via endotracheal tube or tracheostomy and careful surgical repair in the operating room in conjunction with bronchoscopy.

Nurses' views and current practice of trauma-informed pediatric nursing care.

Grounded in research on posttraumatic stress etiology, "trauma-informed pediatric care" integrates understanding of posttraumatic stress, and specific practices to reduce posttraumatic stress, into clinical care of ill or injured children. Across five level I or II pediatric trauma centers, 232 nurses completed a survey of knowledge, opinions, self-rated competence, and current practice with regard to trauma-informed nursing care. Participants were knowledgeable and generally held favorable opinions about trauma-informed care. The majority considered themselves moderately competent in a range of relevant skills; their recent practice showed most variability with regard to teaching patients and parents how to cope with upsetting experiences.

Soccer injuries in children requiring trauma center admission.

BACKGROUND: Soccer continues to gain popularity among youth athletes, and increased numbers of children playing soccer can be expected to result in increased injuries. OBJECTIVE: We reviewed children with soccer injuries severe enough to require trauma activation at our Level I trauma center to determine injury patterns and outcome. Our goal is to raise awareness of the potential for injury in youth soccer. METHODS: A retrospective review was performed using the trauma registry and electronic medical records at a Level I trauma center to identify children (< 18 years old) treated for soccer injury from 1999-2009. Data reviewed include age, gender, mechanism, injury, procedures, and outcome. RESULTS: Eighty-one children treated for soccer injury were identified; 38 (47%) were male. Of these, 20 had injury severe enough to require trauma team activation and 61 had minor injury. Mean age was 14 years old (range 5-17 years, SD 2.3). Lower extremity was the most common site of injury (57%), followed by upper extremity (17%), head (16%), and torso (10%). Mechanisms were: kicked or kneed in 27 patients (33%), collision with another player in 25 (31%), fall in 18 (22%), struck by ball in 10 (12%), and unknown in 1 (1%). Procedures included reduction of fractures, splenectomy, abdominal abscess drainage, and surgical feeding access. Long hospitalizations were recorded in some cases. There were no deaths. CONCLUSION: Although less common, injury requiring prolonged hospital admission and invasive operative procedures exist in the expanding world of youth soccer. With increasing participation in the sport, we anticipate greater numbers of these child athletes presenting with serious injury.

Embolization for pediatric blunt splenic injury is an alternative to splenectomy when observation fails.

BACKGROUND: Management of splenic injury has shifted from operative to nonoperative management in both children and adults with reports of high success rates. Benefits of splenic conservation include decreased hospital stay, blood transfusion, and mortality, as well as avoidance of infectious complications. Angiography with embolization is an innovative adjunct to nonoperative management and has resulted in increased splenic salvage in adults; however, data in the pediatric population are scant. METHODS: A retrospective comparative study of a single-hospital trauma registry reviewed from 1999 to 2009. Patients 18 years and younger admitted with injury to the spleen were included. Children with penetrating injury were excluded. Children were divided into three categories by initial treatment: observation, embolization, or splenectomy. Data recorded include age, radiographic grade of injury, and Injury Severity Score (ISS). Groups were analyzed for success of initial treatment, requirement for transfusion of packed red blood cells, splenic salvage, and mortality. RESULTS: Registry review identified 259 children with blunt splenic injury. Initial treatment was observation in 227, embolization in 15, and splenectomy in 17. In the observation group, 9 (4%) of 227 children failed initial treatment; 8 of these underwent embolization, while 1 unerwent splenectomy. In the embolization group, 1 (7%) of 15 failed initial treatment and underwent splenectomy. Blood transfusion was required by 38 (17%) of 227 in the observation group, 6 (40%) of 15 (p = 0.02) in the embolization group, and 15 (88%) of 17 (p < 0.01) in the splenectomy group. Overall splenic salvage rate was 237 (92%) of 259. Three children died in the observation group, and four children died in the splenectomy group. There was no death in the embolization group. CONCLUSION: Splenic artery embolization for blunt trauma in children is associated with a higher blood transfusion rate compared with observation but offers a safe, intermediate alternative to splenectomy when observation fails. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Penetrating neck injuries in children.

Penetrating neck injuries are uncommon in children, and when they do occur, they can be a challenge to manage. Injuries can be cardiovascular, aerodigestive, and neurovascular. In the past, injuries were explored surgically to evaluate the extent of the injury; studies are now showing that observation and less invasive studies have a positive outcome for the patient. Immediate surgical intervention remains mandatory for the clinically unstable patient, whereas stable patients have studies done that pertain to their signs and symptoms, thus having a conservative nonoperative approach to care.

Weight-based pediatric prescribing in ambulatory setting.

Building on a foundation of a dose-based ambulatory prescribing system, an advanced weight-based pediatric prescribing module was successfully implemented. It provides a complete solution for calculating a dispensable dose and choosing optimal drug strength and form.

Creating an enterprise-wide allergy repository at Partners HealthCare System.

A significant fraction of medication errors and preventable adverse drug events are related to drug-allergy interactions (DAIs). Computerized prescribing can help prevent DAIs, but an accurate record of the patient's allergies is required. At Partners HealthCare System in Boston, the patient's allergy list is distributed across several applications including computer physician order entry (CPOE), the outpatient medical record, pharmacy applications, and nurse charting applications. Currently, each application has access only to its own allergy data. This paper presents details of a project designed to integrate the various allergy repositories at Partners. We present data documenting that patients have allergy data stored in multiple repositories. We give detail about issues we are encountering such as which applications should participate in the repository, whether "NKA" or "NKDA" should be used to document known absence of allergies, and which personnel should be allowed to enter allergies. The issues described in this paper may well be faced by other initiatives intended to create comprehensive allergy repositories.