Objectives

Nursing documentation behavior within electronic health records may reflect a nurse’s concern about a patient and can be used to predict patient deterioration. Our study objectives were to quantify variations in nursing documentation patterns, confirm those patterns and variations with clinicians, and identify which patterns indicate patient deterioration and recovery from clinical deterioration events in the critical and acute care settings.

Methods

We collected patient data from electronic health records and conducted a regression analysis to identify different nursing documentation patterns associated with patient outcomes resulting from clinical deterioration events in the intensive care unit (ICU) and acute care unit (ACU). The primary outcome measures were whether patients were discharged alive from the hospital or expired during their hospital encounter. Secondary outcome measures were clinical deterioration events.

Results

In the ICU, the increased documentation of heart rate, body temperature, and withheld medication administrations were significantly associated with inpatient mortality. In the ACU, the documentation of blood pressure, respiratory rate with comments, singular vital signs, and withheld medications were significantly related to inpatient mortality. In contrast, the documentation of heart rate and “as needed” medication administrations were significantly associated with patient survival to discharge in the ACU.

Conclusion

We successfully identified and confirmed the clinical relevancy of the nursing documentation patterns indicative of patient deterioration and recovery from clinical deterioration events in both the ICU and ACU.

中文翻译：

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识别与患者恶化和从重症和急性护理环境恶化中恢复相关的护理文档模式

目标

电子健康记录中的护理文档行为可能反映护士对患者的关注，并可用于预测患者病情恶化。我们的研究目标是量化护理文档模式的变化，与临床医生确认这些模式和变化，并确定哪些模式表明患者恶化和从重症和急性护理环境中的临床恶化事件中恢复。

方法

我们从电子健康记录中收集患者数据并进行回归分析，以确定与重症监护病房 (ICU) 和急性监护病房 (ACU) 临床恶化事件导致的患者结局相关的不同护理文档模式。主要结局指标是患者是否活着出院或在医院就诊期间死亡。次要结局指标是临床恶化事件。

结果

在 ICU 中，心率、体温和停药的记录增加与住院死亡率显着相关。在 ACU 中，血压记录、呼吸频率及评论、单一生命体征和停药与住院死亡率显着相关。相比之下，心率记录和“按需”用药与患者在 ACU 出院的存活率显着相关。

结论

我们成功地确定并确认了护理文档模式的临床相关性，这些模式指示患者恶化和从 ICU 和 ACU 的临床恶化事件中恢复。