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A comparison of two sources of data on fungaemia in two hospitals
1The Australian Candidaemia Study, St. Vincent's hospital, Darlinghurst, NSW 2010, Australia.
Abstract:
Fungal bloodstream infection (BSI) is of increasing concern in the hospital environment. This study compared routine hospital discharge data at two inner Sydney hospitals with a pathology database over a 6-year period. A high level of underreporting was found, with only 42% of the pathology database cases assigned an appropriate code in the hospital discharge data despite evidence of the infection being found in 97% of the medical records identified from the pathology database. The location of the evidence in the medical record had an impact on whether or not the infection was assigned a code. There was a greater likelihood that a code would be assigned if the infection was documented on the front sheet of the medical record. Improvements can be made to the reporting of fungal BSI if clinicians record it on the front sheet and if coders review the whole medical record before coding.
Insights
Fungal bloodstream infections (BSI) are underreported in hospital data. Improving documentation on patient records increases accurate coding for these serious infections.
Area of Science:
- Medical Microbiology
- Hospital Epidemiology
- Health Informatics
Background:
- Fungal bloodstream infections (BSI) pose a growing threat in healthcare settings.
- Accurate data collection is crucial for understanding BSI epidemiology and management.
- Underreporting of BSIs can lead to underestimation of their true burden.
Purpose of the Study:
- To compare fungal BSI coding in hospital discharge data against pathology records.
- To identify the extent of underreporting of fungal BSIs.
- To determine factors influencing the accurate coding of fungal BSIs.
Main Methods:
- A 6-year retrospective study comparing hospital discharge data with a pathology database.
- Analysis of medical records for evidence of fungal BSI.
- Assessment of coding accuracy based on documentation location within medical records.
Main Results:
- Significant underreporting of fungal BSI was identified; only 42% of cases from the pathology database were coded in discharge data.
- Evidence of fungal BSI was present in 97% of medical records identified via the pathology database.
- Documentation on the front sheet of the medical record increased the likelihood of accurate coding.
Conclusions:
- Routine hospital discharge data significantly underreports fungal BSI.
- Clinical documentation practices, particularly noting infections on the front sheet, impact coding accuracy.
- Enhanced coder review of entire medical records is recommended to improve fungal BSI reporting.
