Identifying children at high risk for infection-related decompensation using a predictive emergency department-based electronic assessment tool

Diagnosis ◽  
2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Robert J. Sepanski ◽  
Arno L. Zaritsky ◽  
Sandip A. Godambe
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Positive Predictive Value ◽  
Firing Rate ◽  
Predictive Value ◽  
Assessment Tool ◽  
Predictive Tool ◽  
High Severity ◽  
Electronic Assessment ◽  
Ed Visits

AbstractObjectivesElectronic alert systems to identify potential sepsis in children presenting to the emergency department (ED) often either alert too frequently or fail to detect earlier stages of decompensation where timely treatment might prevent serious outcomes.MethodsWe created a predictive tool that continuously monitors our hospital’s electronic health record during ED visits. The tool incorporates new standards for normal/abnormal vital signs based on data from ∼1.2 million children at 169 hospitals. Eighty-two gold standard (GS) sepsis cases arising within 48 h were identified through retrospective chart review of cases sampled from 35,586 ED visits during 2012 and 2014–2015. An additional 1,027 cases with high severity of illness (SOI) based on 3 M’s All Patient Refined – Diagnosis-Related Groups (APR-DRG) were identified from these and 26,026 additional visits during 2017. An iterative process assigned weights to main factors and interactions significantly associated with GS cases, creating an overall “score” that maximized the sensitivity for GS cases and positive predictive value for high SOI outcomes.ResultsTool implementation began August 2017; subsequent improvements resulted in 77% sensitivity for identifying GS sepsis within 48 h, 22.5% positive predictive value for major/extreme SOI outcomes, and 2% overall firing rate of ED patients. The incidence of high-severity outcomes increased rapidly with tool score. Admitted alert positive patients were hospitalized nearly twice as long as alert negative patients.ConclusionsOur ED-based electronic tool combines high sensitivity in predicting GS sepsis, high predictive value for physiologic decompensation, and a low firing rate. The tool can help optimize critical treatments for these high-risk children.

Development of a Screen for Ongoing Intimate Partner Violence

2003 ◽  
Vol 18 (2) ◽  
pp. 131-141 ◽  
Author(s):  
Steve J. Weiss ◽  
Amy A. Ernst ◽  
Elaine Cham ◽  
Todd G. Nick
Keyword(s):  
Emergency Department ◽  
Intimate Partner Violence ◽  
Positive Predictive Value ◽  
Partner Violence ◽  
Predictive Value ◽  
Spouse Abuse ◽  
Assessment Tool ◽  
Positive Likelihood Ratio ◽  
Intimate Partner ◽  
Survey Tool

A five-question Ongoing Abuse Screen (OAS) was developed to evaluate ongoing intimate partner violence. Our hypothesis was that the OAS was more accurate and more likely to reflect ongoing intimate partner violence than the AAS when compared to the Index of Spouse Abuse (ISA). The survey included the ISA, the OAS, and the AAS. During the busiest emergency department hours, a sampling of 856 patients completed all aspects of the survey tool. Comparisons were made between the two scales and the ISA. The accuracy, positive predictive value, and positive likelihood ratio were 84%, 58%, and 6.0 for the OAS and 59%, 33%, and 2.0 for the AAS. The OAS was more accurate, had a better positive predictive value, and was three times more likely to detect victims of ongoing intimate partner violence than the AAS. Because the OAS was still not accurate enough, we developed a new screen, based on the ISA, titled the Ongoing Violence Assessment Tool (OVAT).

Atypical Squamous Cells, Cannot Exclude High-Grade Squamous Intraepithelial Lesion: Concordance, High-Risk Human Papillomavirus status, and Positive Predictive Value

2015 ◽  
Vol 4 (6) ◽  
pp. S25-S26
Author(s):  
Mansooreh Eghtesadghalati ◽  
Ruth Dietrich ◽  
Erin Tank ◽  
Michelle Kanter ◽  
John Groth ◽  
...  
Keyword(s):  
Human Papillomavirus ◽  
High Risk ◽  
Positive Predictive Value ◽  
Predictive Value ◽  
High Grade ◽  
Squamous Intraepithelial Lesion ◽  
Squamous Cells ◽  
Intraepithelial Lesion

scholarly journals Reliability of digital panoramic radiography in the diagnosis of carotid artery calcifications

2014 ◽  
Vol 47 (1) ◽  
pp. 28-32 ◽  
Author(s):  
Vilson Lacerda Brasileiro Junior ◽  
Aníbal Henrique Barbosa Luna ◽  
Marcelo Augusto Oliveira de Sales ◽  
Tânia Lemos Coelho Rodrigues ◽  
Priscilla Lopes da Fonseca Abrantes Sarmento ◽  
...  
Keyword(s):  
High Risk ◽  
Carotid Artery ◽  
Positive Predictive Value ◽  
Predictive Value ◽  
Carotid Arteries ◽  
Panoramic Radiography ◽  
Digital Panoramic Radiography ◽  
Significant Difference ◽  
Mcnemar’S Test ◽  
Sensitivity Specificity

Objective The present study evaluated the reliability of digital panoramic radiography in the diagnosis of carotid artery calcifications. Materials and Methods Thirty-five patients under high-risk for development of carotid artery calcifications who had digital panoramic radiography were referred to undergo ultrasonography. Thus, 70 arteries were assessed by both methods. The main parameters utilized to evaluate the panoramic radiography reliability in the diagnosis of carotid artery calcifications were accuracy, sensitivity, specificity and positive predictive value of this method as compared with ultrasonography. Additionally, the McNemar's test was utilized to verify whether there was a statistically significant difference between digital panoramic radiography and ultrasonography. Results Ultrasonography demonstrated carotid artery calcifications in 17 (48.57%) patients. Such individuals presented with a total of 29 (41.43%) carotid arteries affected by calcification. Radiography was accurate in 71.43% (n = 50) of cases evaluated. The degree of sensitivity of this method was 37.93%, specificity of 95.12% and positive predictive value of 84.61%. A statistically significant difference (p < 0.001) was observed between the methods evaluated in their capacity to diagnose carotid artery calcifications. Conclusion Digital panoramic radiography should not be indicated as a method of choice in the investigation of carotid artery calcifications.

scholarly journals Early Prediction of Multiple Organ Dysfunction in the Pediatric Intensive Care Unit

2021 ◽  
Vol 9 ◽  
Author(s):  
Sanjukta N. Bose ◽  
Joseph L. Greenstein ◽  
James C. Fackler ◽  
Sridevi V. Sarma ◽  
Raimond L. Winslow ◽  
...  
Keyword(s):  
High Risk ◽  
Random Forest ◽  
Positive Predictive Value ◽  
Organ Dysfunction ◽  
Predictive Value ◽  
Prediction Models ◽  
Pediatric Intensive Care ◽  
Multiple Organ ◽  
High Risk Group ◽  
Early Prediction

Objective: The objective of the study is to build models for early prediction of risk for developing multiple organ dysfunction (MOD) in pediatric intensive care unit (PICU) patients.Design: The design of the study is a retrospective observational cohort study.Setting: The setting of the study is at a single academic PICU at the Johns Hopkins Hospital, Baltimore, MD.Patients: The patients included in the study were &lt;18 years of age admitted to the PICU between July 2014 and October 2015.Measurements and main results: Organ dysfunction labels were generated every minute from preceding 24-h time windows using the International Pediatric Sepsis Consensus Conference (IPSCC) and Proulx et al. MOD criteria. Early MOD prediction models were built using four machine learning methods: random forest, XGBoost, GLMBoost, and Lasso-GLM. An optimal threshold learned from training data was used to detect high-risk alert events (HRAs). The early prediction models from all methods achieved an area under the receiver operating characteristics curve ≥0.91 for both IPSCC and Proulx criteria. The best performance in terms of maximum F1-score was achieved with random forest (sensitivity: 0.72, positive predictive value: 0.70, F1-score: 0.71) and XGBoost (sensitivity: 0.8, positive predictive value: 0.81, F1-score: 0.81) for IPSCC and Proulx criteria, respectively. The median early warning time was 22.7 h for random forest and 37 h for XGBoost models for IPSCC and Proulx criteria, respectively. Applying spectral clustering on risk-score trajectories over 24 h following early warning provided a high-risk group with ≥0.93 positive predictive value.Conclusions: Early predictions from risk-based patient monitoring could provide more than 22 h of lead time for MOD onset, with ≥0.93 positive predictive value for a high-risk group identified pre-MOD.

scholarly journals Non-mass lesions on screening breast ultrasound

2016 ◽  
Vol 18 (4) ◽  
pp. 446 ◽  
Author(s):  
Jihyun Lee ◽  
Jin Hwa Lee ◽  
Seonmi Baik ◽  
Eun Cho ◽  
Dong Won Kim ◽  
...  
Keyword(s):  
High Risk ◽  
Positive Predictive Value ◽  
Prospective Studies ◽  
Predictive Value ◽  
Breast Ultrasound ◽  
Management Guidelines ◽  
Asymptomatic Patients ◽  
Screening Population ◽  
Mass Lesions

Aim: The purpose of this study was to determine the significance of a non-mass lesion (NML) which is recognized during screening breast ultrasound (US). Materials and methods: We included patients with a NML on screening breast US and no suspicious finding on mammography between March 2008 and June 2012. The final diagnoses were based on pathology results and a clinical or sonographic follow-up for more than 12 months. We calculated the incidence, likelihood of malignancy, and positive predictive value (PPV) of biopsy with a review of imaging and histopathological findings. Results: A total of 17868 screening breast US were performed in 8856 asymptomatic patients. Ninety-five NMLs were detected in 88 patients (1.0%). Among the 93 lesions that were followed or confirmed histopathologically, 2 (2.2%) were malignant, 89 (95.6%) were benign, and 2 (2.2%) were high risk lesions. The likelihood of malignancy in a NML on screening breast US was 2.2% and the PPV of biopsy was 6.3% (2 of 32). Conclusion: The likelihood of malignancy for a NML on screening breast US was greater than 2%. It could be classified as a BI-RADS category 4a lesion and tissue diagnosis is warranted. This provides the potential management guidelines for a NML in screening patients and further prospective studies in a large, multicenter screening population are required.

scholarly journals 838. Oral Vancomycin Prophylaxis Works!

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S10-S10
Author(s):  
Nicholas W Van Hise ◽  
David Hines ◽  
Vishal Didwania ◽  
David Beezhold ◽  
Vishnu Chundi ◽  
...  
Keyword(s):  
High Risk ◽  
Infection Control ◽  
Predictive Value ◽  
Antibiotic Stewardship ◽  
Assessment Tool ◽  
Pay For Performance ◽  
Risk Groups ◽  
Control Measures ◽  
Urban Hospital ◽  
Oral Vancomycin

Abstract Background Clostridium difficile infections (CDI) cause approximately 500,000 cases a year with an estimated cost that exceeds $4.8 billion. Despite interventions that addressed environmental disinfection, antibiotic stewardship, and infection control, many institutions continue to have a significant burden of disease. Public reporting and “pay for performance” have increased the impetus for better control of CDI. We describe the use of an unpublished scoring system to assess the risk of CDI with subsequent use of OVP to prevent exsporulation and infection in high-risk groups. Methods A large urban hospital in the Chicago area of approximately 400 beds, after following recommended guidelines for prevention of C. difficile, instituted an assessment tool to predict the risk of developing C. difficile infection.This is an observational, cohort study reviewing the pre- and post-implementation of OVP (oral Vancomycin prophylaxis) in hospitalized patients. From January 2017 to December 2017, eligible patients were assessed for risk of C. difficile. The intervention period, from January 2018 to December 2018, we prospectively gave eligible patients oral vancomycin (OVP) 125 mg twice daily if the risk score was 13 or above. No changes in environmental cleaning, antimicrobial stewardship, or restriction of testing were instituted during the periods of enrollment. The analysis was approved by the institutional review board. Results In 2017, 82 patients had a score of 13 or over. Of the 82 patients, 72 (87.8%) developed CDI. In 2018, 62 eligible patients had a score of 13 or over and were given OVP. Of the 62 patients, 5 (8%) developed CDI. The relative risk comparing C. difficile in ≥13 vs. <13 patients (RR = 19.2652; 95% CI = 7.3656, 50.3899). The tool is associated with a specificity of 88.54% and sensitivity of 94.67%, along with a negative predictive value of 95.51% and positive predictive value of 86.59%. Fisher’s exact test was performed between OVP and no OVP in relation to the development of CDI in high-risk patients (P < 0.01). VRE rates reported on the antibiogram remained consistent throughout the study period. No significant differences in baseline characteristics were noted. Conclusion In institutions where appropriate infection control measures and antibiotic stewardship have been implemented, the use of a prediction tool to guide OVP is effective in preventing C. difficile. Disclosures All Authors: No reported Disclosures.

P6540Opportunistic screening for atrial fibrillation in an ambulatory geriatric population with a hand held single lead ECG device

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
L A R Zwart ◽  
M E W Hemels ◽  
J R Ruiter ◽  
T Germans ◽  
S Simsek ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Positive Predictive Value ◽  
Outpatient Clinic ◽  
Predictive Value ◽  
Geriatric Patients ◽  
Poor Quality ◽  
Opportunistic Screening ◽  
Geriatric Population ◽  
Handheld Device

Abstract Introduction Atrial fibrillation (AF) is the most common arrhythmia and its incidence rises with age. Especially geriatric patients are at high risk for the development of AF as well as its complications. These high risk patients might benefit the most of oral anticoagulation. AF is however often asymptomatic in these patients and might stay undiagnosed. Purpose To assess the outcomes of opportunistic screening on AF on a geriatric outpatient clinic with a hand held single lead ECG device. Methods All consecutive patients 60 years and older that visited the outpatient clinic between the 1st of June 2017 and the 1st of June 2018 were eligible. Patients who were not able or willing to give informed consent, or had a pacemaker (PM) or internal cardioverter defibrillator (ICD) were excluded. Patients were screened 2 or 3 times at every visit with the MyDiagnostick©, a hand held single lead ECG device with inbuilt algorithm that identifies AF [1]. At baseline all patients underwent a comprehensive geriatric assessment (CGA), including a 12 lead ECG, physical, cognitive and functional assessment and medication review. All baseline ECGs were reviewed by 1 cardiologist and all measurements with the single lead device were reviewed by 2 independent cardiologists. Disagreement about the rhythm on the measurements was resolved by discussion between the cardiologists. Results 498 consecutive patients were eligible for inclusion. We excluded 39 patients: 20 patients had a PM or ICD, 17 did not want to participate and of 2 the medical files were incomplete. A total of 459 patients participated in this study. The mean age was 78±7.3 years and ranged from 60 to 100 years, 245 patients (53%) were female. Patients were known with 5±3 morbidities and used 6±4 different drugs. At baseline 88 (19%) patients were known with AF and AF was first diagnosed in 24 (5%) patients, constituting to an overall prevalence of 23% within this ambulatory geriatric population. Of these 24 patients, 4 (1%) showed AF on their baseline ECG and in 20 (4%) patients AF was found using the handheld device. A total of 1345 measurement with the handheld device were performed, 14 measurements (1%) were of too low quality to use, 32 (2%) were of poor quality, 148 (11%) acceptable and 1151 (86%) were of good quality. Sensitivity of the hand held device for detecting AF is 83.9%, specificity 99.2%, negative predictive value 99.6%, and positive predictive value 72.2%. Conclusions Opportunistic screening for AF with a hand held ECG device has a 5 times higher yield than the standard CGA with an 12 lead ECG at the first visit only. Also, AF can be reliably excluded after a negative measurement. Because of the potential benefit of OAC we advocate screening geriatric patients for AF at every doctor's visit. However, considering the positive predictive value, a confirmatory ECG remains necessary to confirm the diagnosis of AF. Acknowledgement/Funding None

scholarly journals P085: Remember that patient you saw last week – Characteristics of patients experiencing unanticipated death following emergency department discharge

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S95-S95
Author(s):  
R. Hoang ◽  
K. Sampsel ◽  
A. Willmore ◽  
K. Yelle-Labre ◽  
V. Thiruganasambandamoorthy ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Medical Errors ◽  
Medical Error ◽  
Tertiary Care ◽  
Vital Signs ◽  
Diagnostic Error ◽  
Sufficient Information ◽  
Risk Area ◽  
Ed Visits

Background: The emergency department (ED) is an at-risk area for medical error. We measured the frequency and characteristics of patients with unanticipated death within 7 days of ED discharge and whether medical error contributed. Aim Statement: This study aimed to calculate the frequency of patients experiencing death within 7 days after ED discharge and determine whether these deaths were related to their index ED visit, were unanticipated, and whether possible medical error occurred. Measures & Design: We performed a single-centre health records review of 200 consecutive cases from an eligible 458,634 ED visits from 2014-2017 in two urban, academic, tertiary care EDs. We included patients evaluated by an emergency physician who were discharged and died within 7 days. Three trained and blinded reviewers determined if deaths were related to the index visit, anticipated or unanticipated, or due to potential medical error. Reviewers performed content analysis to identify themes. Evaluation/Results: Of the 200 cases, 129 had sufficient information for analysis, translating to 44 deaths per 100,000 ED discharges. We found 13 cases per 100,000 ED discharges were related and unanticipated deaths and 18 of these were due to potential medical errors. Over half (52.7%) of 129 patients displayed abnormal vital signs at discharge. Patients experienced pneumonia (27.1%) as their most common cause of death. Patient characteristic themes were: difficult historian, multiple complaints, multiple comorbidities, acute progression of chronic disease, recurrent falls. Provider themes were: failure to consider infectious etiology, failure to admit high-risk elderly patient, missed diagnosis. System themes included multiple ED visits or recent admission, no repeat vital signs recorded. Discussion/Impact: Though the frequency of related and unanticipated deaths and those due to medical error was low, these results highlight opportunities to potentially enhance ED discharge decisions. These data add to the growing body of ED diagnostic error literature and emphasize the importance of identifying potentially high risk patients as well as being cognizant of the common medical errors leading to patient harm.

Quantitative Monitoring Of Wilms’ Tumor 1 Expression In Predicting Relapse After Allogeneic Hematopoietic Stem Cell Transplantation In Patients With Acute Leukemia and Myelodysplastic Syndrome

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 2075-2075
Author(s):  
Ryotaro Nakamura ◽  
Anna Israyelyan ◽  
Leanne Goldstein ◽  
Weimin Tsai ◽  
Lia Aquino ◽  
...  
Keyword(s):  
High Risk ◽  
Positive Predictive Value ◽  
Myelodysplastic Syndrome ◽  
Negative Predictive Value ◽  
Cell Transplantation ◽  
Predictive Value ◽  
Wilms Tumor ◽  
Allogeneic Hct ◽  
Qrt Pcr ◽  
High Risk Disease

Abstract Relapse is the major cause of treatment failure after allogeneic hematopoietic cell transplantation (HCT) for leukemia and myelodysplastic syndrome (MDS). In order to improve the outcome of leukemia patients after allogeneic HCT, it is imperative to identify reliable markers to predict impending relapse. Wilms’ tumor antigen (WT1) is overexpressed in the majority of leukemia and MDS patients and is being considered as a possible universal diagnostic marker for minimal residual disease (MRD), especially since no chromosomal translocation has nearly the frequency of association as WT1 does with leukemia. In this study we prospectively evaluated the prognostic value of MRD monitoring by qRT-PCR for WT1 transcripts. WT1 transcript levels in peripheral blood mononuclear cells (PBMC) were measured utilizing SYBR-Green qRT-PCR on the ABI7300 instrument (Applied Biosystems, Carlsbad, CA) and results were expressed as a ratio of WT1/c-ABL transcript copies normalized by 104 (WT1 ratio: WT1/c-ABLx104). PBMC samples were obtained monthly for 6 months post-HCT, then on alternating monthly schedule until 3 years post-HCT. Patients >18y.o. with confirmed diagnosis of MDS with <20% blasts, AML/ALL in 1st or 2ndCR, and CML in chronic phase undergoing HCT were eligible for the study. A total of 83 patients (median age: 54, range: 19-74) with AML (n=39), ALL (n=24), MDS (n=17), or CML (n=3) received allogeneic HCT after fully ablative (n=39) or reduced-intensity (n=44) conditioning. Donor sources were matched related (n=33), unrelated (n=50), or umbilical cord blood (n=2). Fifty-one patients were considered low-risk (AML/ALL in CR1, CML in 1stchronic phase, or MDS-RA/RARS subtypes) while the remaining 32 patients were considered high risk. Sixteen of 83 patients relapsed with a median time of 238 days post-HCT (range: 76-747). The minimum WT1 ratio that gave specificity of 100% in predicting relapse was 50 (95% binomial exact CI: 92.5-100%), as none of the non-relapsed patients crossed this level. Of 16 patients who relapsed, 12 crossed the WT1 ratio of 50, providing a sensitivity of 75% (95% binomial exact CI: 48- 93%). The positive predictive value (PPV) and the negative predictive value (NPV) performance parameters for the WT1 ratio of 50 were 100% and 94.4%, respectively (Table 1). There was an average number of 63 days (SD=29.3) from crossing the WT1 ratio of 50 to hematologic relapse for the 12 relapsed patients. Since PBMC samples from healthy donors consistently demonstrated a WT1 ratio <10, we also examined different WT1 cutoff ratios (10 to 50) for their performance characteristics (Table 1). Compared with the WT1 ratio of 50, a cutoff ratio at 20 resulted in an increased sensitivity (87.5%) for relapse prediction and days to relapse (78 days), while the specificity and PPV decreased to 85% and 58.3%, respectively. The performance of the cutoff ratio of 20 was improved on PPV (69%) and days to relapse (85 days) in a subgroup of patients with high-risk disease while maintaining good sensitivity and specificity above 80%. Univariate analysis showed WT1 ratios (as a continuous variable), crossing the WT1 ratio of 20 (as a time-dependent variable), high risk disease, and donor age were significantly associated with relapse. In multivariate analysis, crossing the WT1 ratio of 20 remained the only significant factor predicting relapse (HR 56.9 [18-189], p<0.0001). In summary, our data demonstrate that the quantitative measurement of WT1 transcripts is a reliable marker to assess MRD post-HCT for leukemia patients, and its real-time prospective monitoring provides a 2-3 month window of opportunity to introduce medical/immunologic interventions prior to overt hematologic relapse.Table 2WT1 ratio Specificity Sensitivity Positive Predictive Value Negative Predictive Value Days to Relapse (SD)50100%75%100%94.4%63 days (29)4095.5%75%80%94.1%66.9 days (29)3094%75%75%94%71.5 days (30)2085%87.5%58.3%96.6%78 days (28)1056.7%93.8%34.1%97.4%107.5 days (58) Disclosures: No relevant conflicts of interest to declare.

scholarly journals Positive Predictive Value of ICD-10-CM Definitions for Adolescent Intentional Self-Harm: An Emergency Department Medical Record Review

2020 ◽  
Author(s):  
Anna Hansen ◽  
Dessi Slavova ◽  
Gena Cooper ◽  
Jaryd Zummer ◽  
Julia F Costich
Keyword(s):  
Emergency Department ◽  
Suicide Attempt ◽  
Positive Predictive Value ◽  
Medical Record ◽  
Predictive Value ◽  
Suicide Attempts ◽  
Pediatric Population ◽  
Icd 10 ◽  
Self Harm ◽  
Coding Guidelines

Abstract Background Non-suicidal self-injury and suicide attempts are increasing problems among American adolescents. This study proposed a definition for identifying intentional self-harm injuries (ISHIs) in emergency department (ED) records coded with International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes and sought to estimate: (1) the definition’s positive predictive value (PPV) in a pediatric population treated in one Kentucky ED, and (2) the proportion of Intentional self-harm injuries (ISHIs) with intent to die (i.e., suicide attempt) that cannot be captured by ICD-10-CM codes and can only be identified by a medical record abstraction. Methods The study definition captured initial encounters for ISHIs based on first valid external cause-of-injury self-harm codes in the ICD-10-CM range X71-X83, T14.91, T36-T65, or T71. Medical records for a random sample of 207 ED discharge records were reviewed following a specified protocol. The PPV for the study definition was reported with its 95% confidence interval (95%CI). Results The estimated PPV for the study definition’s ability to capture true ISHIs was 88.9%, 95%CI (83.8%, 92.8%). The estimated percentage of ISHIs with intent to die was 45.9%, 95%CI (47.1%, 61.0%). The ICD-10-CM code “suicide attempt” (T14.91) captured only 7 cases, but coding guidelines allow assignment of this code only when the mechanism of the suicide attempt is unknown. Conclusions This study demonstrated a critical shortcoming in U.S. morbidity surveillance. The ICD-10-CM coding system and coding guidelines do not allow accurate identification of ISHIs with intent to die; modifications are needed to address this issue.

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