RELATIONSHIP BETWEEN NURSING DOCUMENTATION AND PATIENTS' MORTALITY
RELATIONSHIP BETWEEN NURSING DOCUMENTATION AND PATIENTS' MORTALITY
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DOI：
10.4037/ajcc2013426
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发表时间：
2013-07-01
影响因子：
2.7
通讯作者：
Vawdrey, David K.
中科院分区：
文献类型：
--
作者：
Collins, Sarah A.;Cato, Kenrick;Vawdrey, David K.
背景：当病人的临床状况恶化时，护士会改变他们的监测行为，经常在生理趋势明显之前发现并记录细微的变化。假设护士记录可选文件（超出要求）的行为反映了对患者状态的关注，并且从患者的电子健康记录中挖掘这些特征的数据可以帮助预测患者的死亡率。方法采用数据挖掘方法对某大型城市学术医疗中心15个月的电子护理文件进行分析。对一组随机患者和住院期间发生心脏骤停的患者的死亡率、生命体征测量频率（超出要求）和可选护理评论文件进行分析。采用年龄校正Charlson合并症指数对患者进行分层。结果共调查了15 000例急症患者和145例心脏骤停患者。与存活患者相比，死亡患者在48小时内的可选评论平均多0.9至1.5条，生命体征平均多6.1至10个。评论和生命体征记录的频率越高，心脏骤停的可能性也越大。在心脏骤停的患者中，那些有更多书面评论的患者更有可能死亡。结论：护理文件模式首次与患者死亡率相关。研究结果与电子健康记录中护理文件的某些特征可用于预测死亡率的假设一致。在未来的工作中，这些关联可以实时用于建立表明患者病情恶化风险的关注阈值。
Background Nurses alter their monitoring behavior as a patient's clinical condition deteriorates, often detecting and documenting subtle changes before physiological trends are apparent. It was hypothesized that a nurse's behavior of recording optional documentation (beyond what is required) reflects concern about a patient's status and that mining data from patients' electronic health records for the presence of these features could help predict patients' mortality.Methods Data-mining methods were used to analyze electronic nursing documentation from a 15-month period at a large, urban academic medical center. Mortality rates and the frequency of vital sign measurements (beyond required) and optional nursing comment documentation were analyzed for a random set of patients and patients who experienced a cardiac arrest during their hospitalization. Patients were stratified by age-adjusted Charlson comorbidity index.Results A total of 15 000 acute care patients and 145 cardiac arrest patients were studied. Patients who died had a mean of 0.9 to 1.5 more optional comments and 6.1 to 10 more vital signs documented within 48 hours than did patients who survived. A higher frequency of comment and vital sign documentation was also associated with a higher likelihood of cardiac arrest. Of patients who had a cardiac arrest, those with more documented comments were more likely to die.Conclusions For the first time, nursing documentation patterns have been linked to patients' mortality. Findings were consistent with the hypothesis that some features of nursing documentation within electronic health records can be used to predict mortality. With future work, these associations could be used in real time to establish a threshold of concern indicating a risk for deterioration in a patient's condition.