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Peri-Operative Anaesthetic Documentation: A Report of Three Sequential Audits on the Quality of Outcomes, with an Insight Into Surrounding Legal Issues/Peri-Operatif Anestezi Dokumentasyonu: Yasal Sorunlar Acisindan Uc Ardisik Kalite Denetiminin Raporu.

Introduction

The 'anaesthetic record' forms an integral part of a patient's journey through the hospital system. In a true sense, it is a clinical, scientific, legal and administrative document relating to patient care, depicting relevant information in a sequential fashion, thereby justifying the diagnosis, the implemented treatment and obtained end-result. In short, an anaesthetic record captures a patient's 'comprehensive' anaesthetic experience in a succinct format (1).

Given its utmost importance, and in spite of the time and effort spent by anaesthetists on peri-operative documentation, measured outcomes continue to be comparatively mediocre (2-4). Numerous professional bodies including the Australian and New Zealand College of Anaesthetists (ANZCA), American Society of Anesthesiologists (ASA) and Canadian Anesthesiologists' Society (CAS) have outlined the necessity for adequate, accurate and legible anaesthetic records (4).

Apart from medico-legal implications, lack of proper documentation can be detrimental to the quality of care provided to patients, thereby compromising the basic underlying principles of 'clinical governance'.

Methods

Being a quality assurance project, formal approval from the Ethics Committee was not required (Human Research and Ethics Committee, The Queen Elizabeth, Lyell McEwin & Modbury Hospitals, Chair: Dr Timothy Matthew, 15th September 2014).

Three consecutive prospective audits on the quality of peri-operative anaesthetic documentation were undertaken as part of departmental quality assurance program at a tertiary care centre in South Australia in the years 2009, 2011 and 2014 respectively. All anaesthetic records for patients undergoing elective as well as emergency surgical procedures were assessed for 'adequacy of peri-operative documentation'. Anaesthetic records of patients admitted to intensive care and those undergoing procedures at remote locations were excluded from the audit. To avoid performance bias, data collection was performed without prior intimation to the members of the anaesthetic department. Pre- and intra-operative information was manually entered on pre-designed anaesthetic charts, with dedicated space for requisite information. This format for documentation had been in use at the hospital for more than 10 years, prior to the introduction of the Electronic Patient Administration System (EPAS[R]) in the latter half of 2016.

The 'core criteria' for appropriate documentation were determined based on a combination of select criteria outlined by the Royal College of Anaesthetists (5) and ANZCA (6) in 2009. If the anaesthetic records met the criteria listed for 'adequacy of documentation', they were labelled as 'appropriately documented.'

Anaesthetic records were photocopied by nursing staff in the post-operative care unit (PACU). All patients and clinicians performing the pre-anaesthetic assessments, as well as the clinical conduct of anaesthesia, were de-identified during the process of assessment. A Microsoft Excel database was used for data entry and collation in 2009. Subsequent data entries were performed on a dedicated Microsoft Access database in the years 2011 and 2014.
Figure 1. a, b. (a) Pre-operative information collected.
(b) Pre-operative information assessed for 'adequacy of documentation'

Patient Details                    Smoking
Date of Assessment                 Alcohol
Date of Surgery                    Cardiovascular History
Surgical procedure                 Respiratory History
Emergency or elective procedure    Other Past Medical History
Age (years)                        Airway Assessment
Weight (kg)                        Medications
Blood Pressure                     ASA Status
Head: Rate                         Relevant Investigations
Allergies                          Reviewing Anaesthetist
Past Anaesthetic History           Anaesthetic Plan
History of Reflux or Full Stomach  Explanation to patient

Patient Details                    Alcohol
Planned procedure                  Cardiovascular History
Weight (kg)                        Respiratory History
Blood Pressure                     Other Past Medical History
Heart Rate                         Medications
Allergies                          Airway Assessment
Past Anaesthetic History           ASA Status
Smoking                            Reviewing Anaesthetist

Figure 2. a, b. (a) Intra-operative information collected. (b)
Intra-operative information assessed for 'adequacy of documentation'

Patient Details                        End-tidal carbon dioxide
Date of Procedure                      Medications
Identity of Anaesthetist               Ventilation details
Identity of Surgeon                    Position of patient
Surgical Procedure                     Regional block details (if
                                       applicable)
Intravenous access details             Eye protection {if applicable)
Type of airway device (if applicable)  Temperature monitoring
Size of airway device (if applicable)  Care of pressure points
Grade of laryngoscopy (if applicable)  Warming measures
Monitoring modalities                  Intravenous fluids
End-tidal agent concentration          Heal moisture exchanger
Oxygen saturation                      Post-operative orders
Blood pressure and heart rate

Date of Procedure                      Blood pressure and heart rate
Identity of Anaesthetist               End-tidal carbon dioxide
Identity of Surgeon                    Medications
Surgical Procedure                     Position of patient
Intravenous access details             Eye protection (if applicable)
Type of airway device (if applicable)  Care of pressure points
Grade of laryngoscopy (if applicable)  Intravenous fluids
Post-operative orders
End-tidal agent concentration
Oxygen saturation


The 'overall collected' and 'requisite' information required for an anaesthetic record to be labelled as 'appropriately documented' is shown in Figures 1a and b, Figure 2a and b, respectively. All collected information was compared against 'pre-determined criteria', formulated by the process as discussed above.

Collection of information pertaining to temperature, urine output and blood loss was discontinued in 2014 as it was not applicable to all patients. Importantly, presence of patient identity labels was not included in the 'core criteria' for 'adequacy' of intra-operative documentation. This is because the anaesthetic chart was a two-page document, the first page being devoted to pre-anaesthetic assessment (which had a patient identification label) and the second page being dedicated to recording of intra-operative parameters.

The data for 'priority of surgery' (emergency or elective) were not collected in the first audit in 2009, and compliance was quite poor in the second audit in 2011. Looking at this, data collection for the same was discontinued in the last audit in 2014, and henceforth, this information was not included in the compilation of results.

Statistical analysis

Correlation between differences in results was assessed using Pearson's chi-squared test. Statistical significance was achieved at a P-value of less than 0.05. All statistical analyses were performed using Stata 15.1 (Stata Corp College Station, TX, USA).

Results

Data from a total of 1000 anaesthetic records were collected in 2009. Out of these, 998 records were included for pre-operative information (two duplicates) as opposed to 993 for intra-operative documentation (seven duplicates or incompletely photocopied records). Subsequently, 412 consecutive anaesthetic records were assessed in 2011. A total of three records were excluded on account of being duplicates, thereby leaving a balance of 409 for final analysis. Finally, 376 records were included in the third audit in 2014. Enhanced clinical commitments of PACU staff necessitated the quantitative reduction in the numbers in consecutive audits.

The outcomes of documentation of pre-operative information are shown in Table 1. There was a trend towards significant improvement in the recording of the majority of pre-operative parameters (cardiovascular and respiratory history, medications, allergies, as well as lifestyle issues). Of note, airway assessment, which is considered as one of the core components of an anaesthetic assessment, was documented in only 91.2% of the patients in 2014, although up from 80.7% in 2011. Relevant investigations were registered in only 35.1% of the pre-anaesthetic assessments in 2014, which apparently still leaves a vast room for improvement. These findings are summarised in Figure 3.

There was an overall improvement in the standards of documentation of pre-operative assessments over the course of the three audits (Table 2 and Figure 4). A total of 43.8% of pre-operative records were 'appropriately documented' in 2014, as opposed to 25.9% in 2011 (p<0.001) and merely 16.3% in 2009 (p<0.001). This reflects more than twofold improvement over the course of 5 years, which in itself is very reassuring.

Table 3 shows the results for documentation of 'intra-operative parameters'. Of note, there was an improvement in the incidence of documentation of eye care, protection of pressure areas, airway devices and end-tidal carbon dioxide concentration.

Heat moisture exchanger (HME) and active patient warming were the least frequently recorded parameters, although with an improved outcome in comparison to previous audits.

There was a decline in the incidence of documentation of the proceduralists (anaesthetists as well as surgeons) and surgical procedures undertaken. These findings are summarised in Figure 5.

The final analysis of results for documentation of intra-operative information showed an overall improvement in the quantity of 'appropriately' documented records (Table 4 and Figure 6). In total, 35.1% of the intra-operative records were 'optimally' documented in 2014, up by nearly 10% from the first audit in 2009 (p<0.05). Comparison of results from 2014 with those from 2011 demonstrated a high statistical significance (p<0.001).

Discussion

The requirement for written documentation dates back to the Napoleonic civil code adopted under Louis XIV of France in 1667 (7). The first anaesthetic record, the famous 'Ether chart' was devised by Cushing and Codman in 1894 (8). Based on his own collection, the importance of anaesthetic records was further emphasised by Lundy in 1924 (9).

The goal of an anaesthetic record is to capture a patient's response to anaesthesia and surgery by recording the physiological changes, procedures, key events and pharmacological interventions performed throughout the peri-operative period (1). There is no other clinical setting in which such an abundance of physiological and pharmacological data collection is performed.

An 'anaesthetic record' should be accurate, legible, elaborate and have a signature verifying the 'authenticity and truthfulness' of the document. It functions as a data log and therapeutic planning tool, as well as a document for reference during subsequent anaesthetic exposures (7). By means of providing trend analysis and defining events on a time scale, an anaesthetic record allows for appropriate therapeutic planning during future anaesthetic encounters, thereby optimising clinical outcomes. Subsequently, it ends up as a medico-legal document and potentially as a business record.

In our instance, 43.8% of the pre-operative records were 'appropriately' documented in 2014 (Table 2 and Figure 4), up from 16.3% in 2009. A similar positive trend was observed in the documentation of intra-operative records, with the number of 'optimally charted' records standing at 35.1% in 2014, as opposed to 22.7% in 2011 (Table 4 and Figure 6). There was a consistent improvement in the standards of practice with each audit, both in pre- as well as the intra-operative categories. Improvements of 17.9% and 12.4%, respectively, were recorded in 2014, when compared against similar outcomes in 2011.

The attainment of these encouraging results was attributed to the dedication, periodic follow-up and initiative undertaken by the departmental anaesthetic staff. In addition, persistent reminders and emphasis on the importance of good record keeping played a significant role in the consistent improvement of standards. We find these results very encouraging and strongly feel that the quality of peri-operative documentation is a reflector of the quality of care provided to patients.

The low rates of documentation of HME and warming may be related to its inapplicability in select clinical circumstances (e.g. patients undergoing procedural sedation and regional blocks). Importantly, as it is part of the 'standard of care' for general anaesthesia at our institution, it may not have been deemed necessary to document individually by the majority of the anaesthetists.

Additionally, the low rates of documentation of identity of surgeons was found to be concerning. This issue has been addressed by installation of tailor-made white boards in every operating room. These boards identify the whole theatre team, as well as carry relevant information pertaining to the patient (name, date of birth, registration number and allergy status). In addition to facilitation of patient checks prior to surgery, this has further helped to enhance communication and teamwork within the theatre team.

The prospective nature and the quantity of records analysed during this exhaustive exercise is a major strength of this project as it allowed us to get a true picture of our contemporary performance and more importantly, gauge the dynamicity of the trends in practice.

A similar audit by Raff and James (2) found that out of 284 records, only 29.9% met the 'minimum standards' required for data entry. Interestingly, intra-operative vital signs were not intelligible in 53% and surprisingly absent in 19.5% of the documents. Furthermore, anaesthetic drugs were not recorded in 12.5% and illegible in 26.5% of the instances. A French study by Falcon et al. (3) highlighted similar deficiencies, both in pre- as well as intra-operative records.

To the best of our knowledge, there is only one published audit assessing the adequacy of peri-operative documentation against the ANZCA guidelines in contemporary literature. In this audit, only 32% of the pre-anaesthetic records and 27% of the intra-operative encounters were considered to be compliant with existing recommendations (4).

Our sub-optimal performance could partly be attributed to the unfamiliarity of some staff members with the records' format used at our institution. Our hospital is a tertiary teaching facility and gets new rotational trainees twice a year as part of the training scheme. In addition to provision of clinical services, time pressures during busy operating lists may have placed significant demands on the attending anaesthetist, thereby compromising the quality of documented records. Lastly, the impact emergency surgery and inter-individual variability on peri-operative documentation of anaesthetic records cannot be overlooked.

There is a paucity of quality studies on peri-operative documentation in contemporary literature. This may in part be related to the exhaustive nature of the process, which involves voluminous data collection and collation of all clinical parameters to come up with any fruitful conclusions.

Anaesthetic records may be either manual or automated. Paper records are time consuming and prone to subjectivity, incompleteness and data entry bias (8). They can be illegible at times, thereby making it difficult to subsequently audit the data. Electronic record-keeping systems are currently gaining popularity as a tool to enhance objectivity, accuracy and cost-effectiveness. These systems have been shown to produce more accurate physiological data (4) and could represent better utilisation of manpower and resources. This would theoretically lead to an improvement in the standards of documentation as well as clinical care, as anaesthetists could focus on higher level tasks in lieu of charting data. These systems have been endorsed to enhance detection of adverse events under anaesthesia and as a tool for quality improvement (10). Interestingly, Elhalawani et al. (4) did not find any difference in the adequacy of documentation between manually and electronically generated records in their study.

Automated systems take away the role of the 'human scribe', who is intelligent, responsive and most importantly, a 'valuable team member'. Additionally, they provide poor feedback and can interrupt efficient teamwork during times of high workload or clinically stressful periods (11). Also, they bring along with them their own set of controversies. This is highlighted in a recent case report, where failure to recognise loss of incoming data by an automated record-keeping system may have increased medical liability (12). Theoretically, the operator is dependent on the ability of the operating system to perform the task which it has been marketed to do. This is the principle of 'justifiable reliance'. The failure of a serviced product during routine use can create a potential for a product liability suit by means of 'breach of warranty'. This may theoretically create a basis for 'sharing of liability'. However, many vendors of automated record systems disclaim liability for their products, but the extent to which this protects them from liability is not clear (7).

'Justifiable reliance' is counterbalanced by the principle of 'non-delegable duty', which implies that it is the duty of the health care professional to verify his or her own records. This can be a contentious issue, as the argument in favour of 'justifiable reliance' becomes significantly stronger in the presence of rapid and overwhelming data in the context of complex clinical situations. In contrast, with manual records, the argument in support of 'non-delegable duty' grows stronger, as the volume of information is limited, and there are no minimum cut-off standards. There should be clear policies in departments using electronic records, as this could help define acceptable standards and thereby limit institutional liability (7).

A signature, either 'manual' or 'electronic' attests the 'authenticity' and 'veracity' of the document, thereby signifying acceptance of information in the same. The important message is that medical records should be accurate and complete and that the use of an automated record does not absolve the signing physician of liability in case of 'incompleteness' or 'missing information' (7). The paramount importance of mindfulness and vigilance in this regard cannot be overemphasised.

Lastly, it is important to clarify which document is the 'official' or 'original' medical record. This is fairly simple with manual documentation, where only one copy exists. With automated systems, the data are first collected and stored is the 'original record'. Copies never have the same value as the 'actual record' and may be contested in a court of law. Printouts are 'secondary documents' and may not reflect electronic data accurately as they depict information accessed only at a specific point of time. However, the printed record is a 'legaily acceptable' summary, provided that electronic data are available for examination and authentication, if requested (7).

The future could have a lot more novelties in store for clinicians. Touch screen monitors, which were part of fiction a decade ago, have become a reality now. Very soon, we could be looking at smartphone applications for data log and transmission. Further on, bar-coded endotracheal tubes, syringes, ampoules and intravenous fluids could take a lot of workload off anaesthetists. And let us not to forget to mention speech-enabled computers and, possibly, theatre robots!

The incorporation of electronic data systems into contemporary practice is likely to bring its own set of challenges and controversies to the practice of clinical medicine. Clinicians generally lack familiarity with fundamental legal principles, and it is important for them to develop a better understanding of the way electronic data are captured, stored and processed.

Our audits are not devoid of drawbacks. Firstly, we could not sustain the numbers in consecutive audits on account of logistical issues, which necessitated the scaling down of the magnitude of the exercise. Secondly, we did not segregate the records based on clinical priority of the surgical procedures, as clinical commitments and time pressures can have a significant effect on the quality of documentation in such circumstances. However, under no circumstances does this absolve us from our responsibility to maintain and sustain the requisite standards of documentation. Finally, the impact of changeover of trainees on final outcomes cannot be overlooked.

Conclusion

Based on our work, we feel that regular audits of record keeping can lead to an improvement in the standards of this often neglected, but essential scope of our practice. Despite the improvements we have achieved, there is still a vast room for improvement as we still fall short of the outlined standards. Meanwhile, it is equally important not to undermine the fact that sustaining the achieved standards is also going to be a tedious task. It would be interesting to see the effect of EPAS on our outcomes in the upcoming audit planned for late 2018.

Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of The Queen Elizabeth, Lyell McEwin and Modbury Hospitals.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - R.S., W.C., T.V.; Design - R.S., W.C., S.S.; Supervision - W.C., T.V.; Data Collection and/or Processing - S.S., W.C; Analysis and/or Interpretation - R.S., T.V.; Literature Search - R.S., S.S.; Writing Manuscript - R.S., S.S.; Critical Review - R.S., T.V.

Acknowledgements: The authors are indebted to all nurses of the Post-Anaesthesia Care Unit for their help, and also to Sandra Kingisepp, Nurse Unit Manager, for her persistent and valuable support.

Conflict of Interest: The authors have no conflicts of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

Etik Komite Onayi: Bu cahsma icin etik komite onayi The Queen Elizabeth, Lyell McEwin and Modbury Hastanesi'nden alinmistir.

Hakem Degerlendirmesi: Dis bagimsiz.

Yazar Katkilan: Fikir - R.S., W.C, T.V.; Tasarim - R.S., W.C, S.S.; Denetleme - W.C, T.V.; Veri Toplanmasi ve/veya Islemesi -S.S., W.C; Analiz ve/veya Yorum - R.S., T.V.; Literatiir Taramasi - R.S., S.S.; Yaziyi Yazan - R.S., S.S.; Elestirel Inceleme - R.S., T.V.

Tesekkiir: Yazarlar yardimlanndan dolayi Anestezi Sonrasi Bakim Biriminin turn hemsirelerine ve ayrica Hemsirelik Birimi Muduru Sandra Kingisepp'e surekli ve degerli desteginden dolayi tesekkiir ederler.

Cikar Catismasi: Yazarlar cikar catismasi bildirmemislerdir.

Finansal Destek: Yazarlar bu cahsma icin finansal destek al-madiklarmi beyan etmislerdir.

References

(1.) Kadry B, Feaster WW, Macario A, Ehrenfeld JM. Anaesthesia information management systems: past, present and future of anaesthesia records. Mt Sinai J Med 2012; 79: 154-65. [CrossRef]

(2.) Raff M, James MFM. An audit of anaesthetic record keeping. South African Journal of Anaesthesia and Analgesia 2003; 9: 7-9. [CrossRef]

(3.) Falcon D, Francois P, Jaquot C, Payen JF. Evaluating the quality of the anaesthetic records. Annales Francaises dAnesthesie et de Reanimation 1999; 18: 360-7. [CrossRef]

(4.) Elhalawani I, Jenkins S, Newman N. Perioperative anaesthetic documentation: Adherence to current Australian guidelines. J Anaesthesiol Clin Pharmacol 2013; 29: 211-5. [CrossRef]

(5.) Bowers R, Booth D. Anaesthetic record keeping. In: Colvin J, Peden C, editors. Raising the standard: a compendium of audit recipes (3rd edition): RCOA; 2012.pp.94-5.

(6.) Australian and New Zealand College of Anaesthetists Professional Document PS 6: The Anaesthesia Record: Recommendations on the recording of an episode of anaesthesia care, 2006.

(7.) Szalados JE. The legal implications of anaesthesia record shortcomings. Anesthesiology News 2007; 33: 8.

(8.) Beecher HK. The first anaesthesia records (Codman, Cushing). Surgery, Gynecology & Obstetrics 1940; 71: 689-93.

(9.) Lundy JS. Keeping anesthetic records: And what they show. Am J Surg 1924; 38: 16.

(10.) Grant C, Ludbrook G, Hampson EA, Semenov R, Willis R Adverse physiological events under anaesthesia and sedation: A pilot audit of electronic patient records. Anaesth Intensive Care 2008; 36: 222-9.

(11.) Woods DD, Cook RI, Billings CE. The impact of technology on physician cognition and performance. J Clin Monit 1995; 11: 5-8. [CrossRef]

(12.) Vigoda MM, Lubarsky DA. Failure to recognize loss of incoming data in an anaesthesia record-keeping system may have increased medical liability. AnesthAnalg 2006; 102: 1798-802.[CrossRef]

William Brett Curtis (1), Rajesh Sethi (2), Thavarajah Visvanathan (2), Swati Sethi (2)

(1) Department of Anaesthesia, Lyell McEwin Hospital, Elizabeth Vale, Australia

(2) Department of Anaesthesia, The Queen Elizabeth Hospital Woodville South, Australia

Corresponding Author / Sorumlu Yazar: Rajesh Sethi E-mail: rajesh.sethi@sa.gov.au

Received / Gelis Tarihi : 19.12.2017

Accepted / Kabul Tarihi: 30.04.2018

Available Online Date / Cevrimici Yayin Tarihi : 04.09.2018

DOI: 10.5152/TJAR.2018.40222
Table 1. Pre-operative information documented (%) in 2009, 2011 and
2014

Pre-op Parameters          2009  2011   2014

Patient details            99.7  100    100
Date of assessment         91.6   94.4   95.5
Date of surgery            61.8   87.0   76.5
Surgical procedure         94.4   97.1   97.6
Age (years)                83.2   83.1   80.3
Weight (kg)                69.8   85.3   87.2
Blood pressure             53.3   78.0   79.5
Heart rate                 38.7   74.1   79.5
Allergies                  98.3   98.3   98.9
Past anaesthetic history   98.0   94.9   97.8
History of reflux or full  74.2   79.7   82.2
stomach
Smoking                    80.2   85.1   90.7
Alcohol                    64.3   63.1   73.9
Cardiovascular history     91.4   92.9   99.5
Respiratory history        86.4   90.2   98.7
Other past medical         83.2   88.8   98.7
history
Airway assessment          95.8   80.7   91.2
Medications                97.2   98.0   98.7
ASA status                 97.5   98.0   99.2
Relevant investigations    39.4   57.0   35.1
Reviewing anaesthetist     97.1   77.0   84.8
Anaesthetic plan           95.8   98.0   85.4
Explanation to patient     85.5   81.4   86.9

Table 2. Appropriately documented pre-operative anaesthetic records in
2009, 2011 and 2014

Year  Total (n)  Appropriate  % Appropriate

2009  998        162          16.3%
2011  409        106          25.9%
2014  376        165          43.8%

2009 vs. 2011 p=0.0001. 2009 vs. 2014 p=0.0001. 2011 vs. 2014
p=0.0001

Table 3. Intra-operative information documented (%) in 2009, 2011 and
2014

Intra-operative Parameters   2009  2011  2014

Patient details              99.3  97.3  92.3
Date of procedure            98.6  98.0  96.5
Identity of anaesthetist     99.1  96.1  90.7
Identity of surgeon          74.6  72.6  69.1
Type of airway device        93.2  95.8  97.2
Grade of laryngoscopy        95.8  94.1  93.2
End-tidal anaesthetic agent  95.8  93.7  93.3
Oxygen saturation            97.7  95.4  94.7
Blood pressure & heart rate  99.5  94.1  98.9
End-tidal carbon dioxide     94.9  92.7  92.9
Position of patient          90.8  83.6  83.8
Eye protection               71.5  69.1  81.0
Care of pressure points      59.8  56.7  61.0
Warming measures             47.0  43.8  56.1
Intravenous fluids           97.0  97.8  96.0
Heat moisture exchanger       3.3   4.3  11.2
Post-operative orders        99.6  98.0  97.0

Table 4. Appropriately documented intra-operative anaesthetic records
in 2009, 2011 and 2014

Year  Total (n)  Appropriate  % Appropriate

2009  993        255          25.5%
2011  409         93          22.7%
2014  279         98          35.1%

2009 vs. 2011 p=0.246. 2009 vs. 2014 p=0.0001. 2011 vs. 2014 p=0.0001
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Title Annotation:Original Article / Ozgun Arastirma
Author:Curtis, William Brett; Sethi, Rajesh; Visvanathan, Thavarajah; Sethi, Swati
Publication:Turkish Journal of Anaesthesiology and Reanimation
Article Type:Report
Date:Oct 1, 2018
Words:4168
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