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A1482 - Measuring the Quality of Shock Care - Validation of a Chart Abstraction Instrument
Author Block: N. Mould-Millman1, J. Dixon1, J. Thomas2, T. Burkholder1, N. Oberfoell3, S. Oberfoell4, K. McDaniel2, H. Meese2, S. de Vries5, L. Wallis6, A. Ginde1; 1Emergency Medicine, University of Colorado, School of Medicine, Aurora, CO, United States, 2University of Colorado, School of Medicine, Aurora, CO, United States, 3Family Medicine, Saint Joseph Hospital, SCL Health, Denver, CO, United States, 4Emergency Medicine, Denver Health System, Denver, CO, United States, 5Emergency Medical Services, Western Cape Government Health, Cape Town, South Africa, 6Emergency Medicine, University of Cape Town, Cape Town, South Africa.
RATIONALE. Shock is a leading cause of global morbidity and mortality. High quality shock care improves clinical outcomes. This study fills a research and quality assurance gap by developing a valid and reliable instrument that assesses the clinical quality provided in shock care.
METHODS. Investigators selected prehospital trauma hemorrhagic shock care as the prototype condition. In Phase I, a panel of eight experts participated in a modified Delphi process to cognitively validate the construct and content of a desired chart abstraction instrument. In Phase II, a draft instrument was operationalized, pilot tested, and iteratively refined by investigators. In Phase III, three trained data collectors, blinded to outcome, abstracted 50 traumatic shock patients’ charts (amongst a high incidence trauma population in South Africa). Abstraction times were recorded, and abstracted data stored online in REDCap. In Phase IV, physician content experts cross-reviewed 50 charts to provide gold standard quality of care scores (Likert scale 1-5). Analyses: Intra- and inter-rater reliability of data collectors’ scores were calculated using a Cohen’s kappa test. Correlation of abstracted data with gold standard physician responses was conducted using a Fisher’s Exact Test. Analyses were performed in SAS, 9.4. Ethics approvals were granted from the relevant institutional boards.
RESULTS. In Phase I, the expert panel selected 10 domains that represented high quality traumatic shock care. Five domains were considered “core” to hemorrhagic shock care: (i) hemorrhage control, (ii) oxygen delivery, (iii) IV catheter insertion, (iv) transport to appropriate facility, and (v) short scene times. Five domains were agreed as important but “non-core.” In Phase II, the 10 domains were operationalized into 46 abstraction elements (data fields). In Phase III, mean chart abstraction time was 10.5 minutes (SD=2.3). Mean crude agreement of data collectors versus gold standard was 86%. Of the 46 chart abstraction elements, 22 (54%) had substantial (kappa ≥ 0.6) and five (12%) had moderate (kappa ≥ 0.4) inter-rater agreement. Intra-rater reliability demonstrated kappa scores ≥ 0.4 (i.e. moderate reliability). Physician gold standard reviews indicated poor scores for mean quality of care (2.16/5.0; SD=1.12). Seven of ten chart abstracted domains, including all “core” domains, were significantly correlated with gold standard quality of care.
CONCLUSIONS. The initial version of this novel chart abstraction instrument is feasible, valid, and reliable for use by trained data collectors. Further enhancements will optimize instrument performance. The final instrument will be useful in assessing shock care in quality assurance and research initiatives.