识别创伤登记不一致的软件应用试点研究。

IF 0.7 4区 医学 Q4 CRITICAL CARE MEDICINE Journal of Trauma Nursing Pub Date : 2024-01-01 DOI:10.1097/JTN.0000000000000767
Jacob W Roden-Foreman, Laura Garlow, Kathleen M Riordan, Susie Edlund, Valerie Suarez
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引用次数: 0

摘要

背景:创伤登记对于现代创伤中心的运作至关重要,高质量的数据对于确定患者护理问题、制定循证实践等都是必要的。然而,机构经验表明,现有的数据质量评估方法并不充分:本研究旨在比较我们创伤中心开发的新应用软件与现有创伤登记平台在识别登记不一致(即潜在的数据质量问题)方面的能力:我们对 2019 年 9 月至 2020 年 8 月期间的患者进行了试点回顾性队列研究,这些患者在 I 级验证访问期间接受了病历审查,并多次接受了准确性审核。两个验证系统均处理了登记记录,并记录了登记记录的不一致之处:在 63 名患者的登记数据中,新软件发现了 225 处登记不一致之处,登记系统发现了 153 处不一致之处。新软件发现的最常见的不一致是程序开始时间缺失或未知,18/63(28.6%)名患者受到影响;院前补氧为空白,29/53(54.7%)名接受院前护理的患者受到影响。在登记系统发现的 10 个最常见的不一致问题中,没有一个是真正的问题:这项研究发现,与标准登记系统相比,新软件应用程序发现的不一致之处要多出 47%,而登记系统发现的最常见不一致之处都不是与机构实践相关的真正问题。由于现有流程似乎不够完善,各中心应考虑采用其他方法来识别登记册的不一致之处。
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Pilot Study of a Software Application to Identify Trauma Registry Inconsistencies.

Background: Trauma registries are essential to the functioning of modern trauma centers, and high-quality data are necessary to identify patient care issues, develop evidence-based practice, and more. However, institutional experience suggested existing methods to evaluate data quality were insufficient.

Objective: This study aims to compare a new software application developed at our trauma center to our existing trauma registry platform on the ability to identify registry inconsistencies (i.e., potential data quality issues).

Methods: We conducted a pilot retrospective cohort study of patients from September 2019 to August 2020 who underwent chart review during a Level I verification visit and had been audited several times for accuracy. Registry records were processed by both validation systems, and registry inconsistencies were recorded.

Results: In registry data for 63 patients, the new software found 225 registry inconsistencies, and the registry systems found 153 inconsistencies. The most frequent inconsistencies identified by the new software were missing or unknown procedure start times, with 18/63 (28.6%) patients affected and prehospital supplemental oxygen being blank, with 29/53 (54.7%) patients with prehospital care affected. None of the 10 most common inconsistencies detected with the registry systems were true issues.

Conclusions: This study found the new software application identified 47% more inconsistencies than the standard registry systems, and none of the most frequent inconsistencies detected with the registry systems were true issues pertinent to institutional practice. Centers should consider additional methods to identify registry inconsistencies as existing processes appear insufficient.

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来源期刊
Journal of Trauma Nursing
Journal of Trauma Nursing CRITICAL CARE MEDICINENURSING&-NURSING
CiteScore
1.20
自引率
10.00%
发文量
106
期刊介绍: ​Journal of Trauma Nursing (JTN) is the official journal of the Society of Trauma Nurses. The Society of Trauma Nurses believes that trauma is a disease impacting patients through the continuum of care. The mission of STN is to ensure optimal trauma care through education, collaboration, leadership and membership engagement. As the official publication of the Society of Trauma Nurses, the Journal of Trauma Nursing supports the STN’s strategic goals of effective communication, education and patient advocacy with original, peer-reviewed, research and evidence-based articles and information that reflect the highest standard of collaborative care for trauma patients.​ The Journal of Trauma Nursing, through a commitment to editorial excellence, implements STN’s vision to improve practice and patient outcomes and to become the premiere global nursing organization across the trauma continuum.
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