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Poster 337 Strengthening Information Capture in Rehabilitation Discharge Summaries: An Application of the Siebens Domain Management Model
PM&R
ited weight bearing, use of a rolling walker, physical therapy, and cesarean section delivery for both patients due to increased fracture risk with epidural anesthesia and vaginal delivery in the dorsal lithotomy position. Setting: Tertiary care women’s hospital. Results or Clinical Course: Physiatric recommendations were followed and both women underwent cesarean section delivery without complication. At follow up several months postpartum, both patients’ symptoms and physical examination findings had improved significantly and they no longer required assistive devices for ambulation. Discussion: These are the first reported cases of TOP of bilateral hips in women with twin gestation from in vitro fertilization. The pathogenesis of TOP of bilateral hips for these patients is unknown yet may be related to their age, hormonal changes, fertility treatment, and the biomechanics of pregnancy. Conclusions: These two interesting cases demonstrate importance of considering TOP of bilateral hips in women with twin gestation complaining of unilateral hip pain, its implications for delivery, and the crucial role of physiatric involvement in their care. Poster 337 Strengthening Information Capture in Rehabilitation Discharge Summaries: An Application of the Siebens Domain Management Model. Mario Perez, MD (VA Greater Los Angeles Healthcare, Los Angeles, CA, United States); Hyung Kim, MD. Disclosures: M. Perez, No Disclosures. Objective: To increase relevant information capture in inpatient rehabilitation discharge summaries. Design: In July 2008 the Siebens Domain Management Model (SDMM) was incorporated into discharge summaries. This model organizes patients’ health-related issues into four domains: I. Medical/Surgical Issues, II. Mental Status/Emotions/Coping, III. Physical Function, and IV. Living Environment (© Hilary C. Siebens MD 2005). Discharge summary content was measured through retrospective chart review. Setting: Inpatient rehabilitation unit affiliated with a physical medicine and rehabilitation (PM&R) residency program. Participants: 40 cases with discharge summaries: 20 traditional reports (historical controls) and 20 SDMM reports randomly chosen from residents’ final inpatient rotation week. Interventions: A documentation review form included 36 items covering four SDMM domains and assessed item presence in reports. After establishing the review form’s inter-rater agreement through percentage agreement among raters and inter-rater reliability using Fleiss’ kappa statistic, physicians scored discharge summaries. Each report’s Global Score and four Domain Scores reflected percentage of items present in the entire report and each domain respectively. Descriptive statistics for scores compared traditional and SDMM reports using a two-group t-test. Main Outcome Measures: Global Scores and Domain Scores. Results: The overall percent agreement among raters was 87% for the review form. The overall multi-rater kappa value was 0.28 indicating fair inter-rater reliability. The average multi-rater kappa value for items in Domains I and II was around 0.40, Domain III
Vol. 4, Iss. 10S, 2012
S305
0.27, and Domain IV 0.17. Global Scores increased from 34% of items present in traditional reports to 53% in SDMM reports (P⬍.001); Domain scores increased in I (81 to 92%, P⫽.041), II (9 to 47%, P⬍.001), III (25 to 34%, P⫽.062), and IV (11 to 33%, P⬍.001). Conclusions: Traditional rehabilitation discharge summaries lacked information relevant to rehabilitation care. Information capture and total relevant report content increased significantly after SDMM integration into reports. Poster 338 Effects of Intrathecal Opiate Administration on Pituitary Function: A Case Report. Melissa E. Xenidis, DO (Marianjoy Rehabilitation Hospital, Wheaton, IL, United States); Elizabeth M. Hames, DO; Naushira Pandya, MD; Noel Rao, MD. Disclosures: M. E. Xenidis, No Disclosures. Case Description: A 40-year-old chronic pain patient presented with gynecomastia and fatigue. His history was significant for a fall from a height of 35 feet in 1984 resulting in fracture of his pelvis, several vertebrae, and right ankle and calcaneous. He endured 9 separate surgical procedures in order to make his ankle more functional, but suffered constant pain. After attempting various oral analgesics and opiates, it was decided the patient would benefit from an intra-abdominal morphine pump in 1995. In 2002, initial lab results indicated decreased luteinizing hormone, follicular stimulating hormone, total testosterone, and free testosterone. Intramuscular testosterone replacement was initiated every 2 weeks for his hypogonadism. He underwent a left unilateral mastectomy with benign pathology. A normal thyroid stimulating hormone level and decreased thyroxine level were obtained. Levothyroxine was started for secondary hypothyroidism. The patient’s insulin-like growth factor 1 level was low normal. Daily growth hormone replacement injections were initiated. Based on subnormal peak and stimulated rise in cortisol levels on an adrenocorticotropic hormone stimulation test, the patient was diagnosed with adrenal insufficiency. The patient was started on hydrocortisone twice daily. Setting: Outpatient clinic. Results or Clinical Course: Despite gradual lowering of the intrathecal morphine pump dose and eventual discontinuation in 2007, the patient’s chronic fatigue persisted along with low levels of hormones and cortisol levels. Discussion: Intrathecal opiate pain management may produce some generalized effects, as well as pituitary hypofunction. This patient experienced simultaneous suppression of multiple anterior pituitary hormones, which did not reverse with cessation of intrathecal opiate therapy. All axes of the hypothalamus, pituitary, thyroid, adrenals, gonads, as well as functioning of the spinal neurons seem potentially vulnerable to therapy with intrathecal opiates. Conclusions: Chronic intrathecal opiate use can result in pituitary dysfunction. Physiatrists should be aware of these potential side effects and symptoms need to be critically evaluated with appropriate laboratory assessments. Further studies are required in order to create formal recommendations for routine patient surveillance during intrathecal opiate therapy.
ited weight bearing, use of a rolling walker, physical therapy, and cesarean section delivery for both patients due to increased fracture risk with epidural anesthesia and vaginal delivery in the dorsal lithotomy position. Setting: Tertiary care women’s hospital. Results or Clinical Course: Physiatric recommendations were followed and both women underwent cesarean section delivery without complication. At follow up several months postpartum, both patients’ symptoms and physical examination findings had improved significantly and they no longer required assistive devices for ambulation. Discussion: These are the first reported cases of TOP of bilateral hips in women with twin gestation from in vitro fertilization. The pathogenesis of TOP of bilateral hips for these patients is unknown yet may be related to their age, hormonal changes, fertility treatment, and the biomechanics of pregnancy. Conclusions: These two interesting cases demonstrate importance of considering TOP of bilateral hips in women with twin gestation complaining of unilateral hip pain, its implications for delivery, and the crucial role of physiatric involvement in their care. Poster 337 Strengthening Information Capture in Rehabilitation Discharge Summaries: An Application of the Siebens Domain Management Model. Mario Perez, MD (VA Greater Los Angeles Healthcare, Los Angeles, CA, United States); Hyung Kim, MD. Disclosures: M. Perez, No Disclosures. Objective: To increase relevant information capture in inpatient rehabilitation discharge summaries. Design: In July 2008 the Siebens Domain Management Model (SDMM) was incorporated into discharge summaries. This model organizes patients’ health-related issues into four domains: I. Medical/Surgical Issues, II. Mental Status/Emotions/Coping, III. Physical Function, and IV. Living Environment (© Hilary C. Siebens MD 2005). Discharge summary content was measured through retrospective chart review. Setting: Inpatient rehabilitation unit affiliated with a physical medicine and rehabilitation (PM&R) residency program. Participants: 40 cases with discharge summaries: 20 traditional reports (historical controls) and 20 SDMM reports randomly chosen from residents’ final inpatient rotation week. Interventions: A documentation review form included 36 items covering four SDMM domains and assessed item presence in reports. After establishing the review form’s inter-rater agreement through percentage agreement among raters and inter-rater reliability using Fleiss’ kappa statistic, physicians scored discharge summaries. Each report’s Global Score and four Domain Scores reflected percentage of items present in the entire report and each domain respectively. Descriptive statistics for scores compared traditional and SDMM reports using a two-group t-test. Main Outcome Measures: Global Scores and Domain Scores. Results: The overall percent agreement among raters was 87% for the review form. The overall multi-rater kappa value was 0.28 indicating fair inter-rater reliability. The average multi-rater kappa value for items in Domains I and II was around 0.40, Domain III
Vol. 4, Iss. 10S, 2012
S305
0.27, and Domain IV 0.17. Global Scores increased from 34% of items present in traditional reports to 53% in SDMM reports (P⬍.001); Domain scores increased in I (81 to 92%, P⫽.041), II (9 to 47%, P⬍.001), III (25 to 34%, P⫽.062), and IV (11 to 33%, P⬍.001). Conclusions: Traditional rehabilitation discharge summaries lacked information relevant to rehabilitation care. Information capture and total relevant report content increased significantly after SDMM integration into reports. Poster 338 Effects of Intrathecal Opiate Administration on Pituitary Function: A Case Report. Melissa E. Xenidis, DO (Marianjoy Rehabilitation Hospital, Wheaton, IL, United States); Elizabeth M. Hames, DO; Naushira Pandya, MD; Noel Rao, MD. Disclosures: M. E. Xenidis, No Disclosures. Case Description: A 40-year-old chronic pain patient presented with gynecomastia and fatigue. His history was significant for a fall from a height of 35 feet in 1984 resulting in fracture of his pelvis, several vertebrae, and right ankle and calcaneous. He endured 9 separate surgical procedures in order to make his ankle more functional, but suffered constant pain. After attempting various oral analgesics and opiates, it was decided the patient would benefit from an intra-abdominal morphine pump in 1995. In 2002, initial lab results indicated decreased luteinizing hormone, follicular stimulating hormone, total testosterone, and free testosterone. Intramuscular testosterone replacement was initiated every 2 weeks for his hypogonadism. He underwent a left unilateral mastectomy with benign pathology. A normal thyroid stimulating hormone level and decreased thyroxine level were obtained. Levothyroxine was started for secondary hypothyroidism. The patient’s insulin-like growth factor 1 level was low normal. Daily growth hormone replacement injections were initiated. Based on subnormal peak and stimulated rise in cortisol levels on an adrenocorticotropic hormone stimulation test, the patient was diagnosed with adrenal insufficiency. The patient was started on hydrocortisone twice daily. Setting: Outpatient clinic. Results or Clinical Course: Despite gradual lowering of the intrathecal morphine pump dose and eventual discontinuation in 2007, the patient’s chronic fatigue persisted along with low levels of hormones and cortisol levels. Discussion: Intrathecal opiate pain management may produce some generalized effects, as well as pituitary hypofunction. This patient experienced simultaneous suppression of multiple anterior pituitary hormones, which did not reverse with cessation of intrathecal opiate therapy. All axes of the hypothalamus, pituitary, thyroid, adrenals, gonads, as well as functioning of the spinal neurons seem potentially vulnerable to therapy with intrathecal opiates. Conclusions: Chronic intrathecal opiate use can result in pituitary dysfunction. Physiatrists should be aware of these potential side effects and symptoms need to be critically evaluated with appropriate laboratory assessments. Further studies are required in order to create formal recommendations for routine patient surveillance during intrathecal opiate therapy.