Examining the Concordance in the Documented Pressure Injury Site, Stage, and Count in Medical Information Mart for Intensive Care-III.
Examining the Concordance in the Documented Pressure Injury Site, Stage, and Count in Medical Information Mart for Intensive Care-III.
复制标题
检查重症监护医疗信息市场中记录的压力性损伤部位、阶段和计数的一致性 - III。
DOI：
10.1055/s-0041-1735179
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发表时间：
2021
影响因子：
2.9
通讯作者：
Hertzberg,VickiS
中科院分区：
文献类型：
--
作者：
Zhang,Wenhui;Sotoodeh,Mani;Ho,JoyceC;Simpson,RoyL;Hertzberg,VickiS
目的本研究旨在比较电子健康记录 (EHR) 中记录的压力性损伤 (PI) 部位、阶段和计数的一致性；根据诊断或图表事件记录中的 PI 部位或阶段计数，探讨每位患者住院期间的 PI 计数是否一致；方法从重症监护医疗信息集市 (MIMIC)-III 数据库中提取国际疾病分类第九版 (ICD-9) 代码的住院记录、两个系统（CareVue、MetaVision）的图表事件以及 PI 的临床记录。计算了个人住院期间的 PI 部位和分期计数。根据 ICD-9 代码（部位和分期）、CareVue（部位和分期）或 MetaVision（分期）图表，具有相同或不同部位和分期计数的住院被定义为一致或不一致的报告。如果计数差异与患者特征相关，则检查卡方检验、独立检验和 Kruskal-Wallis 检验。还对具有某一部位或分期的患者的 ICD-9 代码和图表进行了比较。结果 总共 31,918 例住院患者有 PI 数据。在具有 ICD-9 编码部位和分期的住院治疗中，55.9% 的人报告了不同的计数。在使用 CareVue PI 图表的住院治疗中，99.3% 的人报告了相同的计数。对于基于 ICD-9 代码或 MetaVision 图表数据的分期住院治疗，只有 42.9% 报告了相同的计数。计数差异与临床记录中的 PI 记录、出院时死亡/临终关怀、更多护理人员、更长的住院或重症监护病房停留时间以及第一次转移的天数等变量始终显着相关。还报告了 ICD-9 代码与图表值在部位和阶段上的差异。结论与 PI 计数差异相关的患者特征确定了患者存在 PI 计数差异或更差结果的风险。通过更好的沟通、护理连续性和完整性，可以提高 PI 文档质量。使用 EHR 的临床研究应采用系统的数据质量分析来告知局限性。
ObjectivesThis study aimed to compare the concordance of pressure injury (PI) site, stage, and count documented in electronic health records (EHRs); explore if PI count during each patient hospitalization is consistent based on PI site or stage count in the diagnosis or chart event records; and examine if discrepancies in PI count were associated with patient characteristics.MethodsHospitalization records with the International Classification of Diseases ninth edition (ICD-9) codes, chart events from two systems (CareVue, MetaVision), and clinical notes on PI were extracted from the Medical Information Mart for Intensive Care (MIMIC)-III database. PI site and stage counts from individual hospitalization were computed. Hospitalizations with the same or different counts of site and stage according to ICD-9 codes (site and stage), CareVue (site and stage), or MetaVision (stage) charts were defined as consistent or discrepant reporting. Chi-squared, independentt-, and Kruskal–Wallis tests were examined if the count discrepancy was associated with patient characteristics. ICD-9 codes and charts were also compared for people with one site or stage.ResultsA total of 31,918 hospitalizations had PI data. Within hospitalizations with ICD-9-coded sites and stages, 55.9% reported different counts. Within hospitalizations with CareVue charts on PI, 99.3% reported the same count. For hospitalizations with stages based on ICD-9 codes or MetaVision chart data, only 42.9% reported the same count. Discrepancies in counts were consistently and significantly associated with variables including PI recording in clinical notes, dead/hospice at discharge, more caregivers, longer hospitalization or intensive care unit stays, and more days to first transfer. Discrepancies between ICD-9 code and chart values on the site and stage were also reported.ConclusionPatient characteristics associated with PI count discrepancies identified patients at risk of having discrepant PI counts or worse outcomes. PI documentation quality could be improved with better communication, care continuity, and integrity. Clinical research using EHRs should adopt systematic data quality analysis to inform limitations.