Preformatted admission charts for poisoning admissions facilitate clinical assessment and research

doi:10.1016/S0196-0644(99)80049-3

Annals of Emergency Medicine

Volume 34, Issue 4, Part 1, October 1999, Pages 476-482

https://doi.org/10.1016/S0196-0644(99)80049-3 Get rights and content

Study objective: The assessment of patients with poisoning should include assessment of psychiatric details, the level of consciousness, and clinical features occurring in a number of Toxidromes (toxicology syndromes). To ensure these aspects were routinely covered, we introduced a preformatted chart (PFC) to record our poisoning admissions. The aim of our study was to determine whether using a PFC improved the quality, accuracy, and completeness of the data obtained from admissions with poisoning.

Methods: Clinical details recorded on patients admitted with tricyclic antidepressant, neuroleptic, or carbamazepine poisoning between 1987 and 1994 were compared according to whether a PFC was used. A large number of items of history and examination of interest in poisonings were analyzed. The reproducibility of the findings recorded on the PFCs was measured in 20 patients. Findings initially recorded on the chart in the emergency department were compared with those recorded within the next 30 minutes by a second more experienced observer who did not have reference to the initial record.

Results: There were large and statistically significant differences in the completeness of recording of neurologic examination, such as pupil size (100% versus 68%), conjugate eye movements (97% versus 35%), deep tendon reflexes (97% versus 51%), and in the percentage that were reported as having abnormal signs, such as dilated pupils (26% versus 14%), nystagmus (12% versus 5%), and hyperreflexia (19% versus 8%). In all cases, more information was recorded when a PFC was used; however, the differences were small for items such as vital signs and drugs ingested. Agreement between 2 observers for history and examination was moderate to good, with items on history and level of consciousness generally recorded with greater agreement than other examination findings, perhaps reflecting fluctuations in these signs.

Conclusion: Data collected prospectively with a PFC collects more information than can be obtained retrospectively from case records. In particular, the validity of data on clinical signs on presentation gained from retrospective chart review is questionable. Centers that are interested in collecting data on series of poisonings would benefit from using a PFC or some other systematic prospective method of data collection.

References (9)

BuckleyNA et al.
Greater toxicity of dothiepin in overdose than of other tricyclic antidepressants
Lancet
(1994)
GilbertEH et al.
Chart reviews in emergency medicine research: Where are the methods
Ann Emerg Med
(1996)
DavenportRJ et al.
Improving the recording of the clinical assessment of stroke patients using a clerking pro forma
Age Ageing
(1995)
HumphreyT et al.
Preformatted charts improve documentation in the emergency department
Ann Emerg Med
(1992)

There are more references available in the full text version of this article.

Cited by (51)

Trends in recreational poisoning in Newcastle, Australia, between 1996 and 2013
2016, Drug and Alcohol Dependence
Citation Excerpt :
Specifically, we hypothesized that young males would be most likely to present for recreational poisoning, and that alcohol would be the most common drug ingested. Data was acquired from a cohort study from 1987 to 2014 of consecutive poisoning presentations to HATS (Buckley et al., 2015, 1999). In 1996, the database underwent changes and data collection was modified.
Poisoning that occurs as the result using alcohol or drugs for recreational purposes or to induce rewarding psychoactive effects (“recreational poisoning”) represents significant harm attributed to drug use. There has been limited focus on recreational poisoning separately from hospital admissions for general harms related to alcohol or drug use. This study aims to detail the drug trends and patient population represented in recreational poisonings in Newcastle, Australia.
Naturalistic analysis of consecutive hospital presentations following poisoning between January, 1996 and December, 2013 was conducted using data from the Hunter Area Toxicology Service (HATS). 13805 patient records were included (aged 18–98), 1209 (8.8%) of those were recreational poisonings.
Compared to non-recreational poisonings, recreational poisonings were more likely to occur in males than females (OR = 2.87, 95% CI: 2.44–3.40, p < 0.001) and in patients under the age of 30 compared to their older counterparts (OR = 1.58, 95% CI: 1.35–1.85, p < 0.001). Hospital presentations for recreational poisonings were more likely to occur between 0300 and 0600 h than 0900–1700 h (OR = 3.07, 95% CI: 2.29–4.11, p < 0.001) and more likely to occur on the weekend than on a Monday. Overall, recreational poisoning admissions declined over time.
Overall, the trends reported in this analysis reflect general use and availability of alcohol and illicit substances in Australia over the time period. Looking at specific sub-types of alcohol and drug-related harm, like poisoning, is important for service planning and government initiatives.
Critical Aspects of Emergency Department Documentation and Communication
2009, Emergency Medicine Clinics of North America
Citation Excerpt :
Marill and colleagues24 confirmed this reimbursement improvement and added the advantage of physician satisfaction when they compared the T-System of paper templates (Emergency Services Consultants, Irving, TX) with undirected written documentation. Other studies have also shown documentation improvements in areas such as asthma,25 head injury,26 and poisonings.27 Numerous electronic versions of complaint-specific charts have also been developed,28 and they carry the same advantages and disadvantages discussed previously.
The toxidromes
2006, Reanimation
Les toxidromes ou syndromes toxiques recouvrent un ensemble de symptômes qui résultent de l'action toxicodynamique des xénobiotiques. Ces symptômes représentent une constellation de signes cliniques, biologiques et/ou électrocardiographiques qui orientent le clinicien vers une classe particulière de toxiques. Ils représentent le tableau clinique caractéristique mais non spécifique d'une intoxication. Il peut s'agir d'une intoxication aiguë suite à la prise d'un médicament, ou d'une drogue mais aussi d'un sevrage. L'intérêt de la connaissance du toxidrome réside dans l'aide au diagnostic, dans l'indication d'antidotes et la surveillance des intoxications aiguës qu'il procure. L'examen clinique doit être complet et répété dans la prise en charge des intoxications et ne doit pas se focaliser sur la seule recherche des éléments d'un toxidrome. Cependant, certains toxiques (lésionnels) ou certaines situations (polyintoxication ou complications) ne s'accompagnent pas de toxidromes définis. Les principaux toxidromes sont représentés par : le syndrome opioïde, de myorelaxation, anticholinergique, adrénergique, stabilisant de membrane, sérotoninergique et d'hyperthermie maligne.
Toxidromes or toxic syndromes include a combination of signs and symptoms resulting from the toxicodynamic action of xenobiotics. They include a myriad of clinical, biological and/or electrophysiological signs, which help the physician to identify the class of toxin involved. Toxidromes evidence the characteristic, but nonspecific, clinical signs of poisoning. Acute intoxication may be caused by a prescribed drug, an illicit drug or may result from a withdrawal syndrome. Recognition of toxidromes is crucial for the prompt diagnosis, monitoring and management (possibly with an antidote) of poisoned patients. The physical examination must be thorough, repeated regularly and should not merely focus on specific toxic signs. Although toxidromes are not always present in patients exposed to certain toxins, the most common toxic syndromes are: opioid, benzodiazepine, anticholinergic, sympathomimetic, and serotonin. Malignant hyperthermia is also a common toxidrome.
Improved documentation of wound care with a structured encounter form in the pediatric emergency department
2005, Ambulatory Pediatrics
Objective.—Accurate and complete documentation may enhance reimbursement and compliance with financial intermediary regulations, protect against litigation, and improve patient care. We measured the effect of introduction of a structured encounter form on the completeness of documentation of pediatric wound management in a teaching hospital.
Methods.—The Children's Hospital Emergency Department introduced a structured encounter form for use in the documentation of wound care in place of the existing free-text dictation method. Attending physicians and trainees, all unaware of the study, had the option of using the form in place of free-text dictation for patients with lacerations requiring closure. We abstracted 100 consecutive free-text dictations from patients treated before the form's introduction. Following a 3-month run-in period, we abstracted 100 consecutive structured wound records. We compared the 2 chart types for completeness of documentation based on 20 predetermined criteria relevant to pediatric wound care.
Results.—Overall completeness of documentation improved with structured forms (80% vs 68% for free text, P < .001), with significant improvements in 6 of 20 individual criteria. Trainees demonstrated improvement in documentation with the structured form, with the greatest improvements among senior-level residents. Documentation of the general physical examination worsened with structured charting.
Discussion.—In an academic pediatric emergency department, the use of a structured complaint-specific form improved overall completeness of wound-care documentation. Structured encounter forms may provide for more standardized documentation for a variety of pediatric chief complaints, thereby facilitating communication and ultimately transition to template-driven systems in anticipation of an electronic medical record.
Self-poisoning by older Australians: A cohort study
2017, Medical Journal of Australia
Citation Excerpt :
HATS routinely records data for patients who present to hospital (even if the poisoning is uncomplicated) in a purpose-built database.10 A structured data collection form is used by HATS to prospectively capture information about patient demographics (age, sex), the drugs ingested, co-ingested substances, previous suicide attempts, whether the overdose was intentional or unintentional, management (including intensive care unit [ICU] admission), and complications of poisoning (hypotension, arrhythmias, ventilation requirement, death).11 At discharge, further information is collected, including hospital length of stay [LOS], and psychiatric and substance misuse diagnoses.
To examine the epidemiology and severity of self-poisoning by older people in Australia; to compare these data with those for overdoses in younger adults.
A cohort study of people presenting to a tertiary toxicology centre after self-poisoning over 26 years (1987–2012).
Hospital length of stay (LOS); types of drug ingested; intensive care unit (ICU) admissions; in-hospital deaths.
Of 17 276 admissions, 626 patients (3.6%) were at least 65 years old. There was a steady decline in the number of overdoses with age. Most self-poisoning by older people was intentional (80% of admissions), but the proportion of unintentional poisonings increased with age (P < 0.001). Median LOS for older patients was 34 h (interquartile range [IQR], 16–75 h), longer than for younger patients (16 h; IQR, 9–25 h; P < 0.001). 133 older patients (21.2%) were admitted to an ICU, compared with 1976 younger patients (11.9%; P < 0.001). 24 older patients (3.8%) and 93 younger patients (0.6%) died; mortality among older patients declined over time. Hypotension and arrhythmias were more common in patients over 65. Benzodiazepines (24%) were the drugs most commonly ingested by older patients, but opioids the most frequently taken drugs in fatal cases. Toxic ingestion of cardiovascular drugs increased threefold over the 26 years; about one-third of poisonings were unintentional or iatrogenic. Recreational drugs were implicated in the admissions of four older patients (0.6%), but in 7.8% of those of people under 65.
Older patients treated for self-poisoning differ in several important respects from patients under 65. They are more severely affected by self-poisoning: LOS is greater, and ICU admission and mortality rates are higher.
Compliance with national snakebite treatment guidelines in rural Sri Lankan hospitals: a cluster randomized controlled trial of a brief educational intervention
2023, BMC Medical Education

View all citing articles on Scopus

View full text

Preformatted admission charts for poisoning admissions facilitate clinical assessment and research

Lancet

Ann Emerg Med

Improving the recording of the clinical assessment of stroke patients using a clerking pro forma

Age Ageing

Preformatted charts improve documentation in the emergency department

Ann Emerg Med