Evelyn M. Kasworm

Electronic screening of dictated reports to identify patients with do-not-resuscitate status.

OBJECTIVE Do-not-resuscitate (DNR) orders and advance directives are increasingly prevalent and may affect medical interventions and outcomes. Simple, automated techniques to identify patients with DNR orders do not currently exist but could help avoid costly and time-consuming chart review. This study hypothesized that a decision to withhold cardiopulmonary resuscitation would be included in a patients dictated reports. The authors developed and validated a simple computerized search method, which screens dictated reports to detect patients with DNR status. METHODS A list of concepts related to DNR order documentation was developed using emergency department, hospital admission, consult, and hospital discharge reports of 665 consecutive, hospitalized pneumonia patients during a four-year period (1995-1999). The list was validated in an independent group of 190 consecutive inpatients with pneumonia during a five-month period (1999-2000). The reference standard for the presence of DNR orders was manual chart review of all study patients. Sensitivity, specificity, predictive values, and nonerror rates were calculated for individual and combined concepts. RESULTS The list of concepts included: DNR, Do Not Attempt to Resuscitate (DNAR), DNI, NCR, advanced directive, living will, power of attorney, Cardiopulmonary Resuscitation (CPR), defibrillation, arrest, resuscitate, code, and comfort care. As determined by manual chart review, a DNR order was written for 32.6% of patients in the derivation and for 31.6% in the validation group. Dictated reports included DNR order-related information for 74.5% of patients in the derivation and 73% in the validation group. If mentioned in the dictated report, the combined keyword search had a sensitivity of 74.2% in the derivation group (70.0% in the validation group), a specificity of 91.5% (81.5%), a positive predictive value of 80.9% (63.6%), a negative predictive value of 88.0% (85.5%), and a nonerror rate of 85.9% (77.9%). DNR and resuscitate were the most frequently used and power of attorney and advanced directives the least frequently used terms. CONCLUSION Dictated hospital reports frequently contained DNR order-related information for patients with a written DNR order. Using an uncomplicated keyword search, electronic screening of dictated reports yielded good accuracy for identifying patients with DNR order information.

Low Incidence of Toxic Shock Syndrome in Children with Staphylococcal Infection

Children have frequent staphylococcal infections, and many lack antibody to TSST-1, a toxin associated with the toxic shock syndrome (TSS). To determine why there have been no nonmenstrual cases of TSS reported in children in Utah, the authors tested S. aureus isolated from children for TSST-1 by radial immunodiffusion and sera from other hospitalized children by radioimmunoassay for antibody to TSST-1. TSST-1 was produced by 25% of S. aureus. Fifty-two children had infections with toxin producing strains. None had TSS. The prevalence of presumably protective levels of antibody (⩾1: 100) was high in newborns (80%), declined until age 2 years and then gradually increased with age. Therefore, there may have been about 20 children with toxigenic infection who lacked protective antibody but did not show the usual features of TSS. We conclude that the rarity of TSS in children is not caused by misdiagnosis, underreporting, or the absence of toxigenic strains or susceptible patients. Additional factors, such as local conditions or duration of carriage, may influence the clinical presentation of infection with TSST-1 producing staphylococci.

Effect of bacteriologic monitoring of urinary catheters on recognition and treatment of hospital-acquired urinary tract infections.

Catheter-associated urinary tract infections remain the most common hospital-acquired infection. Regular bacteriologic monitoring of urine from catheterized patients has been advocated as a measure for reducing the morbidity associated with this infection. To assess the effectiveness of this measure we reviewed the records of 100 catheterized patients hospitalized before implementation of a monitoring program and 200 such patients admitted after a daily monitoring program was operational. We found that culturing urine from catheterized patients was infrequent prior to monitoring but, when done, patients usually were febrile, cultures usually were positive, and patients were treated. Monitoring identified more cases of bacteriuria, but less than half of the patients so identified were treated. Being febrile was associated with receiving antibiotics. Infection rates increased with duration of catheterization; long periods of catheterization typically occurred on the neurosurgical, orthopedic, and medical services. Daily bacteriologic monitoring of all catheterized patients is relatively inefficient and does not predictably lead to therapeutic intervention in infected patients. The cost:benefit ratio of this measure might be decreased by applying it to selected patients chosen on the basis of risk factors, including hospital service assignment.

May I take your order: a user-friendly resuscitation status and medical treatment plan form.

Practice did not conform with our hospitals Do Not Resuscitate (DNR) policy. We sought explanations and suggestions from parties involved in the DNR order process. From what we learned, we developed an easy to use, specific form for Resuscitation Status and a Medical Treatment Plan. Surveillance of form use indicates we have addressed unrealistic expectations about efficacy of CPR, improved documentation of Do Not Attempt Resuscitation (DNAR) discussions, and clarified DNAR orders and other medical treatments intended for DNAR patients.