HNE Health, Newcastle, NSW, 2305, Australia.
HNE Health, Tamworth, NSW, 2340, Australia.
Infect Dis Health. 2021 Feb;26(1):67-71. doi: 10.1016/j.idh.2020.09.004. Epub 2020 Oct 15.
In 2016, the Australian Commission on Safety and Quality in Healthcare (ACSQHC) released a list of 16 categories of potentially preventable, high impact hospital-acquired complications (HAC) identified by using administrative coded data (ACD). An important category are hospital-acquired infections (HAI). Within this category, hospital-acquired pneumonia (HAP) is among the most frequent complications documented. There are no published studies concerning the current ACSQHC approach to HAI surveillance using ACD and no pneumonia-specific ACD studies reported from Australia. Published work indicates that ACD detection of HAP has low a sensitivity and positive predictive value (PPV). The current study was designed to examine whether coders correctly reflected the documentation of HAP that was present in the medical record and also evaluated the medical documentation that was present.
One hundred patients with ACD encoded HAP were selected for review, drawn from admissions to 2 Hunter New England Health hospitals during 2017. Patient records and the eMR were reviewed by two medical officers to assess medical and radiological documentation of pneumonia. The district coding manager reviewed the accuracy of coding of a subset of 23 cases where medical review had not located documented evidence of HAP.
Of the 100 reviewed cases, the median patient age was 75 years (range 0-95 years) with 3% under 16 years of age. Twenty one were intensive care-associated of which 13 were associated with ventilation. In 23 cases the documentation was disputed and a secondary review took place - the coding manager confirmed coding changes in 14 of these 23 cases.
This study found that administrative coded data of HAP, utilizing the ACSQHC method reliably reflected the available documentation with a PPV of 86% (95% binomial exact confidence interval 77-92%), much higher than documented by previous ACD studies. The actual documentation of pneumonia by medical staff frequently used the non-specific term 'lower respiratory infection (LRTI)' which we recommend to be avoided. Radiological confirmation was absent in one third of cases. We recommend the adoption of a medical note template checklist for HAP to prompt clinicians with the accepted diagnostic criteria. We also recommend documenting a reason as to why any antibiotic has been commenced in a hospitalized patient in accord with the ACSQHC Antimicrobial Stewardship Clinical Care Standard.
2016 年，澳大利亚安全与质量医疗保健委员会（ACSQHC）发布了一份清单，其中列出了使用行政编码数据（ACD）确定的 16 种潜在可预防的、高影响的医院获得性并发症（HAC）类别。其中一个重要类别是医院获得性感染（HAI）。在这一类别中，医院获得性肺炎（HAP）是记录最频繁的并发症之一。目前还没有关于使用 ACD 进行 HAI 监测的 ACSQHC 方法的已发表研究，也没有来自澳大利亚的专门针对肺炎的 ACD 研究报告。已发表的研究表明，ACD 对 HAP 的检测灵敏度和阳性预测值（PPV）较低。本研究旨在检查编码员是否正确反映了医疗记录中存在的 HAP 记录，并评估了现有的医疗记录。
从 2017 年期间在亨特新英格兰卫生区的两家医院接受治疗的 HAP 编码 ACD 的 100 名患者中选择了 100 名患者进行审查。由两名医务人员审查患者记录和电子病历，以评估肺炎的医疗和放射学记录。地区编码经理审查了对 23 例未发现有记录证据的 HAP 病例子集的编码准确性进行审查。
在审查的 100 例病例中，患者的中位年龄为 75 岁（0-95 岁），3%的患者年龄在 16 岁以下。21 例为重症监护相关，其中 13 例与通气有关。在 23 例病例中存在争议，进行了二次审查-编码经理确认对这 23 例中的 14 例进行了编码更改。
本研究发现，使用 ACSQHC 方法的 HAP 行政编码数据可靠地反映了现有的记录，其阳性预测值为 86%（95%二项式精确置信区间为 77-92%），远高于以前的 ACD 研究记录的水平。医务人员记录肺炎的实际情况经常使用非特异性术语“下呼吸道感染（LRTI）”，我们建议避免使用该术语。三分之一的病例没有放射学确认。我们建议采用 HAP 医疗记录模板检查表，以提醒临床医生使用公认的诊断标准。我们还建议记录在住院患者中开始使用任何抗生素的原因，以符合 ACSQHC 抗菌药物管理临床护理标准。
