Abstract TP329: True Failures Versus Ambiguous Documentation in Core Measures Noncompliance

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Natalie C Wheeler ◽  
William J Meurer ◽  
Aditya S Pandey ◽  
James F Burke ◽  
Jenevra Foley ◽  
...  
Keyword(s):  
Chart Review ◽  
Clinical Care ◽  
Stroke Care ◽  
Routine Practice ◽  
University Of Michigan ◽  
Acute Stroke Care ◽  
Appropriate Care ◽  
Quality Guideline ◽  
The University ◽  
Core Measures

Introduction: Stroke Core Measures are intended to ensure that patients receive high quality, guideline-concordant acute stroke care. Compliance data is collected and reported to the public and to regulatory agencies for benchmarking and for reimbursement. Hypothesis: Core Measures noncompliance within one academic institution will often reflect ambiguous or incomplete documentation instead of true failure to provide medically appropriate care. Methods: We retrospectively reviewed Core Measures data for all ischemic and hemorrhagic stroke patients discharged from the University of Michigan between January 2013 and May 2014. Core Measures data was collected and reported per routine practice and contemporaneously reviewed by the institutional team. For this study, Core Measures failures were cross-referenced with the full medical chart and classified as “true failures” when care was not compliant with the Core Measure standard or “documentation failures” when chart review revealed poor documentation of otherwise appropriate care--for example, where a normal neurological examination was not explicitly linked with a decision to defer assessment for rehabilitation. Determinations of the basis for noncompliance on chart review were made by two different reviewers, with 100% agreement. Results: A total of 40 failures in 872 patients were identified and reviewed. Core Measures failures were documentation failures in 20 patients. Additional details are provided in Table 1. Conclusion: The high number of documentation-based failures in our experience illustrates potential problems in the use of administratively-defined measures as a marker of the quality of clinical care.

Abstract P121: Update on Regional Stroke Activation Trends During Covid-19 Mitigation

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Emily Sayles ◽  
Jessica Hsiao ◽  
Heidi Sucharew ◽  
Eleni Antzoulatos ◽  
Robert J Stanton ◽  
...  
Keyword(s):  
Stroke Care ◽  
Significant Decline ◽  
Mitigation Measures ◽  
Segmented Regression ◽  
Acute Stroke Care ◽  
Healthcare Facilities ◽  
Hospital Capacity ◽  
Stroke Team ◽  
Segmented Regression Analysis ◽  
The University

Background: The University of Cincinnati Stroke Team provides acute stroke care to the southwest Ohio, northern Kentucky, and southeast Indiana catchment area of ~2 million people and 30 healthcare facilities. We previously published a significant decline in stroke activations and reperfusion treatment (IV thrombolysis and EVT) rates following state announcements of COVID-19 mitigation measures. Here, we update these trends after state reopening guidelines. Methods: We compared Stroke Team activations and reperfusion treatments logged in a prospectively collected database, comparing the same period in 2020 versus 2019. Kentucky and Ohio announced school and restaurant closures on March 12 and 13, respectively, followed by Indiana. A stepwise reopening of our tristate area started on May 1, 2020. We also compared trends in activations and treatment rates before (Weeks 1-10), during (Weeks 11-17), and after (Weeks 18-26) the lifting of COVID-19 mitigation efforts using the Poisson test, and graphically with segmented regression analysis. Results: Compared to 2019, stroke team activations declined by 12% in 2020 (95% CI 7 - 16%; p<0.01). During 2020, an initial decline in stroke activations following COVID-19 mitigation announcements was followed by a 28% increase in activations after reopening (Weeks 18-26: 95% CI 15 - 42%; p<0.01). In contrast, compared to 2019, treatment rates were unchanged (0%, 95% CI -15 - 18%; p=1.00), including specifically IV thrombolysis and thrombectomy rates. Similarly, an initial decline in reperfusion treatments was followed by a 24% nonsignificant increase after reopening (95% CI -10 - 71%; p=0.19) in 2020. Conclusion: The initial decline in stroke team activations during COVID-19 mitigation efforts was followed by an increase in activations after reopening. Hospital capacity and 911 services remained fully intact, suggesting that the reduction in activations were related to reduced presentation by patients for emergent stroke care.

How Informed Is Informed Consent?

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 2556-2556
Author(s):  
Karl Desch ◽  
Jun Z. Li ◽  
Scott Kim ◽  
Naomi Laventhal ◽  
David Siemieniak ◽  
...  
Keyword(s):  
Informed Consent ◽  
Biomedical Research ◽  
Reading Time ◽  
Conflicts Of Interest ◽  
Clinical Care ◽  
Informed Consent Process ◽  
Low Risk ◽  
Consent Process ◽  
University Of Michigan ◽  
The University

Abstract Abstract 2556 The informed consent process is a critical component of human subject protection in biomedical research, with the goals of informing participants of the purpose of the study, as well as the likely risks, benefits and alternatives. The signed informed consent document (ICD) is a required legal disclosure which documents that the informed consent process has taken place and provides research subjects with comprehensive information about their role in a study. Despite efforts to optimize the ICD, only limited data are available regarding the utilization of these documents by participants in biomedical research. We measured the time taken by participants, in a genetic study of hematologic traits, to review a 2833 word online ICD prior to indicating consent. ICDs were generated utilizing standard templates provided by the University of Michigan IRB with the addition of a hyperlink at word 2254 of the ICD that read “If you are reading this form, please click on this sentence”. Identification of the hyperlink, as a proxy for thorough reading of the ICD, was recorded. The study was approved by the University of Michigan IRB (IRBMED# 2005-0080.) A total of 1209 subjects were recruited from the University of Michigan, Ann Arbor student population from 2/12/08 to 1/30/09. Age ranged from 14 to 35 years with a mean of 21. Standard reading speeds predicted a range of 567 to 850 seconds to read the full ICD text. The distribution of consent times was heterogeneous, heavily weighted toward times that would suggest little to no reading of the ICD. Twenty-eight percent of participants consented within ten seconds. Only 78 participants (6.4%) took longer than the minimum estimated reading time (566 seconds) to indicate consent. The hyperlink was identified by 2.2% of participants with a median reading time of 621 seconds, significantly longer than those who did not (52 seconds, p<3×10−11). Additionally, significant differences in consent time were noted for sex, age, and downloading of the ICD PDF file. Our results demonstrate that the majority of participants in this study (93.6%) provided consent without spending sufficient time to thoroughly read and comprehend the ICD. The 6.4% of participants with consent times greater than the minimum predicted ICD reading times is likely a significant overestimate of ICD comprehension since the consent interval recorded could also include time spent on other distracting activities. In conclusion, these observations imply that the consent by subjects to participate in this and many other low-risk studies is unlikely to have been as truly informed as originally intended by the investigators and the IRB. This lack of truly informed consent is also likely to extend beyond research studies, to include ICDs used for treatment in the routine clinical care setting. These data suggest that current ICDs, particularly for low-risk studies, may no longer serve the intended informed consent purpose and that ICD length and complexity should be reassessed. Disclosures: No relevant conflicts of interest to declare.

Abstract WP352: Stroke Rounds: An Organizational Approach to Core Measures Improvement

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Mandi Counters ◽  
Amy Barna ◽  
Beth Krage
Keyword(s):  
Patient Care ◽  
Stroke Patient ◽  
Chart Review ◽  
Stroke Care ◽  
Care Plan ◽  
Nursing Knowledge ◽  
Nurse Leader ◽  
Stroke Education ◽  
Bedside Nursing ◽  
Core Measures

Background & Purpose: In 2011 our team realized a deficiency in nursing knowledge of stroke patient care and Stroke Core Measures, after discovering that our stroke education scores were 84% overall for the year. An innovative stroke rounding process was launched following hospital-wide education regarding stroke patient care and the Stroke Core Measures with the purpose of increasing bedside nursing knowledge and competency with these topics. Methods: A rounding worksheet was created using the Stroke Core Measures. Stroke rounds are completed three times weekly by the Neuroscience Nurse Educator, Clinical Nurse Leader, and bedside nurse. A discussion with the nurse includes chart review, completion of a rounding worksheet, and individualizing stroke care plan goals. This may progress to obtaining additional orders and/or consulting additional disciplines. Results: Preliminary data for the second quarter of 2012 identifies that stroke education scores increased to 100% as of the end of April. Review of the stroke rounding worksheets identified that initiation of stroke education is occurring earlier in patients’ hospitalizations. Anecdotal reports from nurses indicate increased knowledge of Core Measures and comfort in caring for stroke patients. A formal facility-based survey to nursing will be completed prior to presentation in 2013. Conclusions: Success with rounds in the stroke unit precipitated the process in critical care. Both units now are utilizing the process and have received positive feedback from nursing staff.

scholarly journals GME Innovations Grant Program at the University of Michigan Health System—Fostering Changes in Education and Clinical Care

2013 ◽  
Vol 5 (4) ◽  
pp. 665-667 ◽  
Author(s):  
Lisa M. Colletti ◽  
Joseph C. Kolars ◽  
James O. Woolliscroft
Keyword(s):  
Health System ◽  
Educational Research ◽  
Clinical Care ◽  
Assessment Methods ◽  
Assessment Tools ◽  
University Of Michigan ◽  
Educational Grant ◽  
Grant Program ◽  
Simulation Center ◽  
The University

Abstract Background Changes in graduate medical education (GME) have resulted in curricula, goals and objectives, and assessment methods becoming more formal, yet there is little financial support for the educational research required to develop better teaching approaches and assessment tools. Objective We sought to encourage the development of new educational tools and assessment methods to improve the overall conduct of GME at the University of Michigan. Intervention The University of Michigan Health System has recently established a new educational grant that is designed to foster innovative educational research in GME. We describe the experience with a new and robust internal educational grant, including the source of funding, mechanisms for reviewing and assessing the proposals, the types of proposals that have currently been funded, and the effect and results of these studies on GME at the University of Michigan Health System. Outcomes Projects funded by the grant have changed the curriculum in the involved programs, and many have resulted in sustained changes, including new methodologies in the simulation center, the development of an “academy” of faculty physicians with significant teaching expertise, and the creation of web-based teaching and assessment tools for “just in time” learning, and have been disseminated at national meetings and in peer-reviewed journals. Conclusions The GME Innovations Grant Program at the University of Michigan Health System has been successful to date, funding 11 proposals during the course of 6 years. Some of these proposals have resulted in permanent changes and additions to residency training programs.

scholarly journals Comparing administrative and clinical data for central line associated blood stream infections in Pediatric Intensive Care Unit and Pediatric Cardiothoracic Intensive Care Unit

2016 ◽  
Vol 8 (3) ◽  
Author(s):  
Jory Bond ◽  
Mohamed Issa ◽  
Ali Nasrallah ◽  
Sheena Bahroloomi ◽  
Roland A. Blackwood
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Administrative Data ◽  
Chart Review ◽  
Pediatric Intensive Care ◽  
Central Line ◽  
University Of Michigan ◽  
Coding System ◽  
The University ◽  
Hospital Acquired

Central line associated bloodstream infections (CLABSIs) are a frequent source of health complication for patients of all ages, including for patients in the pediatric intensive care unit (PICU) and Pediatric Cardiothoracic Intensive Care Unit (PCTU). Many hospitals, including the University of Michigan Health System, currently use the International Classification of Disease (ICD) coding system when coding for CLABSI. The purpose of this study was to determine the accuracy of coding for CLABSI infections with ICD-9CM codes in PICU and PCTU patients. A retrospective chart review was conducted for 75 PICU and PCTU patients with 90 events of hospital acquired central line infections at the University of Michigan Health System (from 2007-2011). The different variables examined in the chart review included the type of central line the patient had, the duration of the stay of the line, the type of organism infecting the patient, and the treatment the patient received. A review was conducted to assess if patients had received the proper ICD-9CM code for their hospital acquired infection. In addition, each patient chart was searched using Electronic Medical Record Search Engine to determine if any phrases that commonly referred to hospital acquired CLABSIs were present in their charts. Our review found that in most CLABSI cases the hospital’s administrative data diagnosis using ICD-9CM coding systems did not code for the CLABSI. Our results indicate a low sensitivity of 32% in the PICU and an even lower sensitivity of 12% in the PCTU. Using these results, we can conclude that the ICD-9CM coding system cannot be used for accurately defining hospital acquired CLABSIs in administrative data. With the new use of the ICD- 10CM coding system, further research is needed to assess the effects of the ICD-10CM coding system on the accuracy of administrative data.

Adult and Pediatric Cochlear Implant Programs at the University of Michigan

1996 ◽  
Vol 5 (1) ◽  
pp. 9-19 ◽  
Author(s):  
Teresa A. Zwolan ◽  
Paul R. Kileny ◽  
Susan Zimmerman-Phillips ◽  
Steven A. Telian
Keyword(s):  
Cochlear Implant ◽  
Cochlear Implants ◽  
Clinical Care ◽  
Team Work ◽  
Team Approach ◽  
University Of Michigan ◽  
Rehabilitation Process ◽  
The Past ◽  
The University

The Cochlear Implant Program at the University of Michigan has evolved over the past several years and is strongly dependent on a team approach to clinical care. Members of the team work closely together to assist patients and their families as they participate in the implant evaluation and rehabilitation process. We feel fortunate that we have been able to help so many profoundly deaf individuals and look forward to continued growth and future advances that will inevitably come about in the field of cochlear implants.

Adrenocortical Tumors: An Integrated Clinical, Pathologic, and Molecular Approach at the University of Michigan

2010 ◽  
Vol 134 (10) ◽  
pp. 1440-1443
Author(s):  
Thomas J. Giordano
Keyword(s):  
Signaling Pathway ◽  
Scientific Discovery ◽  
Clinical Care ◽  
Wnt Signaling Pathway ◽  
Transcriptome Profiling ◽  
Growth Factor Signaling ◽  
University Of Michigan ◽  
Adrenocortical Tumors ◽  
Genome Wide ◽  
The University

Abstract Context.—The University of Michigan Health System has a rich tradition in the study and treatment of endocrine neoplasia. Recently, an integrated clinical and research program focused on primary cancer of the adrenal gland has been developed. Objective.—To discuss the foundation of the University of Michigan Adrenal Cancer Program that consists of 3 components: (1) advancement of excellent clinical care, (2) dissemination of resources and knowledge, and (3) scientific discovery. Data Sources.—Recent programmatic activity includes genome-wide transcriptomic evaluation of human adrenocortical tumors for diagnostic and prognostic evaluation; interrogation of the Wnt signaling pathway in adrenocortical carcinoma, using mouse models and transcriptome profiling; and clinical trials with targeted therapy focused on inhibition of insulin-like growth factor signaling pathway. Conclusions.—This review article presents an overview of this program and its recent activity.

Abstract P282: Which Telestroke Transfers to the Hub Expire or Receive Hospice Within 48 Hours of Arrival?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kristie Chu ◽  
Liang Zhu ◽  
Christy T Ankrom ◽  
Alyssa Trevino ◽  
Michele Joseph ◽  
...  
Keyword(s):  
Clinical Characteristics ◽  
Chart Review ◽  
Significant Proportion ◽  
Stroke Care ◽  
Decision Time ◽  
Demographic Characteristics ◽  
Stroke Severity ◽  
Acute Stroke Care ◽  
Significant Difference ◽  
Race Ethnicity

Introduction: Telestroke (TS) expands access to acute stroke care and facilitates swift transfer of patients to tertiary stroke centers. However, patients transferred from spoke hospitals who expire shortly after arrival raises the question of whether there is opportunity to predict futility of transfer to a higher level of care. We examined acute ischemic stroke (AIS) patients transferred to our hub from TS spoke hospitals and identified who expired or went on to hospice within 48 hours of arrival. Methods: In our TS network, we identified AIS patients who were transferred from spoke hospitals following TS consultation (9/2015 - 12/2018). We compared demographic and clinical characteristics of patients who expired or went on to hospice within the first 48 hours versus those who did not. Hospice decision time was determined by chart review for documentation of goals of care discussions. Results: Of 530 transfers to the hub, there were 32 (6%) patients who expired or went on to hospice within 48 hours. Compared to those who did not, these patients had increased age (OR 1.08; 95% CI 1.05-1.12), higher incidence of atrial fibrillation (OR 2.24; 95% CI 1.02-4.90) or cancer (OR 3.04; 95% CI 1.17-7.87), higher pre-morbid mRS (OR 5.14; 95% CI 1.57-16.88), and higher NIHSS (OR 1.23; 95% CI 1.16-1.31). Interestingly, the same characteristics were also significantly different in those who expired or went on to hospice beyond 48 hours. There was no significant difference in demographic characteristics of sex and race/ethnicity. There was also no significant difference in the frequency of treatment with tPA or IAT; of the 32 patients who expired or went on to hospice within 48 hours, 21 (66%) had received tPA and 3 (9%) had undergone IAT. Palliative care was consulted for 31 (97%) of those patients. Conclusions: A relatively small but significant proportion of TS transfers to our hub expired or went on to hospice within 48 hours. These patients were characterized by increased age, poorer pre-stroke functional status and high stroke severity. In light of the current strain on resources with the pandemic, telepalliative services may help to better serve certain patients, in particular those who are elderly or debilitated, at spoke hospitals without the need for transfer to hub.

Abstract TMP71: Marked Circadian Variation in Number and Type of Hyperacute Strokes During the 24 Hour Day-Night Cycle

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Eeman Khorramian ◽  
Sidney Starkman ◽  
Nerses Sanossian ◽  
David Liebeskind ◽  
Gilda Avila ◽  
...  
Keyword(s):  
Cerebral Ischemia ◽  
Clinical Care ◽  
Circadian Variation ◽  
Resource Planning ◽  
Stroke Care ◽  
Bimodal Distribution ◽  
Acute Stroke Care ◽  
Night Time ◽  
Imaging Characteristics ◽  
Acute Cerebral Ischemia

Background: Circadian variations in stroke onset provide critical information for allocation of prehospital and hospital resources in clinical care and clinical trials. Studies of stroke circadian timing have had conflicting findings, and understanding would benefit from analysis confined to patients with defined onset in waking and clearly distinguished ischemic and hemorrhagic stroke subtypes. Methods: We analyzed all patients enrolled in the NIH FAST-MAG phase 3 trial of field-initiated neuroprotective agent in patients with hyperacute stroke within 2h of onset (last known well). Onset times were analyzed in 1h time blocks throughout the 24h day-night cycle. Patient demographic and clinical features, medical history, imaging characteristics, and stroke deficit severity were evaluated for association with onset times. Results: Among 1632 patients, final diagnoses were acute cerebral ischemia in 76.2% and intracranial hemorrhage in 23.7%. Hourly circadian variation in onset is shown in the Figure. Acute cerebral ischemia (ACI) had a unimodal distribution with peak onset at midday (12:00-12:59); intracerebral hemorrhage (ICH) a bimodal distribution with peaks at mid-morning (08:00-08:59) and early evening (18:00-18:59). Events were markedly reduced in early morning, with only 3.4% starting in the 25% of the day between 00:00-05:59. The proportion of events that were hemorrhagic was higher in the first 8h of the day (00:00-07:59) than the remaining 16h, 33.3% vs 22.5%, p=0.006. Both among ACI and ICH patients, vascular risk factors, presenting deficit severity, and initial brain imaging findings were fairly homogenous throughout all day-night time periods. Conclusion: There is marked, more than 10-fold, circadian variation in onset of acute cerebrovascular disease, and circadian variation in the ratio of ischemic to hemorrhagic neurovascular events. These findings can inform resource planning for regional systems of acute stroke care.

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