Background: Nursing records play an important role in multidisciplinary collaborations in delirium care. This study aims to develop a self-rated nursing record frequency scale for delirium care among nurses in acute c...Background: Nursing records play an important role in multidisciplinary collaborations in delirium care. This study aims to develop a self-rated nursing record frequency scale for delirium care among nurses in acute care hospitals (NRDC-Acute). Methods: A draft of the scale was developed after a literature review and meeting with researchers with experience in delirium care, and a master’s or doctoral degree in nursing. We identified 25 items on a 5-point Likert scale. Subsequently, an anonymous self-administered questionnaire survey was administered to 520 nurses from 41 acute care hospitals in Japan, and the reliability and validity of the scale were examined. Results: There were 232 (44.6%) respondents and 218 (41.9%) valid responses. The mean duration of clinical experience was 15.2 years (SD = 8.8). Exploratory factor analysis extracted 4 factors and 13 items for this scale. The model fit indices were GFI = 0.991, AGFI = 0.986, and SRMR = 0.046. The Cronbach’s alpha coefficient for the entire scale was .888. The four factors were named “Record of Pharmacological Delirium Care on Pro Re Nata (PRN)”, “Record of Non-Pharmacological Delirium Care”, “Record of Pharmacological Delirium Care on Regular Medication”, and “Record of Collaboration for Delirium Care”. Conclusion: The scale was relatively reliable and valid. Nurses in acute care hospitals can use this scale to identify and address issues related to the documentation of nursing records for delirium care.展开更多
Nursing records contain information on patients’treatment processes,which reflect the changes in patients’conditions and have legal effects.However,some of the written records of intensive care unit(ICU)nurses are i...Nursing records contain information on patients’treatment processes,which reflect the changes in patients’conditions and have legal effects.However,some of the written records of intensive care unit(ICU)nurses are incomplete according to our observations.This paper proposes an approach extracting structured nursing events from unstructured nursing records for detecting the missing items automatically.According to the PIO(problem,intervention,outcome)principle in the field of medical care,we propose event schemas for nursing records and annotate a Chinese nursing event extraction dataset(CNEED)on ICU nursing records.We find that several events may occur in a nursing record.Therefore,we present a multi-event extraction model for the nursing records.The experimental results demonstrate that our model achieves good results on CNEED and outperforms competitive methods on the multi-event argument attribution problem.By observing the results of automatic event extraction by our model,we detect missing items in the existing nursing records.This proves that our model can be used to help nurses check and improve the method of recording nursing processes.展开更多
Purpose： Recording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The Modified Early Warning Score （MEWS） uses vital signs to categorise ...Purpose： Recording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The Modified Early Warning Score （MEWS） uses vital signs to categorise the severity of a patient＇s physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions. This descriptive study measured the quality of vital sign recordings in an acute care trauma setting, and used the MEWS to determine the impact the documentation quality had on the detection of physiological derangements and thus, clinical decision making. Methods： Vital signs recorded by the nursing staff of all trauma patients in the acute care trauma wards at a regional hospital in South Africa were collected from January 2013 to February 2013. Investigator- measured values taken within 2 hours of the routine observations and baseline patient information were also recorded. A MEWS for each patient was calculated from the routine and investigator-measured observations. Basic descriptive statistics were performed using EXCEL Results： The details of lgl newly admitted patients were collected. Completion of recordings was 81% for heart rate, 88~; for respiratory rate, 98~; for blood pressure, 92% for temperature and 41~ for GCS. The recorded heart rate was positively correlated with the investigator＇s measurement （Pearson＇s correlation coefficient of 0.76）; while the respiratory rate did not correlate （Pearson＇s correlation coefficient of 0.02）. In 59~ of patients the recorded respiratory rate （RR） was exactly 20 breaths per minute and 27~ had a recorded RR of exactly 15. Seven percent of patients had aberrant Glasgow Coma Scale readings above the maximum value of 15. The average MEWS was 2 for both the recorded （MEWS（R）） and investigator （MEWS（1）） vitals, with the range of MEWS（R） 0-7 and MEWS（1） 0-9. Analysis showed 59% of the MEWS（R） underestimated the physiological derangement （scores were lower than the MEWS（1））; 80%; of patients had a MEWS（R） requiring 4 hourly checks which was only completed in 2%;; 86% of patients had a MEWS（R） of less than three （i.e. not necessitating escalation of care）, but 33% of these showed a MEWS（1） greater than three （i.e. actually necessitating escalation of care）. Conclusion： Documentation of vital signs aids management decisions, indicating the physiological derangement of a patient and dictating treatment. This study showed that there was a poor quality of vital sign recording in this acute care trauma setting, which led to underestimation of patients＇ physi- ological derangement and an inability to detect deteriorating patients. The MEWS could be a powerful tool to empower nurses to become involved in the diagnosis and detection of deteriorating patients, as well as providing a framework to communicate the severity of derangement between health workers. However, it requires a number of strategies to improve the quality of vital sign recording, including continuing education, increasing the numbers of competent staff and administrative changes in vital sign charts.展开更多
文摘Background: Nursing records play an important role in multidisciplinary collaborations in delirium care. This study aims to develop a self-rated nursing record frequency scale for delirium care among nurses in acute care hospitals (NRDC-Acute). Methods: A draft of the scale was developed after a literature review and meeting with researchers with experience in delirium care, and a master’s or doctoral degree in nursing. We identified 25 items on a 5-point Likert scale. Subsequently, an anonymous self-administered questionnaire survey was administered to 520 nurses from 41 acute care hospitals in Japan, and the reliability and validity of the scale were examined. Results: There were 232 (44.6%) respondents and 218 (41.9%) valid responses. The mean duration of clinical experience was 15.2 years (SD = 8.8). Exploratory factor analysis extracted 4 factors and 13 items for this scale. The model fit indices were GFI = 0.991, AGFI = 0.986, and SRMR = 0.046. The Cronbach’s alpha coefficient for the entire scale was .888. The four factors were named “Record of Pharmacological Delirium Care on Pro Re Nata (PRN)”, “Record of Non-Pharmacological Delirium Care”, “Record of Pharmacological Delirium Care on Regular Medication”, and “Record of Collaboration for Delirium Care”. Conclusion: The scale was relatively reliable and valid. Nurses in acute care hospitals can use this scale to identify and address issues related to the documentation of nursing records for delirium care.
基金supported by the National Key R&D Program of China (No.2020AAA0106600).
文摘Nursing records contain information on patients’treatment processes,which reflect the changes in patients’conditions and have legal effects.However,some of the written records of intensive care unit(ICU)nurses are incomplete according to our observations.This paper proposes an approach extracting structured nursing events from unstructured nursing records for detecting the missing items automatically.According to the PIO(problem,intervention,outcome)principle in the field of medical care,we propose event schemas for nursing records and annotate a Chinese nursing event extraction dataset(CNEED)on ICU nursing records.We find that several events may occur in a nursing record.Therefore,we present a multi-event extraction model for the nursing records.The experimental results demonstrate that our model achieves good results on CNEED and outperforms competitive methods on the multi-event argument attribution problem.By observing the results of automatic event extraction by our model,we detect missing items in the existing nursing records.This proves that our model can be used to help nurses check and improve the method of recording nursing processes.
文摘Purpose： Recording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The Modified Early Warning Score （MEWS） uses vital signs to categorise the severity of a patient＇s physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions. This descriptive study measured the quality of vital sign recordings in an acute care trauma setting, and used the MEWS to determine the impact the documentation quality had on the detection of physiological derangements and thus, clinical decision making. Methods： Vital signs recorded by the nursing staff of all trauma patients in the acute care trauma wards at a regional hospital in South Africa were collected from January 2013 to February 2013. Investigator- measured values taken within 2 hours of the routine observations and baseline patient information were also recorded. A MEWS for each patient was calculated from the routine and investigator-measured observations. Basic descriptive statistics were performed using EXCEL Results： The details of lgl newly admitted patients were collected. Completion of recordings was 81% for heart rate, 88~; for respiratory rate, 98~; for blood pressure, 92% for temperature and 41~ for GCS. The recorded heart rate was positively correlated with the investigator＇s measurement （Pearson＇s correlation coefficient of 0.76）; while the respiratory rate did not correlate （Pearson＇s correlation coefficient of 0.02）. In 59~ of patients the recorded respiratory rate （RR） was exactly 20 breaths per minute and 27~ had a recorded RR of exactly 15. Seven percent of patients had aberrant Glasgow Coma Scale readings above the maximum value of 15. The average MEWS was 2 for both the recorded （MEWS（R）） and investigator （MEWS（1）） vitals, with the range of MEWS（R） 0-7 and MEWS（1） 0-9. Analysis showed 59% of the MEWS（R） underestimated the physiological derangement （scores were lower than the MEWS（1））; 80%; of patients had a MEWS（R） requiring 4 hourly checks which was only completed in 2%;; 86% of patients had a MEWS（R） of less than three （i.e. not necessitating escalation of care）, but 33% of these showed a MEWS（1） greater than three （i.e. actually necessitating escalation of care）. Conclusion： Documentation of vital signs aids management decisions, indicating the physiological derangement of a patient and dictating treatment. This study showed that there was a poor quality of vital sign recording in this acute care trauma setting, which led to underestimation of patients＇ physi- ological derangement and an inability to detect deteriorating patients. The MEWS could be a powerful tool to empower nurses to become involved in the diagnosis and detection of deteriorating patients, as well as providing a framework to communicate the severity of derangement between health workers. However, it requires a number of strategies to improve the quality of vital sign recording, including continuing education, increasing the numbers of competent staff and administrative changes in vital sign charts.
