Evaluation of discharge instructions among hospitalized Lebanese patients

BACKGROUND: Hospital readmissions are considered as the primary indicator of insufficient quality of care and are responsible of increasing annual medical costs by billions of dollars. Different factors tend to reduce readmissions, particularly instructions at discharge. OBJECTIVES: Our study objective was to evaluate discharge instructions given to hospitalized Lebanese patients and associated factors. METHODS: Two hundred patients, aged between 21 and 79 years and admitted to the emergency department, were recruited from a Lebanese university hospital. Discharge instructions were evaluated by a face-to-face interview to fill a questionnaire with the patients immediately after their final contact with the physician or nurse in charge. We mainly focused on medications instructions and created two scores related to "instructions given" and "instructions appropriate" to later conduct bivariate analysis. RESULTS: We found that discharge instructions were not completely given to all our study population. The degree of appropriateness fluctuated between 25% and 100%. The instructor in charge of giving discharge instructions had its significant influence on medication instructions given (p = 0.014). In addition, the instructor and his experience influenced the degree of "appropriate instructions". In fact, our study showed that despite being capable of giving good medication advice, nurses' instructions were significantly less effective in comparison with physicians, fellows and residents. However, nurses gave 52% of the instructions, which questions the quality of those instructions. CONCLUSIONS: In conclusion, our observational study showed that in a Lebanese university hospital, patients' understanding of discharge instructions is poor. Careful attention should be drawn to other hospitals as well and interventions should be considered to improve instructions quality and limit later complications and readmissions. The intervention of clinical pharmacists and their medication-related advice might be crucial in order to improve instructions' quality

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CDA-Compliant Section Annotation of German-Language Discharge Summaries: Guideline Development, Annotation Campaign, Section Classification.

We present the outcome of an annotation effort targeting the content-sensitive segmentation of German clinical reports into sections. We recruited an annotation team of up to eight medical students to annotate a clinical text corpus on a sentence-by-sentence basis in four pre-annotation iterations and one final main annotation step. The annotation scheme we came up with adheres to categories developed for clinical documents in the HL7-CDA (Clinical Document Architecture) standard for section headings. Once the scheme became stable, we ran the main annotation campaign on the complete set of roughly 1,000 clinical documents. Due to its reliance on the CDA standard, the annotation scheme allows the integration of legacy and newly produced clinical documents within a common pipeline. We then made direct use of the annotations by training a baseline classifier to automatically identify sections in clinical reports.

Integración del proceso enfermero en la historia clínica electrónica de un hospital universitario / Integration of the nursing process in the electronic health record in an university hospital

Objetivo. Describir el proceso de implantación del Plan de Cuidados Individualizado Enfermero en la Historia Clínica Electrónica y su impacto en el Hospital Universitario Fundación Alcorcón. Metodología. Grupos de trabajo de enfermeras asistenciales que analizaron inicialmente las actividades enfermeras que realizaban habitualmente para crear el catálogo de diagnósticos, resultados e intervenciones. Se creó un grupo de referentes que depuró el catálogo para hacerlo manejable. Se diseñaron un plan de formación, los formularios de valoración enfermera y el Informe de Cuidados Enfermeros al alta. Resultados. En febrero de 2016 se implementó la nueva metodología en las unidades de hospitalización de adultos. Al 74,86-88,18% de los pacientes se les realizó un plan de cuidados con la nueva metodología. Entre un 69,41 y un 76,25% de los pacientes son dados de alta con un Informe de Cuidados Enfermeros conforme a la normativa. Se observó un aumento del 24,13% de los pacientes con Informe de Cuidados Enfermeros tras la implantación (p=0,000; RR 1,46; IC 95% 1,36-1,56). Se ha formado a un total de 116 enfermeras. Conclusiones. En las condiciones del estudio, la utilización de taxonomías enfermeras ha generado capacidad de reflexión y ha permitido emitir juicios enfermeros, aportar calidad de cuidados y aplicar intervenciones con unos resultados planificados. La taxonomía enfermera y el plan de cuidados en la historia clínica electrónica han permitido aumentar la comunicación interprofesional para mejorar la continuidad asistencial, a través de la mejora del Informe de Cuidados Enfermeros (AU)

Aim. To describe the process of implementation of Individualized Care Plan in the Electronic Health Record and its impact on the University Hospital Alcorcón Foundation. Methodology. Working groups of staff nurses who analyzed activities usually performed to create a catalog of diagnoses, outcomes and interventions. A group of referents that refined the catalog to make it manageable was created. A training plan, nursing assessment forms and the Nursing Discharge Report were designed. Results. In February 2016 the new methodology was implemented in inpatient units of adults. Between 74.86 and 88.18% of the patients underwent a care plan with the new methodology. Between 69.41 and 76.25% of patients are discharged with a Nursing Discharge Report accordance with regulations. An increase of 24.1% of patients with Nursing Discharge Report after implantation is observed (P=.000; RR: 1.46; 95% CI 1.36-1.56). A total of 116 nurses has been trained. Conclusions. In the study conditions, the use of nursing taxonomies has generated thinking skills and allowed nurses to issue judgments, ensure quality of care, and implementing interventions with a planned results. The nursing taxonomy and care plan in the Electronic Health Record have increased interprofessional communication to improve continuity of care through improved Nursing Discharge Report (AU)

Rationale for Quantification in Nursing Services Using the International Council of Nurses Nurse-Patient Summary.

This review provides evidence that new data from nurses meets criteria that explains variation in hospital charges, length of hospital stay and end results of hospital care compared with ICD data; that nurses' data can be used to evaluate assignments of nurses to patients; that new data properly distinguishes patients' human needs within ICD categories. These new data are derived from the professional literature indexed and synthesized by Henderson. It is proposed to adopt the ICN-NPSum to standardize quantification in nursing services.

Are we talking about the same patient?

The objective of this study is to determine the degree of similarities between the clinical terms used by physicians and nurses in their documentation.

[The information about discharge medication: what do general practitioners need?]. / Die Informationen zur Arzneimitteltherapie im Arztbrief: Was erwarten Hausärzte?

BACKGROUND: The information about the patient's discharge medication (DM) in the discharge letter guarantees the subsequent pharmacotherapy at the interface between tertiary to primary care. International data however shows that general practitioners (GPs) receive discharge letters with a delay and relevant information about DM is lacking. The aim of this study was to assess the point of view of German GPs concerning the information about DM, since no recent data about this topic is available. METHODS AND PARTICIPANTS: In a postal survey 516 GPs in the city of Berlin were contacted and asked about the transit of discharge letters and the information about DM. Results | 117 GPs answered the questionnaire (23 %). Most frequently, the patient himself handed over the information about DM to the GP on the day of his first visit in the practice after discharge. However, more than two third of GPs wished to receive the information before the patient's first consultation (73 %). Therefore, the majority preferred the electronic communication via fax (46 %) or email (9 %). Almost half of the GPs stated that discharge letters were lacking information about changes in medication and reasons for these changes. At the same time, nearly all GPs thought that these informational aspects were important. DISCUSSION: GPs wish an early and electronic transit of the DM with information concerning changes in medication and reasons. If these wishes were considered, a continuous and thus safer pharmacotherapy at the interface could be guaranteed.

Design, development and first validation of a transcoding system from ICD-9-CM to ICD-10 in the IT.DRG Italian project.

In Italy, ICD-9-CM is currently used for coding health conditions at hospital discharge, but ICD-10 is being introduced thanks to the IT-DRG Project. In this project, one needed component is a set of transcoding rules and associated tools for easing coders work in the transition. The present paper illustrates design and development of those transcoding rules, and their preliminary testing on a subset of Italian hospital discharge data.

Enrich classifications in psychiatry with textual data: an ontology for psychiatry including social concepts.

We propose a modular approach to develop an ontology of psychiatry, ONTOPSYCHIA, based on Patient Discharges Summaries (PDS) and divided into three modules (i.e. social, mental disorders and treatments). We decided to take into account the social aspects of the patient life described in PDS to consider information such as family history, social environment or education.

Patient-centered handovers between hospital and primary health care: an assessment of medical records.

BACKGROUND: Handovers between hospital and primary healthcare possess a risk for patient care. It has been suggested that the exchange of a comprehensive medical record containing both medical and patient-centered aspects of information can support high quality handovers. OBJECTIVE: The objective of this study was to explore patient handovers between primary and secondary care by assessing the levels of patient-centeredness of medical records used for communication between care settings and by assessing continuity of patient care. METHODS: Quantitative content analysis was used to analyze the 76 medical records of 22 Swedish patients with chronic diseases and/or polypharmacy. RESULTS: The levels of patient-centeredness documented in handover records were assessed as poor, especially in regards to informing patients and achieving a shared understanding/agreement about their treatment plans. The follow up of patients' medical and care needs were remotely related to the discharge information sent from the hospital to the primary care providers, or to the hospital provider's request for patient follow-up in primary healthcare. CONCLUSION: The lack of patient-centered documentation either indicates poor patient-centeredness in the encounters or low priority given by the providers on documenting such information. Based on this small study, discharge information sent to primary healthcare cannot be considered as a means of securing continuity of patient care. Healthcare providers need to be aware that neither their discharge notes nor their referrals will guarantee continuity of patient care.

Complex epilepsy phenotype extraction from narrative clinical discharge summaries.

Epilepsy is a common serious neurological disorder with a complex set of possible phenotypes ranging from pathologic abnormalities to variations in electroencephalogram. This paper presents a system called Phenotype Exaction in Epilepsy (PEEP) for extracting complex epilepsy phenotypes and their correlated anatomical locations from clinical discharge summaries, a primary data source for this purpose. PEEP generates candidate phenotype and anatomical location pairs by embedding a named entity recognition method, based on the Epilepsy and Seizure Ontology, into the National Library of Medicine's MetaMap program. Such candidate pairs are further processed using a correlation algorithm. The derived phenotypes and correlated locations have been used for cohort identification with an integrated ontology-driven visual query interface. To evaluate the performance of PEEP, 400 de-identified discharge summaries were used for development and an additional 262 were used as test data. PEEP achieved a micro-averaged precision of 0.924, recall of 0.931, and F1-measure of 0.927 for extracting epilepsy phenotypes. The performance on the extraction of correlated phenotypes and anatomical locations shows a micro-averaged F1-measure of 0.856 (Precision: 0.852, Recall: 0.859). The evaluation demonstrates that PEEP is an effective approach to extracting complex epilepsy phenotypes for cohort identification.

Construction of the integrated multicentre discharge summary database.

We started a multi-year project to collect discharge summaries from multiple hospitals and create a big text database to build a common document vector space, and develop various applications such as the autoselection of the disease. As the first step, we extracted discharge summary from two hospitals. Using a text mining method, we carried out a DPC selection. There was a difference in term structure and number of terms between the discharge summaries from both hospitals. Nevertheless, the selection rate of the disease is resembled closely.

Analyzing differences between chinese and english clinical text: a cross-institution comparison of discharge summaries in two languages.

Worldwide adoption of Electronic Medical Records (EMRs) databases in health care have generated an unprecedented amount of clinical data available electronically. There has been an increasing trend in US and western institutions towards collaborating with China on medical research using EMR data. However, few studies have investigated characteristics of EMR data in China and their differences with the data in US hospitals. As an initial step towards differentiating EMR data in Chinese and US systems, this study attempts to understand system and cultural differences that may exist between Chinese and English clinical documents. We collected inpatient discharge summaries from one Chinese and from three US institutions and manually analyzed three major clinical components in text: medical problems, tests, and treatments. We reported comparison results at the document level and section level and discussed potential reasons for observed differences. Documenting and understanding differences in clinical reports from the US and China EMRs are important for cross-country collaborations. Our study also provided valuable insights for developing natural language processing tools for Chinese clinical text.

A rule-based method for continuity of care identification in discharge summaries.

Discharge summaries are an important clinical narrative as they include the continuity of care information. Identification of data contained in their text is a difficult task due to its freeform text and lack of consensus on essential content. This research proposes a rule-based method to verify the presence of information about continuity of care in Portuguese texts, applying Natural Language Processing (NLP) techniques, and based on an annotated medical corpus. After the experiments, 4 rules were defined and applied in the text of 200 summaries to identify if they have or not the continuity of care information. This process had resulted in Precision value of 84%, Recall value of 70%, Specificity value of 97% and F-Measure value of 76% related to algorithm evaluation.