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Pharmaceutical services at the Tenth Pan American Games.

The pharmaceutical services provided by volunteers, including more than 100 pharmacists, at the 1987 Pan American Games in Indianapolis, Indiana, are described. Pharmacists at a local hospital were given responsibility for doping control and operation of the medical clinic pharmacy at the games. Barracks at a U.S. Army facility within the games' boundaries were converted into the clinic; an area on the second floor was equipped as the pharmacy. The pharmacy secured the necessary licensure and obtained drug products and supplies. Volunteer pharmacists were recruited and instructed about responsibilities, procedures, and security. The formulary was based on the 1983 Pan American Games formulary, the 1988 Olympic Games formulary, and requests from the Pan American Sports Organization. In the 26 days that the pharmacy was open, 968 prescriptions were filled. The drugs most commonly prescribed were ibuprofen, terfenadine, acetaminophen, penicillin V potassium, clotrimazole cream, and naproxen. A doping control center located at each competition venue was staffed by a physician, pharmacists, nurses, medical technologists, and nonmedical personnel. After an event, selected athletes were escorted to a doping control center, where a medical history and urine sample were obtained. The urine was tested for pH and specific gravity, and the coded specimen bottles were sealed for transport to the laboratory. Each step was documented on special forms. A total of 981 athletes were tested; six athletes had positive test results. The 1987 Pan American Games provided a unique opportunity for pharmacists to assist in providing medical services at a large athletic event and to become involved in doping control.

Americas↗

Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993-2002.

OBJECTIVE: Patients who require tracheostomy for prolonged mechanical ventilation have poor outcomes and high costs of care. However, recent longitudinal trends relevant to these patients and their care have not been described. We aimed to describe trends in the annual incidence and timing of tracheostomy for prolonged mechanical ventilation, as well as prolonged mechanical ventilation patient resource utilization and overall in-hospital mortality. DESIGN AND SETTING: Retrospective review of the North Carolina Hospital Discharge Database, a comprehensive record of all state nonfederal, nonpsychiatric hospital discharges between 1993 and 2002. PATIENTS: Patients were 9,794 medical and surgical patients >/=18 yrs of age with International Classification of Diseases, Ninth Revision, Clinical Modification code 96.72 (mechanical ventilation for >96 hrs) and Diagnosis Related Group code 483 (tracheostomy except for face, neck, and mouth diagnoses). INTERVENTIONS: None. MEASUREMENTS: Incidence rates adjusted for annual population growth, mechanical ventilation days until tracheostomy placement, length of stay, and hospital charges and payments adjusted by the medical component of the Consumer Price Index. MAIN RESULTS: Between 1993 and 2002, the incidence of tracheostomy for prolonged mechanical ventilation increased across all age groups from 8.3 of 100,000 to 24.2 of 100,000 (p < .001), although most significantly among patients <55 yrs of age. During this period, a decrease was seen in mortality (from 39% to 25%), median mechanical ventilation days to tracheostomy placement (from 12 to 10 days), and median length of stay (from 47 to 33 days). By 2002, patients were almost three times less likely to be discharged to home independently although twice as likely to be sent to a skilled nursing facility. Although prolonged mechanical ventilation patients with tracheostomies represented only 7% of all who required mechanical ventilation, their total charges during the study period were 1.74 billion dollars-22% of all mechanical ventilation patient charges. CONCLUSION: The incidence of tracheostomy for prolonged mechanical ventilation increased by nearly 200% during the past decade in North Carolina, exceeding changes in the overall incidence of respiratory failure three-fold. Although in-hospital mortality, length of stay, and charges per patient fell over time, the overall resource utilization of prolonged mechanical ventilation patients increased dramatically.

Adult↗

Quality of life in school-age children following liver transplantation.

A descriptive exploratory study was conducted to ascertain the quality of life in school-age children 3 to 6 years following liver transplantation for chronic liver disease. Thirty children were to be included, however only 25 were recruited, and 20 of the 25 children became the study sample. The 20 school-age children ranged in age from 5 years 4 months to 11 years 9 months. The setting for the study was a conference room adjoining a social work office in a 220-bed university-affiliated children's hospital located in a large city in the Northeastern United States. The data were collected through the use of individual interviews, which were audiotaped and transcribed, and the written completion of an 80-item, self-report inventory. Interviews ranged in length from 1 hour 15 minutes to 1 hour 45 minutes. They were scheduled at a time that was convenient to the children's yearly pediatrician follow-up examination. Since the children and their families lived in other states and countries a great distance from the hospital, all communication with the families and scheduling of appointments were coordinated by the secretary of the pediatrician. The children in this study experienced liver transplantation 3 to 6 years prior to the interview for biliary atresia (n = 15), alpha 1-antitrypsin deficiency (n = 3), tyrosinemia (n = 1), and neonatal hepatitis (n = 1). Eighty-five percent of the children (n = 17) experienced liver transplantation before the age of 6 years, and 15 percent of the children (n = 3) experienced transplantation after 6 years of age. Responses from the modified Pigem's test, a projective test of children's values and attributes about self, and from the Zamberlan Questionnaire were content analyzed, then categorized according to the specific areas representative of the children's evaluation of the quality of life. Interrater reliability of the categories demonstrated 87% agreement of the coded items on the interview data. Five categories were derived from analysis of the interview and Pigem's data and included: (a) psychosocial adjustment at school and relationships with peers and family members; (b) internalization of the donor organ, the knowledge of the liver transplant experience, and thoughts about the donor person; (c) changes in physical appearance and physical functioning; (d) emotions, fears, or concerns about rejection and future outcome of the liver transplant(s); and (e) children's satisfaction with present and future life, and thoughts about self as reflected on the Pigem's test.(ABSTRACT TRUNCATED AT 400 WORDS)

Activities of Daily Living↗

Implementing family-centred care: an exploration of the beliefs and practices of paediatric nurses.

OBJECTIVE: This study explored paediatric nurses' perceptions of how they include and involve parents in the care of hospitalised children. DESIGN: This qualitative study used individual unstructured interviews to gather data, the data was analysed using thematic coding. SETTING: Paediatric wards within two regional area health services of New South Wales, Australia. SUBJECTS: Fourteen paediatric nurses were asked to describe their beliefs and practices regarding the clinical application of family-centred care. MAIN OUTCOME MEASURE: Paediatric nurses' beliefs and practices about family-centred care were explored in an effort to explain how the concept was implemented. RESULTS: The findings are presented as four interconnected themes. The first describes how participants either allocated tasks to parents or retained them, the second relates to the nurses' professional identity, the third theme identifies barriers and constraints to the implementation of family-centred care, while the fourth describes the nurses' beliefs about their responsibilities when delivering family-centred care. CONCLUSIONS: Together these findings suggest that while nurses endorse the concept of family-centred care, the implementation into practice is more problematic. While it is not possible to generalise these findings to other paediatric nurses, the authors believe the insight gained will resonate with paediatric nurses internationally. The findings from this study are being used as the basis for the development of clinical practice guidelines to assist paediatric nurses to more consistently apply the concepts of family-centred care to their practice.

Adult↗

The Australian joint inquiry into the Protection of Human Genetic Information.

The Australian Law Reform Commission (ALRC) and the Australian Health Ethics Committee are currently engaged in an inquiry into the Protection of Human Genetic Information. In particular, the Attorney-General and the Minister for Health and Ageing have asked us to focus, in relation to human genetic information and tissue samples, on how best to ensure world's best practice in relation to: privacy protection; protection against unlawful discrimination; and the maintenance of high ethical standards in medical research and clinical practice. While initial concerns and controversies have related mainly to aspects of medical research (e.g. consent; re-use of samples) and access to private insurance coverage, relevant issues arise in a wide variety of contexts, including: employment; medical practice; tissue banks and genetic databases; health administration; superannuation; access to government services (e.g. schools, nursing homes); law enforcement; and use by government authorities (e.g. for immigration purposes) or other bodies (e.g. by sports associations). Under the Australian federal system, it is also the case that laws and practices may vary across states and territories. For example, neonatal genetic testing is standard, but storage and retention policies for the resulting 'Guthrie cards' differ markedly. Similarly, some states have developed highly linked health information systems (e.g. incorporating hospitals, doctors' offices and public records), while others discourage such linkages owing to concerns about privacy. The challenge for Australia is to develop policies, standards and practices that promote the intelligent use of genetic information, while providing a level of security with which the community feels comfortable. The inquiry is presently reviewing the adequacy of existing laws and regulatory mechanisms, but recognizes that it will be even more important to develop a broad mix of strategies, such as community and professional education, and the development of official standards and industry codes that reflect emerging international best practice in the area.

Advisory Committees↗

Care staff attributions for violent incidents involving male and female patients: a field study.

OBJECTIVES: This article presents a study of naturally occurring attributions recorded by care staff following incidents of restraint in a psychiatric secure unit. The relationship between control for patient, control for staff and behavioural outcomes including use of medication, seclusion and duration of restraint were explored for male and female patients. DESIGN AND METHODS: In all, 557 forms documenting incidents of control and restraint, and completed over a four-year period by nurses in a UK psychiatric hospital, were content analysed using the Leeds Attributional Coding System (LACS; Munton, Silvester, & Hanks, 1999). Additional information concerning duration of restraint, severity of injuries sustained by patient and care staff, use of medication and seclusion, and patient was also gathered. It was hypothesized that perceived patient control over causes of the restraint incident would be associated with duration of restraint, use of seclusion and medication. It was also predicted that male patients would be perceived as having more control over incidents, and thus be more likely to be secluded and less likely to be prescribed medication, than female patients. RESULTS: Seclusion was associated with controllable attributions for patient and uncontrollable attributions for care staff. Use of medication was associated with uncontrollable attributions for patient, but only for male patients. Contrary to prediction, female patients were more likely to be secluded than males and less likely to receive medication. Staff were also more likely to state that they had 'no explanation' for restraint incidents involving female patients. CONCLUSIONS: The investigation of naturally occurring attributions raises important questions regarding the relationship between patient gender and attributional models of helping behaviour. The results are discussed in terms of their potential implications for future research and health care practice.

Adolescent↗

Dignity and the challenge of dying in nursing homes: the residents' view.

BACKGROUND: human dignity is discussed in almost all public debates on the care of the dying, as well as in international policies for health and social care of older people. Because nursing homes are gaining importance as places where residents live out their lives in modern western societies and since there is evidence that end-of-life care in nursing homes lacks quality, there is a growing discussion on introducing improved end-of-life care in these institutions. In order to accomplish this, the view of those who are most affected is of utmost importance. OBJECTIVE: to explore the meaning of dignity with regard to end-of-life issues from the perspective of older nursing home residents in western Germany. METHODS: this qualitative study is based on the Grounded Theory Approach, and the design included three steps of data generation; narrative interviews with residents of nursing homes constitute the main data pool (n = 20) of the results presented in this paper. Theoretical sampling was aimed at maximising the variety of organisational as well as residents' characteristics. Analysis of the transcripts was supported by Atlas/ti program and followed several different coding procedures and aimed at generating a concept of dignity. RESULTS: dignity was differentiated into intrapersonal dignity and relational dignity, socially constructed by the act of recognition. Social relations and encounters are a prerequisite for relational dignity, which underlines the vulnerability of nursing home residents' who increasingly lack social networks. A broad spectrum of attitudes and behaviour, which aimed at recognising dignity, was bundled under the category 'not being a burden'. In this light, dignity was challenged most by the threat of illness and having care needs. This was fostered by the perception of insufficient care in the nursing homes. In the light of this concept, death with dignity meant 'death at the right time', though the residents in the sample did not want to comment on the time of death, other than aspects like (i) being active to the very last, (ii) respecting one's will and being allowed to die, (iii) not being in pain, (iv) being amongst persons close to one (valediction and showing respect). CONCLUSION: the study emphasizes the high vulnerability of nursing home residents with regard to dignity. They place their dignity under the constraints of the need for help and care into question. This appears alarming, if one does not manage to, with the help of different ethics, obtain a new perspective on these phases of life. It is evident that the understanding of dignity is not solely individualistic and personal, but rather has a close relationship to social ideas of value, which ultimately influence the basic requirements of institutions in which 'frail old people' live.

Aged↗

The diversity of family health: constituent systems and resources.

The purpose of this study was to explore changes in family health associated with child's chronic illness and hospitalization. The aim was to answer the following questions: (i) What kind of changes do families experience when a child in the family is afflicted by a chronic illness; and (ii) What kind of changes do families experience when their child is admitted to hospital? The data were collected in 2002 in interviews with 29 such families whose children were receiving treatment or who had previously received treatment on the paediatric wards of two hospitals in Finland. Data were collected until reaching theoretical saturation, in which no additional data are found. Data analysis was based on the grounded theory method, proceeding to the stage of axial coding. Family health was formed out of two different dimensions: the constituent systems and the resources of family health. The constituent systems describe the impact of the child's chronic illness and period of hospitalization at the level of both individual family members and the family as a whole. These systems were described by five categories: (i) ill child at the centre of family attention, (ii) siblings in a minor role, (iii) the child's illness governs parental well-being, (iv) the roller coaster of the couple relationship and (v) the whole family is ill. The resources promoting and maintaining family health were divided into six different categories: (i) creative and maintaining mental images, (ii) active involvement, (iii) internal coping means, (iv) reinforcement of coping means, (v) awareness and change of values and (vi) social network shares emotional burden and responsibility for care. The results of the study show that family health is highly vulnerable when a child has to be admitted to hospital because of a chronic condition. They should help nursing staff gain a clearer picture of the depth and diversity of family health and support the resources that promote family health. Future research should study the methods of family nursing used in the care of families with children with chronic conditions.

Adaptation, Psychological↗

Do nurses really care? Some unwelcome findings from recent research and inquiry.

This paper examines the position of nursing as a caring profession, in terms of an ethical code that stresses collegial relationships, a sense of obligation to a clientele that is realized in terms of expert service, and a clearly defined body of research-derived knowledge as the basis for practice. It also investigates the substance of the claim that nursing has tended to arrogate to itself another operational distinction-its exclusive capacity to blend physical and emotional support into care. A review of recent research and investigation, undertaken in a number of countries, suggests that nursing as practiced, rather than as theorized, fails to fulfil its wider professional aspirations, and to fulfil its caring rhetoric. A related paper will consider how the absorption of nursing into higher education might begin to play a part in developing and consolidating the professionalization of nursing.

Attitude of Health Personnel↗

Intervention research: establishing fidelity of the independent variable in nursing clinical trials.

BACKGROUND: Internal validity of a randomized clinical trial of a nursing intervention is dependent on intervention fidelity. Although several methods have been developed, evaluating audio or audiovisual tapes for prescribed and proscribed interventionist behaviors is considered the gold standard test of treatment fidelity. This approach requires development of a psychometrically sound instrument to meaningfully categorize and quantify interventionist behaviors. OBJECTIVE: To outline critical steps necessary to develop a treatment fidelity instrument. METHODS: A comprehensive literature review was conducted to determine procedures used by other researchers. The literature review produced five quantitative studies of treatment fidelity, all in the field of psychotherapy, and two replication studies. A synthesis of methodologies across studies combined with researchers' experiences resulted in identification of the steps necessary to develop a treatment fidelity measure. RESULTS: Seven sequential steps were identified as essential to the development of a valid and reliable measure of treatment fidelity. These steps include (a) identification of the essential elements of the experimental and control treatment modalities; (b) construction of scale items; (c) development of item scaling; (d) identification of the units for coding; (e) item testing and revision; (f) specification of rater qualifications and development of rater training program; and (g) development and completion of pilot testing to test psychometric properties. Development of the Possibilities Project Psychotherapy Coding Questionnaire is described as an illustration of the seven-step process. DISCUSSION: The results show the essential steps that are unique to the development of treatment fidelity measures and show the feasibility of using these steps to construct a psychometrically sound treatment-specific fidelity measure.

Adolescent↗

One-year use of the Bloodloc system in an orthopedic institute.

UNLABELLED: Human error in patient or specimen identification due to fatigue, stress and lack of attention by technologists, nurses, interns, and physicians, can cause routinely safety procedures to be circumvented. Clerical errors may occur during the specimen collection, the issue of blood unit and the transfusion of blood. The introduction in an increasing number of hospital of preoperative autologous blood donation programs further increases the chance of error, because a single patient can predeposit multiple units of blood. In this cases there is a greater commitment not only to transfuse any blood unit that is ABO compatible but to transfuse the specific units the patient previously donated for his own use. Human error has been recognized as a significant cause of transfusion-associated fatalities. The persistence of the frequency and type of errors observed in spite of extensive efforts to eradicate them, suggests that errors are inevitable as long as large number of repetitive procedures are performed unless major system changes are adopted. A system (Bloodloc System) that physically prevents the possibility of error was adopted since January 1993 and cuncurrently a quality improvement program (QI) was implemented specifically designed to monitor: 1. the absence of the code on the blood samples, 2. the blood bank error in setting the Bloodloc, 3. the misidentification of blood samples, 4. any attempt to transfuse the wrong blood unit, 5. any attempt to transfuse, the wrong patients. RESULTS: 4895 blood units (2469 autologous and 2426 allogeneic units) were transfused to 1478 patients (849 predeposited an average of 3.3 +/- 2.0 units). The methodological errors (absence of three-letter code on the patient's specimen tube, wrong transcription of the code on the blood sample, wrong setting of the Bloodloc in the blood bank)--41 cases--were limited at the first four months of implementation of the system. In the same period however have been reported 3 potentially fatal errors which have been avoided by the Bloodloc. Two cases of misidentification of blood samples at the moment of the specimen collection, and one attempt to transfuse the wrong units to the wrong patients. CONCLUSIONS: The Bloodloc system is effective in preventing potential transfusion-associated fatalities caused by units or recipients misidentification.

Blood Banks↗

Spiritual needs of dying patients: a qualitative study.

PURPOSE/OBJECTIVES: To identify dying patients' definitions of spirituality and their spiritual needs. DESIGN: Descriptive, qualitative. SETTING: Participants' places of residence. SAMPLE: 19 hospice patients (10 females and 9 males), mean age 72, with a range of length of time as a hospice patient of 2 weeks to 12 months. METHODS: Semistructured interviews were conducted. Interview transcripts and field notes were analyzed to reduce data into codes and themes. Data were coded by extracting verbatim phrases used to describe spirituality and spiritual needs. Themes emerged from the data as commonalities among the codes developed. MAIN RESEARCH VARIABLES: Meaning of "spiritual" and perceived spiritual needs. FINDINGS: Participants initially defined spiritual as relating to God or religion; however, as interviews progressed, it was apparent that their spirituality was a part of their total existence. Twenty-nine unique spiritual needs were identified and grouped into six themes: need for religion, need for companionship, need for involvement and control, need to finish business, need to experience nature, and need for positive outlook. CONCLUSIONS: Participants perceived spirituality as a broad concept that may or may not involve religion. Spiritual needs were likewise broad in scope and were linked closely to purpose and meaning in life. IMPLICATIONS FOR NURSING PRACTICE: Spiritual care of dying patients is within the scope of nursing practice. Spiritual needs are quite varied and encompass more than religion. If nurses are to enhance the quality of life of dying patients, spiritual needs must be addressed.

Aged↗

Implementation of a clinical workstation for general practice.

It is now well recognized that achieving international best practice in the primary health sector will require the development of methods based on a fundamental integration of communications and information technologies with clinical practice. This will have far reaching effects, both on the pattern of medical practice and domiciliary care and on patient outcomes. In the past, information and communications technology has been presented as a tool for management, rather than as a tool for supporting, improving, and making more efficient the professional practice of medicine and the delivery of health care to the patient and the community. In this paper, we propose that an essential element for the achievement of international best practice in the health sector is the development and widespread use of information, measurement, and communications technology targeted towards the clinical practice of medicine, the provision of health services and domiciliary care in the community, and the analysis of morbidity patterns and health care outcomes. A key element of this strategy is the development of an integrated Clinical Workstation specifically designed for the general practitioner, practice nurses, and domiciliary care nurses in their professional tasks of measurement, diagnosis, management, and delivery of health care to the community. We will present our work on the design of an integrated Clinical Workstation for Primary Health Care. The Workstation is Windows based, has a sophisticated user interface, and supports a wide range of computing platforms, from desktop to laptop to hand-held notebook computers. The Workstation will be modular and expandable, both in its software and hardware components, so that users may select only those modules appropriate to their own roles, clinical practice, and levels of expertise. The design will focus on the provision of clinical services and will integrate the following key components: Patient records and basic practice management; Clinical records. Based on ICD10, ICPC, or Read Code classifications; Clinical measurements. Blood pressure, spirometry, ECG, and basic hematology and biochemistry; Clinical decision support. Based on epidemiologic data, protocols, and medical expert systems; Domiciliary care and evaluation of the functional health status of the elderly; Communications and networks. Wireless LAN, modem, and fax; Clinical reporting. Morbidity profiles prescribing profiles, and laboratory services and procedures. Implementation of these requirements will ultimately take the form of an untethered, portable notepad computer supporting a communications link via modem, LAN, or wireless LAN, and removable instrumentation and clinical measurement modules.

Computer Systems↗

Reporting of adverse events in hospitals in Victoria, 1994-1995.

OBJECTIVE: To describe the nature and frequency of adverse events (AEs) reported in routine inpatient data collection. DESIGN: Retrospective analysis of data from the Victorian Inpatient Minimum Database. SETTING: All public (135) and private (112) acute-care hospitals in Victoria, 1994-1995. PARTICIPANTS: All patients with separations recording an E-code identified as an AE through the International classification of diseases, ninth revision (ICD-9), classification system. MAIN OUTCOME MEASURES: Australian national diagnosis-related groups (AN-DRGs) associated with AEs; prevalence of major organ system disease in each of the AE groups; AE rates by hospital type; and impact of AEs on discharge destination, or death. RESULTS: AEs were recorded in 5% of separations, with incidence increasing with patient age. Most (81%) were complications after surgery or other procedures (E878-E879); 19% were adverse drug effects (E930-E949) and 1.7% were misadventures (E870-E876). The most frequently reported complications were infections, haemorrhage and pneumonia. AN-DRGs--joint replacement of the lower limb, bowel excision and hysterectomy--contributed most to the volume of AEs, while the greatest risk was associated with ventricular shunt, major organ transplantation and surgery for complicated injuries. The in-hospital death rate in patients with AEs was 2.9% (95% confidence interval [95% CI], 2.7%-3.2%), compared with 1.3% (95% CI, 1.0-1.4) in those without an AE. Of patients with an AE, fewer were discharged directly home, and higher proportions were discharged to other acute-care facilities or nursing homes compared with those without an AE. CONCLUSION: Inpatient data collection can provide information about AE rates associated with individual procedures, and the nature of these AEs. It can be used by hospitals to direct and complement their own quality improvement activities. Its limitation is that it cannot identify the severity or long term outcome of AEs.

Data Collection↗

After the merger. Quality assurance for combined services.

The Patient Support Services Supervisory/Lead Staff have adapted well to using the MQAI format. We had always used a Quality control of Inspection sheet internally to evaluated performance levels, correct problems and generate work orders. Interviewing patients directly on a random basis was first approached with some fear and reticence. However, the positive comments, especially about the friendliness of our staff, made the task more enjoyable. The input of the nurse or area manager has been more difficult to obtain because of busy work schedules. We receive mostly favorable marks about our staff's service, quality and attitude. The most consistent feedback reflects the desire of area managers to have a dedicated support service person for their unit. This is not based on job performance, but personality, a support person who "fits in" with the other unit staff. This is probably a result of a clear shift to a patient centered care of "team" concept. From the MQAI form, we still generate many work orders for the engineering department and seek to correct housekeeping deficiencies. The problem area that seems to stand out is carpet spotting and odor. We have come to the conclusion that due to rising patient acuity levels, carpeting simply does not belong in a patient room. A program to replace carpeted patient rooms, one at a time if necessary, has been initiated. By constant repetition, our staff knows the hospital codes, safety procedures and universal precautions. We are proud to say, the most "appropriate action" based on our Quality Assessment and Improvement Plan has been to congratulate our staff for a job well done.

Consumer Behavior↗

Unspecified falls among youth: predictors of coding specificity in the emergency department.

BACKGROUND: Deficiencies in emergency department (ED) charting is a common international problem. While unintentional falls account for the largest proportion of injury related ED visits by youth, insufficient charting details result in more than one third of these falls being coded as "unspecified". Non-specific coding compromises the utility of injury surveillance data. OBJECTIVE: To re-examine the ED charts of unspecified youth falls to determine the possibility of assigning more specific codes. METHODS: 400 ED charts for youth (aged 0-19 years) treated at four EDs in an urban Canadian health region between 1997 and 1999 and coded as "Other or unspecified fall" (ICD-9 E888) were randomly selected. A structured chart review was completed and a blinded nosologist recoded the cause of injury using the extracted data. Differences in coding specificity were compared with the original data, and logistic regression was undertaken to examine variables that predicted assignment of a specific E-code. RESULTS: A more specific code was assigned to 46% of cases initially coded as unspecified. Of these, 73% were recoded as "Slips, trips, and stumbles" (E885), which still lacks the specificity required for injury prevention planning; 2% of charts had no fall documented. Multivariate analysis revealed that dichotomized injury severity (adjusted odds ratio (OR) = 1.75 (95% confidence interval, 1.11 to 2.78)), arrival at the ED by ambulance (adjusted OR = 5.41 (1.07 to 27.0)), and the availability of nurse's notes or triage forms, or both, in the chart (adjusted OR = 3.75 (2.17 to 6.45)) were the strongest predictors of a more specific E-code assignment. CONCLUSIONS: Deficiencies in both chart documentation and coding specificity contribute to the use of non-specific E-codes. More comprehensive triage coding, improved chart documentation, and alternative methods of data collection in the acute care setting are required to improve ED injury surveillance initiatives.

Accidental Falls↗

Founding and processes of the International Council on Women's Health Issues: attentive partnering. The first 19 years.

I present a theoretical analysis and global influence of the first 19 years of the International Council on Women's Health Issues (ICOWHI). To do so, I analyzed observational, documented, and casual data using the constant comparative method of classical grounded theory. All data bits were analyzed with one another, coded, categorized, and reexamined until I discovered a central category that seemed to explain most of the social scene under study. The explanatory power of the central category, attentive partnering, is presented in terms of its applicability to the interactive relationship between participants working for a common goal, and within the cultural, temporal, social, and social structural context of the relationships. Partnering can occur wherever individuals with a common purpose assemble. The conditions under which the interactive process of attentive partnering occurs seem to be the presence of determined, persuasive leaders, who foster growth-enhancing collegial relationships. When this social system is in place, a small volunteer organization can have a global impact.

Cooperative Behavior↗

Improving documentation of patient acuity level using a progress note template.

BACKGROUND: Accurately documenting patient comorbidities and complications improves case-mix representation, coding accuracy, and risk-adjusted mortality estimates for benchmarking. We hypothesized that a progress note template containing comorbidities and complications would improve documentation and teach residents to correctly document comorbidities and complications. STUDY DESIGN: Surgical residents and patients on three inpatient services were followed for a 1-year prospective cohort study. After a 6-month baseline period, a progress note template was developed and implemented for 6 months, and administrative data were retrieved. Residents were given three case examinations assessing documentation knowledge pre- and postintervention, and a satisfaction survey. Demographics, Charlson comorbidity score, ICD-9 codes, template-specific ICD-9 codes, All Patient Refined (APR)-DRG patient severity, DRG relative weight, predicted mortality (University Healthcare Consortium), pre- and postexam scores, and resident satisfaction were collected. RESULTS: No difference in age, gender, race, or Charlson comorbidity score existed between pre- and postintervention patient groups. The length of stay decreased from 5.5 days to 4.8 days (p = 0.013). In the intervention group, total ICD-9 codes, template-specific ICD-9 codes, APR-DRG, DRG weight, and UHC predicted mortality had significant increases. Residents exposed to the progress note template improved their knowledge scores from 52% to 63% (p < 0.001), and 73% agreed that the progress note template was an improvement over handwritten notes. Residents not exposed to the progress note template did not improve their scores. CONCLUSIONS: A progress note template improves documentation of comorbidities and complications, APR-DRG patient severity for benchmarking, and case-mix index, and increases patient-specific predicted mortality. The progress note template also improves surgical residents' documentation knowledge and satisfaction.

Acute Disease↗