Dr Eddy Lang: Making the Most of Chart Reviews

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A few months back Dr Eddy Lang [Co-editor of the Royal College Research Guide [link]] graced us with his kind and friendly personality and dropped some pearls on retrospective chart reviews.

Medical Record Review [MRR] Research in General

“Chart reviews don’t get  the respect they may deserve” Dr Lang

Dr Lang lamented the fact that MRR doesn’t get the street cred it deserves. This is large part because of a historical pattern of:

  • Wrong questions
  • Poor methods
  • Action/Documentation Divide = what happened vs what was documented
  • Missing Data
  • Case identification

Gilbert and others. 1996. Chart Reviews in Emergency Medicine [Pubmed link] showed that 25% of EM publications between 1988-1995 relied on chart reviews. However, although inclusion citeria were present 98% of the time, important data regarding methodology was generally absent:

  • abstractor training, 18% (95% CI, 13% to 23%)
  • standardized abstraction forms, 11% (95% CI, 7% to 15%)
  • periodic abstractor monitoring, 4% (95% CI, 2% to 7%)
  • abstractor blinding to study hypotheses, 3% (95% CI, 1% to 6%)
  • Interrater reliability was mentioned in 5% (95% Cl, 3% to 9%) and tested statistically in 0.4%

In their article – Gilbert et. al. lay out their solutions

The 7 Key Ingredients of good MRR:

 1. Abstractor Training: Need to convince the reader that the people pulling the charts

  • Describe the Qualifications and Training procedure for the data Abstractors
  • before the study begins pull some Trial charts to Test the data abstraction process

2. Case Selection: Needs to be explicit and well described

  • Administrative codes is a start but has flaws
    • Often this can lead to a substudy [i.e do the ultimate codes reflect the Dx?]
  • Clear inclusion/exclusion criteria
  • Screening procedures must be solid

3. Definition of the variables: Need to be done well

  • Dictionary – define things e.g. vitals signs … at triage? by the EP? on reassessment?
  • Timing and Source of the info needs to be described
  • Adjudication – how are you going to categorise contradictions and inconsistencies?

4. Data Abstraction Tool: Make it good

  • need to have a standardised data abstraction tool – use your research staff here
  • need to have a uniform process of handling missing data  – need to think about what to do with missing or unclear data
  • Consider using software to manage data [e.g. Using Redcap Software [link]

5. Blinding:

  • Are the abstractors unaware of the study hypothesis? – consider quizzing them afterwards to see!

6. Quality Control

  • regular meetings to ensure standard process
  • need to monitor the abstractors work – consider audits
  • resolution of conflicting assessments

7. Inter-rater reliability: Report inter-rater reliability – it’s eKspected …get it?

  • reported on a sample of charts reviewed by another [blinded] reviewer

Eddy then introduced another landmark article by Jansen and others who created a guideline on how to conduct MRR – [Pubmed Link]

Criteria to Follow

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Dr Lang finished by giving us some examples of good MRR

Instructive Examples – MRR CAN change practice!

Answer questions that change local practice … e.g. Eddy’s 1995 Publication on the prognostic value of amylase in the evaluation of the abdominal pain patient. [Pubmed Link]

  • Pulled lab results
  • Showed that there was no difference between patients with intermediate levels of amylase and normal patients

Answer questions that change global practice e.g. Ross Baker et al Canadian Adverse Events Study [Pubmed Link]

  • Retrospective review of 3500 charts from 5 provinces in Canada
  • Sowed an AE rate of 7.5 % which translates into 70, 000 annual AE’s in Canadian hospitals
  • placed the spotlight on patient safety

Good MRR Questions

How are we doing? [care practices, quality of care e.g. Look at time to analgesia after intro of new acute pain protocol for say... renal colic]

What does this condition look like? [e.g looking for key word search "Rugby" ... pull charts associated with rugby injuries]

Derivations Models  [e.g. Risk Factors for Hospitalization after Dog Bite injury [Pubmed Link]]

Ethics of MMR?

  • Are there ways to bypass ethics? Yes! If it’s labeled as “more QI” may not require full ethics look and have “expedited review”
  •  Consider using the ARECCI Ethics Screening Tool [Link]

Last word on our guest speaker:

I have known Eddy for a few years, having collaborated on a couple of occasions putting on workshops at SAEM and CAEP. He is one of Canada’s best researchers, a solid ER doc, a great dad and family man and a true ambassador for Emergency Medicine. Thanks Eddy for letting me replay your words of wisdom.

My Ideas/Homework:

  1. Buy that Royal College Guide
  2. Start in on a Project:
    1. Renal Colic after new pain protocol – time to analgesia
    2. Time to EKG after New Protocol
    3. Reduction in Flex/Ex Ordering after journal club on C spine
    4. Reduction in Time in ER after New HS Trop
    5. Change in medication use in migraine after Journal Club
    6. Management of abscesses [packing vs loops] after our Journal CLub



The post Dr Eddy Lang: Making the Most of Chart Reviews appeared first on ERMentor.

It’s a Patient Hand-Off Miracle

Transitions of care – more frequent now in medicine than ever before – are fertile opportunities for error and miscommunication.  Most institutions have developed, at least, informal protocols to exchange patient information during hand-off.  But, certainly, everyone has some anecdotal tale of missed information leading to a near-miss or actual patient harms.

This study tells the story of I-PASS, a handoff bundle implemented and measured as an error prevention strategy by a pre- and post-intervention study design.  Across 9 pediatric residency training programs, residents were observed for six months for time spent in hand-offs, time spent in patient care, and a variety of classifications of preventable and non-preventable errors.  Then, the I-PASS bundle was introduced – a structured sign-out mnemonic, a 2-hour workshop on communication skills, a 1-hour role-playing and simulation intervention, a faculty development program, direct-observation tools, and a culture-change campaign with a logo, posters, and other promotional activities.

Following the intervention, residents were, again, observed for six-months.  And, in general, preventable medical errors decreased a small absolute amount, along with a larger absolute decrease in near misses.  2 of 9 hospitals had increases in medical errors after the interventions, and the bulk of the effect size was a result of improvements at two hospitals whose baseline error rate was double that of the other 7 facilities.

The authors, then, are very excited about their I-PASS bundle.  But, as they note at the end of their discussion: “Although bundling appears to have been effective in this instance, it prevents us from determining which elements of the intervention were most essential.”  And, on face validity, this is obvious – the structured sign-out sheet was only one of many quality improvement interventions occurring simultaneously.  A decisive change in culture will trump the minor components of implementation anytime.

The final takeaway: if your institutional audit reveals handoff-related errors are pervasive and troublesome, and if reductions in such errors are prioritized and supported with the correct resources, you will probably see a reduction.  The I-PASS tool itself is not important, but the principles demonstrated here probably are.

“Changes in Medical Errors after Implementation of a Handoff Program”

Episode 24: What do I read, and how do I do it?

In Episode 24, EM Res vets Drs. Kaminstein and Kochert return with Dr. Becker’s debut to talk about how residents should approach reading medical research articles.  Do you need to read everything?  What should you read?  How do you do it?  All this and more in the first of a series on reading original research for residents.  

The first thing you need to know is that if you are an intern, and maybe even a second year, it is ok if you are not keeping up to date on the latest and greatest in original EM research.  The most important thing you can do during this time is to cover the basics.  Develop your basic knowledge and skills in EM.  

Once you do delve into research, pick one or two journals to start out with.  Annals of EM and Journal of EM come to mind (full disclosure: I am on the Annals Social Media team, and on the AAEM YPS board).  Once you have a journal or two, skim the titles and see what interests you.  If you see an interesting title, read the abstract and see if the full article is worth your time.  

Remember, once you start reading, the discussion is the writer’s chance to slant their results as they see fit.  There is a reason this section is last - it should be the least important part of your analysis.  

Think about articles in PICO format.  

P: What type of patient are they looking at/what is the patient population?

I: What is the intervention?

C: What is the control?

O: What are the outcomes?

This should give you the foundation to start.  This is the first in a series of podcasts where we will cover more advanced topics so that you too can be able to critically read and appraise the medical literature by the time you are done with your EM residency.  

Here are some great resources cited during our discussion:

The Skeptics Guide to EM

Emergency Medicine Abstracts


EM Literature of Note

EM Nerd

EM Journal Watch

EM:RAP paper chase


A few announcements:

  1. I have been away for the last month working on Emergency Board Review!  Go check it out.  Check out our latest review lecture on nervous system disorders.  Find the lectures on our podcast on iTunes, or any podcast software.  Check out the revamped website, rate the board review resources, and get involved.  Are you an upper level resident and want to help out with the Emergency Board Review project?  Get in touch with me at bobstuntzmd@gmail.com, or use the website contact form if you are interested in any of the open topics
  2. Want to write for the EM Res Blog?  Have an idea for an article, or even a series (US of the week, Image of the week…)?  Want to help with podcast episodes?  I want to expand the EM Res Blog and Podcast, but I need your help to do it.  Residents, educators, anyone anywhere - send your ideas to me at bobstuntzmd@gmail.com or @BobStuntz, and let’s see if we can make this thing even better!
  3. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  
  4. Allowed to use my podcasts for asynchronous learning?  Check out the test below!

Check out the podcast below, or go listen here

If you have gotten approval from your program director to use the EM Res Podcast for individualized interactive instruction (asynchronous learning), the check out the test below or go take it Posted in , , , |

Developmental Milestones in the ED

Developmental Milestones


Full Disclosure: I am the proud product of Combined Emergency Medicine and Pediatric training (thank you mentors Mattu, Rogers, Winters, Carraccio et al at U of Maryland).  As such, I worked nearly equal amounts of time in the Emergency Department (caring for kids and adults) as I did in my Pediatric clinic over 5 years of residency.  That being said, there is a reason I do Emergency Medicine… I could not stand going through the assessment of kids’ Developmental Milestones in the clinic!  Certainly it is important… but not for me in the ED… right?  Actually, there are many aspects of Developmental Milestones that can be useful to the vigilant clinician in the Pediatric ED.


Not Trying to Make You a PCP

  • Many of us in the ED have violent expulsion of gastric contents at the mere mention of considering any topic that is related to primary care.
  • While that is understandable (much like, we would not expect or want a Primary Care Physician to be expert in the EM realm), it is still useful to know some topics that bridge both worlds.
    • Some EM clinicians are serving as the only access to care a patient has… and need to know some primary care issues.
        • Almost 30% of 6- to 36-month-old children presenting to an urban PED without prior developmental concerns screened positive for possible delay. (Grossman, 2010)
    • Prescription of Controller Medications for Asthma is a good example of this (see Twitter conversation for additional thoughts).
  • Childhood Development is another topic that is not typically placed within the EM realm.
    • A full development assessment is actually beyond what can be done in a typical pediatrician’s office schedule.
    • Knowledge of basic developmental milestones, however, can help detect important aberrations that warrant further assessment.
    • This is particularly true with respect to the very young, as this can have implications in their neurologic exam.
    • This is similar to how knowledge of typical growth estimates can help you manage a child in the ED.


Developmental Milestones Basics


Typical Infant Developmental Milestones

  • Again, kids achieve milestones are various paces… so these are just estimates… but can help define marked abnormalities.
  • Motor
    • Head Posture / Control
      • 8 weeks – can hold head up while prone
      • 12 weeks – has some head lag when being pulled from supine position
      • 20 weeks – no head lag
      • 6  months – complete head control
    • Fine Motor
      • 2 months – grasps offered item
      • 4 months – reaches for objects. Brings hands to mouth (now we are in trouble)
      • 6 months – transfers objects form one hand to another
    • Gross Motor
      • 2 months – begins to push up while prone
      • 4 months – able to roll from tummy to back (essentially pushes self over). Bears weight on legs when feet are on a surface. Sits with curved spine.
      • 6 months – able to roll from back to tummy. Can sit without support.
      • 9 months – sits with straight spine.
      • 18 months – should sit, stand, and walk independently.
  • Social / Language
    • 2 months – attempts to look at parents.  Smiles.  Coos.
    • 4 months – smiles at people spontaneously.
    • 6 months – indicates desire to be picked up.  Knows familiar faces and recognizes when someone is a stranger.  Babbles.
    • 9 months – the height of separation anxiety! Plays “peek-a-boo” and waves “bye-bye.”  Understands “No.”
    • 12 months – knows one – two words.
    • 18 months – knows three – six words (body parts often).
    • 24 months – uses two word phrases.
    • 36 months – uses three word sentences.
  • Cognitive
    • Language and Social milestones are closely tied with Cognitive milestones, particularly early on.
    • 2 months – regards faces, has differential coos and cries and can indicate wants.
    • 4 months – reaches for objects, uses hands and eyes together.
    • 6 months – shows curiosity. Uses visual and oral exploration of environment.
    • 9 months – has object permanence (looks for item when it is hidden). Learns interactive games.
    • 12 months – can follow simple instructions. Bangs objects together.



Noritz GH, Murphy NA; Neuromotor Screening Expert Panel. Motor delays: early identification and evaluation. Pediatrics. 2013 Jun;131(6):e2016-27. PMID: 23713113. [PubMed] [Read by QxMD]

Grossman DS1, Mendelsohn AL, Tunik MG, Dreyer BP, Berkule SB, Foltin GL. Screening for developmental delay in high-risk users of an urban pediatric emergency department. Pediatr Emerg Care. 2010 Nov;26(11):793-7. PMID: 20944512. [PubMed] [Read by QxMD]

The post Developmental Milestones in the ED appeared first on Pediatric EM Morsels.


Dice la RAE: Maldad, injusticia grande.

Desde luego es algo que no nos gusta a nadie...pero hay algunos que se lo toman francamente mal. Lo bueno empieza en el minuto 1:34.

Que conste que creo que en sanidad tenemos bastante  de esto.

The Pace of Life, supporting ICU of Galdakao at Videomed

Hola a tod@s, my dear friends:

Today we want to support to our partners of the ICU of Hospital de Galdakao.

From November 17 to 21 in Badajoz will take place the 19th  International Competition of Medical Cinema, Health and Telemedicine, VIDEOMED 2014.

We would like to thanks again to Dr. Luis Fernandez-Yarritu Suárez, head of that service. We can enjoy, support and spread their video in the competition. Powerful message in less than 3 minutes.

Here it is. I am sure that you will love and we need you to help in sharing the video to your contacts. Because it is the essence of the ICU.

And because teaching also form part of our specialty. What is not given, is lost.

Congratulations mates, I am sure that you are already winners for all friends of IC-HU project.

We continue providing intensive medicine.

We are professionals of the critical patient and work as a team. A world reference.

Good luck mates!

Happy Friday,