PDF(Pubmed)
Abstract：
BACKGROUND: Digitalization in medicine is steadily increasing. Complex treatments, scarce personnel resources and a high level of documentation are a constant burden on healthcare systems. The balancing between correct manual documentation in the digital records and limited staff resources is rarely successful. The aim of this study is to evaluate the adherence between documentation and lack of documentation in the treatment of critical care patients.
METHODS: For the evaluation, data from the hospital information system (HIS) of several intensive care units (ICU) were examined in conjunction with data collected from a checklist. All boluses of sedatives, analgesics and catecholamines were documented paper based across all shifts and all weekdays and compared with corresponding digital data from the HIS (2019-2022) of previous years.
RESULTS: 939 complete digital patient records revealed a massive under-documentation of the medication administration compared to that applied according to the checklist. Only 12% of all administered catecholamines, 11% of α2-agonists, 33% of propofol, 92% of midazolam and 46% of opioids were found in the digital recordings. In comparison, the effect was more pronounced on weekdays compared to weekends. In addition, the highest documentation gap was found in the comparison of early shifts. Comparing neurosurgical vs. internal vs. anesthesiologic ICUs there was a highly significant difference between anesthesiologic ICUs compared with other disciplines (p < 0.0001).
CONCLUSIONS: Our data shows that there is a remarkable documentation gap and incongruence in the area of applied boli. Automated documentation by connecting syringe pumps that enter data directly into the HIS can not only reduce the workload, but also lead to comprehensive and legally required documentation of all administered medication.
METHODS: For the evaluation, data from the hospital information system (HIS) of several intensive care units (ICU) were examined in conjunction with data collected from a checklist. All boluses of sedatives, analgesics and catecholamines were documented paper based across all shifts and all weekdays and compared with corresponding digital data from the HIS (2019-2022) of previous years.
RESULTS: 939 complete digital patient records revealed a massive under-documentation of the medication administration compared to that applied according to the checklist. Only 12% of all administered catecholamines, 11% of α2-agonists, 33% of propofol, 92% of midazolam and 46% of opioids were found in the digital recordings. In comparison, the effect was more pronounced on weekdays compared to weekends. In addition, the highest documentation gap was found in the comparison of early shifts. Comparing neurosurgical vs. internal vs. anesthesiologic ICUs there was a highly significant difference between anesthesiologic ICUs compared with other disciplines (p < 0.0001).
CONCLUSIONS: Our data shows that there is a remarkable documentation gap and incongruence in the area of applied boli. Automated documentation by connecting syringe pumps that enter data directly into the HIS can not only reduce the workload, but also lead to comprehensive and legally required documentation of all administered medication.
摘要：
背景：医学数字化正在稳步增加。复杂的治疗,稀缺的人力资源和高水平的文件是医疗保健系统的持续负担。数字记录中正确的手动文档与有限的员工资源之间的平衡很少成功。这项研究的目的是评估重症监护患者治疗中文件和缺乏文件之间的依从性。
方法：对于评估，结合从检查表中收集的数据,对来自多个重症监护病房(ICU)的医院信息系统(HIS)的数据进行了检查.所有的镇静剂，镇痛药和儿茶酚胺是基于所有班次和所有工作日的记录纸,并与前几年HIS(2019-2022)的相应数字数据进行比较.
结果：939个完整的数字患者记录显示，与根据检查表应用的药物管理相比，存在大量的不足记录。只有12%的儿茶酚胺类药物,11%的α2-激动剂,33%的异丙酚，在数字录音中发现了92％的咪达唑仑和46％的阿片类药物。相比之下,与周末相比，工作日的影响更为明显。此外,在早期班次的比较中发现了最大的文件差距。比较神经外科与内部vs.麻醉ICU与其他学科相比，麻醉ICU之间存在高度显着差异（p<0.0001）。
结论：我们的数据表明，在应用boli的领域存在显着的文献差距和不一致。通过连接将数据直接输入到HIS的注射泵来实现自动化文档，不仅可以减少工作量，但也导致所有给药的全面和法律要求的文件。
方法：对于评估，结合从检查表中收集的数据,对来自多个重症监护病房(ICU)的医院信息系统(HIS)的数据进行了检查.所有的镇静剂，镇痛药和儿茶酚胺是基于所有班次和所有工作日的记录纸,并与前几年HIS(2019-2022)的相应数字数据进行比较.
结果：939个完整的数字患者记录显示，与根据检查表应用的药物管理相比，存在大量的不足记录。只有12%的儿茶酚胺类药物,11%的α2-激动剂,33%的异丙酚，在数字录音中发现了92％的咪达唑仑和46％的阿片类药物。相比之下,与周末相比，工作日的影响更为明显。此外,在早期班次的比较中发现了最大的文件差距。比较神经外科与内部vs.麻醉ICU与其他学科相比，麻醉ICU之间存在高度显着差异（p<0.0001）。
结论：我们的数据表明，在应用boli的领域存在显着的文献差距和不一致。通过连接将数据直接输入到HIS的注射泵来实现自动化文档，不仅可以减少工作量，但也导致所有给药的全面和法律要求的文件。
