Background The National Institute for Health and Care Excellence recommends documenting all delirium episodes in the discharge summary using the term “delirium”. Previous studies demonstrate poor delirium documentation rates in discharge summaries and no studies have assessed delirium documentation quality. The aim of this study was to determine the frequency and quality of delirium documentation in discharge summaries and explore differences between medical and surgical services. Methods This was a multi-center retrospective chart review. We included 110 patients aged ≥ 65 years identified to have delirium during their hospitalization using the Chart-based Delirium Identification Instrument (CHART-DEL). We assessed the frequency of any delirium documentation in discharge summaries, and more specifically, for the term “delirium”. We evaluated the quality of delirium discharge documentation using the Joint Commission on Accreditation of Healthcare Organization’s framework for quality discharge summaries. Comparisons were made between medical and surgical services. Secondary outcomes included assessing factors influencing the frequency of “delirium” being documented in the discharge summary. Results We identified 110 patients with sufficient chart documentation to identify delirium and 80.9 % of patients had delirium documented in their discharge summary (“delirium” or other acceptable term). The specific term “delirium” was reported in 63.6 % of all delirious patients and more often by surgical than medical specialties (76.5 % vs. 52.5 %, p = 0.02). Documentation quality was significantly lower by surgical specialties in reporting delirium as a diagnosis (23.5 % vs. 57.6 %, p < 0.001), documenting delirium workup (23.4 % vs. 57.6 %, p = 0.001), etiology (43.3 % vs. 70.4 %, p = 0.03), treatment (36.7 % vs. 66.7 %, p = 0.02), medication changes (44.4 % vs. 100 %, p = 0.002) and follow-up (36.4 % vs. 88.2 %, p = 0.01). Conclusions The frequency of delirium documentation is higher than previously reported but remains subpar. Medical services document delirium with higher quality, but surgical specialties document the term “delirium” more frequently. The documentation of delirium in discharge summaries must improve to meet quality standards.
Pressure injuries increase morbidity and mortality in geriatric patients by 400%. Residents in long-term care (LTC) are at high risk of developing pressure injuries because of limited mobility, poor nutritional status, impaired cognition, and incontinence. This study aims to determine whether a no-sting barrier film (NSBF) treatment protocol is more effective than current physician practices for treating stage 1 and 2 pressure injuries in LTC. A retrospective cohort study of 129 residents from one LTC facility was performed after a six-month implementation trial of a NSBF treatment protocol. The six-month incidence rate of stage 1 and 2 pressure injuries was 9% and 38% respectively. There was a statistically significant reduction in healing time in those treated with the NSBF protocol. In summary, the NSBF protocol reduces healing time of stage 1 and 2 pressure injuries; this protocol could be easily incorporated into existing pressure injury treatment strategies in LTC.
Objective: We assessed the accuracy of the ICD-10 code for delirium (F05) and its relationship with delirium discharge summary documentation. Methods: We performed a retrospective chart review at three academic hospitals. The Chart-based Delirium Identification Instrument (CHART-DEL) was used to identify 108 hospitalized patients aged ≥65 years with delirium, and 758 patients without delirium as controls. We assessed the proportion of patients who received the F05 code and calculated the sensitivity and specificity. We compared the rates of F05 code received between patients with and without “delirium” documented in the discharge summary. Results: Among delirious patients, 46.3% received a F05 code, which has a sensitivity of 46.3% and specificity of 99.6% for delirium. Of charts with “delirium” in the discharge summary ( n = 67), 67.2% were appropriately coded. Conclusions: Current ICD-10 data inadequately capture delirium. Delirium documentation in the discharge summary is associated with improved delirium coding.
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