Processo de enfermagem direcionado a pacientes com COVID-19: registro de suas etapas / Nursing process directed to patients with COVID-19: record of the stages / Proceso de enfermería dirigido a pacientes con COVID-19: registro de sus etapas

Objetivo: identificar o registro das etapas do Processo de Enfermagem direcionado a pacientes com COVID-19. Método: pesquisa descritiva e documental, com análise de 37 prontuários. Resultados: 83,8% dos prontuários apresentaram registro da Coleta de Dados de Enfermagem; 56,8%, da Avaliação de Enfermagem; e, 51,4%, da Implementação. Contudo, não foram identificados registros envolvendo a etapa de Diagnóstico de Enfermagem e do Planejamento de Enfermagem. Conclusão: os achados revelam que o registro das etapas do Processo de Enfermagem direcionado a pacientes com COVID-19 tem ocorrido de forma insipiente e descontínua; contudo, trata-se uma análise realizada em um cenário pandêmico, em que a sobrecarga e os sentimentos de impotência e insegurança do profissional devem ser considerados. Sugere-se, portanto, a realização de pesquisas que avaliem o impacto da pandemia no contexto da enfermagem, possibilitando assim, subsídios para o desenvolvimento de estratégias que visem amparar o registro do Processo de Enfermagem pelo profissional

Objective: to identify the record of the stages of the Nursing Process directed to patients with COVID-19. Method: descriptive and documentary research, with analysis of 37 medical records. Results: 83.8% of the medical records presented a record of Nursing Data Collection; 56.8%, from the Nursing Assessment; and, 51.4%, of Implementation. However, no records were identified involving the stage of Nursing Diagnosis and Nursing Planning. Conclusion: the registration has occurred in an insipient and discontinuous way; however, it is an analysis carried out in a pandemic scenario, in which the professional's overload and feelings of helplessness and insecurity must be considered. Therefore, it is suggested that research be carried out to assess the impact of the pandemic in the context of nursing, thus enabling subsidies for the development of strategies that aim to support the registration of the Nursing Process by the professional

Objetivo: identificar el registro de las etapas del Proceso de Enfermería dirigido a pacientes con COVID-19. Método: investigación descriptiva y documental, con análisis de 37 historias clínicas. Resultados: el 83,8% de las historias clínicas presentó un registro de Recolección de Datos de Enfermería; 56,8%, de la Evaluación de Enfermería; y, 51,4%, de Implementación. Sin embargo, no se identificaron registros relacionados con la etapa de Diagnóstico y Planificación de Enfermería. Conclusión: el registro se ha producido de forma insipiente y discontinua; sin embargo, se trata de un análisis realizado en un escenario pandémico, en el que se debe considerar la sobrecarga del profesional y los sentimientos de impotencia e inseguridad. Sugiere que se realicen investigaciones para evaluar el impacto de la pandemia en el contexto de la enfermería, posibilitando así subsidios para el desarrollo de estrategias que tengan como objetivo apoyar el registro del Proceso de Enfermería por parte del profesional

Balanço hídrico em unidade de terapia intensiva / Balance hídrico en una unidad de cuidados intensivos / Water balance in an intensive care unit

Objetivo: Discorrer e analisar o preenchimento dos impressos de balanço hídrico de pacientes internados em uma Unidade de Terapia Intensiva pela equipe de enfermagem. Método: Estudo transversal, realizado de fevereiro a dezembro de 2016. Amostra aleatória simples, composta de 220 impressos de balanço hídrico, aprovado no Comitê de Ética em Pesquisa, Protocolo nº. 2.494.058. Análise por meio do SPSS Statistics 22.0 (IBM), utilizando-se estatística descritiva, cálculo de distribuição de frequência, medidas de tendência central e de dispersão. Resultados: 92,7% dos balanços hídricos foram concluídos. Deste total, 54,5% apresentaram erros de cálculos; 37,30%, uso de caneta imprópria; 53,20%, letra ilegível; 84,1%, rasuras; 78,6% erros de registro de dados; 50,50%, anotações inadequadas em colunas. Há 40,7% de chances de um balanço hídrico correto se não houver falhas nos registros e o mesmo for concluído. Conclusão: Os resultados evidenciam a necessidade de capacitação da equipe de enfermagem e de revisão do protocolo assistencial.(AU)

Objective: To discuss and analyze the filling out of fluid balance forms for patients admitted to an Intensive Care Unit by the nursing team. Method: A cross-sectional study, conducted from February to December 2016. A simple random sample, composed of 220 water balance forms, approved by the Research Ethics Committee, Protocol No. 2.494.058. Analysis using SPSS Statistics 22.0 (IBM), using descriptive statistics, calculation of frequency distribution, measures of central tendency and dispersion. Results: A total of 92.7% of the hydric balances were completed. Of this total, 54.5% presented calculation errors; 37.30%, use of improper pen; 53.20%, illegible handwriting; 84.1%, erasures; 78.6% data registration errors; 50.50%, inadequate annotations in columns. There is a 40.7% chance of a correct water balance if there are no flaws in the records and it is completed. Conclusion: The results show the need for training of the nursing team and revision of the care protocol(AU)

Objetivo: Describir y analizar el balance hídrico realizado por el personal de enfermería en una Unidad de Cuidados Intensivos. Método: Estudio transversal, celebrada de febrero a diciembre de 2016. Muestra aleatoria simple, compuesta por 220 balances hídricos, aprobada por el Comité de Ética en Investigación, Protocolo nº. 2.494.058. Análisis a través del SPSS Statistics 22.0 (IBM), utilizando estadística descriptiva, cálculo de distribución de frecuencias, medidas de tendencia central y dispersión. Resultados: 92,7% de los balances hídricos. De este total, el 54,5% tuvo errores de cálculo; 37,30%, utilizando un bolígrafo inadecuado; 53,20%, caligrafía ilegible; 84,1%, tachaduras; 78,6% de errores de entrada de datos; 50,50%, anotaciones de columna inapropiadas. Hay un 40,7% de probabilidad de un correcto balance hídrico si no hay errores en los registros y se completa el mismo. Conclusión: Los resultados muestran la necesidad de capacitar al personal de enfermería y revisar el protocolo de atención.(AU)

Assessing the relation of the coded nursing care and nursing intensity data: Towards the exploitation of clinical data for administrative use and the design of nursing workload.

Patient-care data from the electronic health record systems are increasingly in demand for re-use in administration and resource planning. Nursing documentation with coded concepts is expected to produce more reliable data, fulfilling better requirements for re-use. The aim was to ascertain what kind of relation exist between coded nursing diagnoses, nursing interventions, and nursing intensity and to discuss the possibilities for re-using nursing data for workload design. We analysed the retrospective nursing records of 794 patients documented by the Finnish Care Classification and nursing intensity data assessed by the Oulu Patient Classification over a 15-day period in nine inpatient units at a university hospital. Using the generalised linear mixed model, the clear relationship between the number of coded nursing notes and nursing intensity levels were ascertained. The number of coded nursing notes increases when the nursing intensity increases. The outcomes construct a good basis for continuing elaboration of electronic health record data re-use.

Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia.

OBJECTIVE: The objective of this study was to investigate documentation practice and factors affecting documentation practice among nurses working in public hospital of Tigray region, Ethiopia. RESULTS: In this study, there were 317 participants with 99.7% response rate. The result of this study shows that practice nursing care documentation was inadequate (47.8%). Inadequacy of documenting sheets AOR = 3.271, 95% CI (1.125, 23.704), inadequacy of time AOR = 2.205, 95% CI (1.101, 3.413) and with operational standard of nursing documentation AOR = 2.015, 95% CI (1.205, 3.70) were significantly associated with practice of nursing care documentation. To conclude, more than half of nurses were not documented their nursing care. Employing institutions should provide training on documentation of nursing care to enhance knowledge and create awareness on nurses' documentation to nursing directors and chief executive officer to access adequate documenting supplies besides employing more nurses.

Medical-surgical nurses' documentation of client teaching and discharge planning at a Jamaican hospital.

AIM: This study sought to review documentation of client teaching and discharge planning performed on the medical wards of an urban Jamaican hospital. BACKGROUND: Amid a chronic disease epidemic in Jamaica, adequate discharge planning and client education among hospitalized clients are essential to ensure optimal health outcomes and reduced healthcare costs. METHOD: A total of 131 records from six medical wards were audited. The audit instrument was developed based on the Ministry of Health, Jamaica guidelines, and appraised the completeness of assessment, use of the nursing process, client teaching and discharge planning. Quota sampling facilitated the selection of medical records which met the inclusion criteria. The SPSS® version 22 for Windows® facilitated data analysis. RESULTS: Eighty-eight adult (67.2%) and 43 (32.8%) paediatric records were audited; 89.3% indicated the clients were diagnosed with at least one non-communicable disease. Fourteen percent of records reflected documented evidence of client teaching within the first 72 h of admission. On the day of discharge, only 18.3% reflected client teaching. Nurses seldom began discharge planning within the first 24 h of admission as only 6.9% records had documented evidence. These trends were common to adult and paediatric units. DISCUSSION AND CONCLUSION: The requisite client teaching and discharge planning appeared to be lacking in the records reviewed and may be contributory to deficiencies noted in self-care management. Research is needed to determine factors which could facilitate improved client teaching and discharge planning in the local context. Failure to address this gap in nursing care can significantly affect the country's ability to the reduce the economic burden associated with chronic diseases. IMPLICATIONS FOR NURSING AND HEALTH POLICY: This study highlighted an opportunity for advocacy among nurses and requires nursing leadership to collaboratively develop policies and guidelines to address discharge planning and client education among hospitalized clients. Given the significant health costs associated with non-communicable diseases this should be made a priority in the National Strategic and Action Plan for the Prevention and Control Non-communicable Diseases in Jamaica with clear articulations.

Content analysis of nursing diagnoses in mental health records in Portugal.

AIMS: To identify the diagnoses documented by nurses in Portugal to describe the nursing needs within the scope of mental health nursing and the main problems in documenting these needs. BACKGROUND/INTRODUCTION: The diagnosis process is an essential step in nursing care planning. This process should be carried out by nurses in a rigorous and standardized manner, in order to ensure quality practices and to obtain indicators that can increase the visibility of nursing care. A DESCRIPTIVE STUDY COMBINING: 1. quantitative content analysis of nursing diagnosis records written by nurses working in 39 psychiatry departments of the Portuguese National Health Service, and 2. An focus group meeting with 14 nurses exploring the results of first study phase. Qualitative and quantitative data were analysed by content analysis. FINDINGS: The 2014 initial diagnosis records were systematized into 78 final diagnostic categories, which may represent the most relevant diagnoses in the field of mental health nursing in Portugal. The main problems found in the diagnostic identification by nurses included lack of a standardized language; confusion between nursing diagnoses and focus areas and identification of incongruent clinical judgements. DISCUSSION/CONCLUSION: The changes observed in the fields of behaviour, emotions and psychological process correspond to the largest concentration of nursing diagnoses and challenges in Portugal. This study revealed the lack of standardized language used by nurses in defining diagnoses. The problems identified in the diagnoses documentation suggest that more training in this area is needed. NURSING IMPLICATIONS: This study provides information on the most relevant diagnoses in the area of mental health nursing in Portugal and may offer an important contribution towards improving nursing informatics systems and care to patients by means of standardization of language used in diagnosis definitions. IMPLICATION FOR NURSING POLICIES: The standardization of language used by mental health nurses may contribute towards producing health indicators that provides evidence to policymakers about the contribution made by nursing care towards improved population health.

Validação de um histórico de enfermagem para indivíduos hospitalizados com doenças infectocontagiosas / Validation of a nursing assessment for hospitalized individuals with infectious diseases

Analisar a validade dos indicadores empíricos das necessidades humanas básicas contidos em um histórico de enfermagem para indivíduos hospitalizados com doenças infectocontagiosas. Pesquisa metodológica, desenvolvida em duas etapas: análise de conteúdo e validação clínica. Na primeira etapa participaram 37 enfermeiros especialistas e, da segunda, 65 indivíduos internados nas clínicas de doenças infectocontagiosas de dois hospitais universitários. Na validação clínica, foram avaliadas a presença e a ausência dos indicadores empíricos. Na análise de conteúdo, foram eliminados 14 indicadores empíricos, considerando o critério de relevância. Quanto aos critérios de clareza e precisão, 33 indicadores empíricos tiveram suas definições operacionais reformuladas, com alfa de Cronbach de 0,967 a 0,986. Na validação clínica, foram realizados ajustes para a estruturação final do histórico de enfermagem. Concluiu-se que os indicadores empíricos do histórico de enfermagem representaram adequadamente o foco de interesse e apresentaram excelente consistência interna.

To analyze the validity of empirical indicators of basic human needs contained in a nursing assessment for individuals hospitalized with infectious diseases. Methodological study developed in two stages: content analysis and clinical validation. A total of 37 specialist nurses participated in the first stage, and in the second stage there were 65 individuals admitted to the infectious disease clinics of two university hospitals. In the clinical validation, the presence and absence of empirical indicators were evaluated. In the content analysis, 14 empirical indicators were eliminated, considering the relevance criterion. Regarding the criteria of clarity and precision, 33 empirical indicators had their operational definitions reformulated, with Cronbach's alpha from 0.967 to 0.986. In clinical validation, adjustments were made to the final structure of the nursing assessment. It was concluded that the empirical indicators of the nursing assessment adequately represented the focus of interest and showed excellent internal consistency.

Evaluación de la exactitud del diagnóstico de enfermería en un hospital universitario / Avaliação da acurácia dos diagnósticos de enfermagem em um hospital universitário / Evaluation of nursing diagnoses accuracy in a university hospital

El objetivo de este estudio fue evaluar el grado de precisión de los diagnósticos de enfermería de pacientes ingresados en un hospital universitario. Es una investigación documental, transversal, retrospectiva con análisis cuantitativo. Los datos fueron recogidos a partir de los registros médicos de pacientes hospitalizados en el servicio de neurología de un hospital universitario en la región oeste del estado de Paraná, Brasil. Se evaluaron 292 historias clínicas, tras el análisis de los criterios de inclusión y exclusión, 12 (4,1%) fueron parte del estudio. Se identificaron 19 diagnósticos de enfermería, documentado 94 veces. La evaluación de la exactitud del diagnóstico de enfermería se realizó a través de EADE-2. La mayoría de los diagnósticos de enfermería (n=88; 93,6%) fue evaluada como muy precisa. El grado de precisión más frecuente fue de 13,5 (n=87; 92,6%) y el grado de precisión promedio fue de 12,9, con una variación de 2 a 13,5. Se concluye que los diagnósticos de enfermería son muy precisos, pero es notoria la carencia en la aplicación del proceso de enfermería en la institución investigada

O estudo objetivou avaliar o grau de acurácia dos diagnósticos de enfermagem de pacientes internados em um hospital universitário. Trata-se de uma pesquisa documental, transversal, retrospectiva com análise quantitativa. Os dados foram coletados de prontuários de pacientes internados no setor de neurologia de um hospital de ensino da região oeste do Paraná, Brasil. Foram avaliados 292 prontuários, após a análise dos critérios de inclusão e exclusão, 12 (4,1%) fizeram parte do estudo. Foram identificados 19 diagnósticos de enfermagem, documentados 94 vezes. A avaliação da acurácia dos diagnósticos de enfermagem foi feita por meio EADE-2. A maioria dos diagnósticos de enfermagem (n=88; 93,6%) foi avaliada como sendo altamente acurada. O grau de acurácia mais frequente foi 13,5 (n=87; 92,6%) e a média do grau de acurácia foi 12,9, com variação de 2 a 13,5. Conclui-se que os diagnósticos de enfermagem analisados foram altamente acurados, porém é notória a carência na realização do processo de enfermagem na instituição pesquisada

The study aimed to evaluate the degree of accuracy of the nursing diagnoses of patients hospitalized in a university hospital. This is a documentary, cross-sectional and retrospective research with quantitative analysis. Data were collected from records of patients hospitalized in the neurology sector of a teaching hospital in the western region of Paraná, Brazil. 292 patients' records were evaluated and after the analyses of inclusion and exclusion criteria, 12 (4.1%) were part of the study. Nineteen nursing diagnoses were identified, documented 94 times. The evaluation of the accuracy of the nursing diagnoses was done using EADE-2. Most of nursing diagnoses (n = 88, 93.6%) were evaluated as highly accurate. The most frequent degree of accuracy was 13.5 (n = 87; 92.6%) and the mean accuracy was 12.9, with a variation from 2 to 13.5. It is concludedthat the nursing diagnoses analyzed were highly accurate, but it's notorious the lack of nursing process at the institution studied

Seguridad clínica del Método Madre Canguro: en pacientes pediátricos hospitalizados en la Unidad de Cuidados Intensivos / Clinical security of the mother kangaro method in pediatric patients hospitalized in the intensive care unit

Introducción: La literatura existente en el campo del Método Madre Canguro (MMC) ofrece resultados contradictorios sobre las modificaciones que sufre cada constante vital mientras este se practica. Objetivo: El presente estudio tuvo como objetivo principal evaluar si se produce una mejoría de las constantes vitales (frecuencia cardiaca, saturación de oxígeno y temperatura) al practicar el MMC a niños prematuros o de muy bajo peso, hospitalizados en Cuidados Intensivos. Como objetivo secundario se propuso comprobar cómo afectaba el grado de prematuridad en la mejoría de las constantes vitales. Metodología: Para responder a esta cuestión, se planteó un estudio observacional, analítico, retrospectivo con diseño pretest y postest, sin grupo control. Los datos se recogieron a partir de los registros de enfermeras y el análisis e interpretación de los datos se realizó mediante el paquete estadístico R. Resultados: Cincuenta neonatos pretérmino o de muy bajo peso se incluyeron en el estudio. Se encontró que durante la realización del MMC se produjo una disminución de la frecuencia cardíaca (p = 0.005), un aumento en la saturación de oxígeno (p = 0.004) y un incremento de la temperatura (p = 0.002). En cuanto a la comparación de los dos grupos en los que se dividió la muestra para comprobar cómo afectaba el grado de prematuridad, no se encontraron diferencias estadísticamente significativas (p > 0.05). Conclusión: Se concluye que durante la realización del MMC mejoran las constantes vitales de los neonatos y esta mejoría no difiere en neonatos con diferente grado de prematuridad

Introduction: The literature in the field of Kangaroo Mother Care (KMC) provides conflicting results on the changes that suffers each vital constant while it is practiced. Aim: This study's main aim was to assess whether an improvement of vital signs (heart rate, oxygen saturation and temperature) occurs when practicing KMC premature or infants very low weight, hospitalized in critical care. As a secondary aim set out to see how it affected the level of prematurity in improving vital signs. Methods: To answer this question, an observational, analytical, retrospective study with pre-test and post-test design without control group was raised. Data were collected from nursing records and analysis and interpretation of the data was performed using the statistical package R. Results: Fifty preterm or very low birth weight were included in the study. It was found that during the realization of KMC was decreased heart rate (p = 0.005), an increase in oxygen saturation (p = 0.004) and an increase in temperature (p = 0.002). As for the comparison of the two groups in which the sample to see how it affected the degree of prematurity was divided, no statistically significant differences (p > 0.05). Conclusion: It is concluded that during the performance of KMC improve the vital signs of newborns and this improvement does not differ although its application is performed in neonates with different degree of prematurity

Estudio situacional de los registros electrónicos en una unidad de medicina interna: barreras y oportunidades / A situational study of electronic records in an internal medicine unit: barriers and opportunities

El objetivo de este trabajo fue conocer los recursos, flujos de trabajo y percepción de las enfermeras de una unidad de medicina interna, relacionados con los registros electrónicos, con el fin de determinar si la implantación de tablets en las unidades de hospitalización, podrían responder a sus expectativas. Se llevó a cabo un estudio descriptivo, transversal, muestreo no probabilístico, consecutivo durante los meses de julio y agosto del 2016. Se realizaron 31 observaciones, a 18 enfermeras, 392 pacientes ingresados. Las variables: turno, metodología de trabajo, tiempo 'ronda', tiempo transcripción de datos, tiempo total, número de pacientes ingresados y tiempo invertido por paciente. También se preguntó a cada enfermera sobre cómo trabajaban y el motivo. La media de tiempo total fue 59,16 min (DT:16,6), y 12,65 (DT:1,11) pacientes ingresados. Tiempo invertido por paciente 4,65 min (DT:1,15), inferior en el turno tarde [M:4,14; DT: 0,84] que el de noche [M: 5,47; DT: 1,12]. El turno noche siempre utilizaba el mismo método de trabajo y era el turno tarde que presentaba sistemáticas diferentes. Las enfermeras manifestaron la necesidad de un sistema de registro ligero, en tiempo real, a pie de cama del enfermo, evitando desplazamientos, de fácil acceso para la consulta e intercambio de información. Los dos métodos de trabajo de la unidad de observación no satisfacen las necesidades de las enfermeras, son lentos, pesados y dificultan el acceso a la información y el registro. La incorporación de tablets podría reducir estos problemas y cubrir sus expectativas, abriendo una nueva línea de investigación

The objective of this study was to identify the resources, workflows and perception of nurses of internal medicine unit, related to electronic records in order to determine if the implementation of tablets in hospital units could cover the nurses’ needs more satisfactorily. A descriptive, cross-sectional study with non-probability sampling was carried out during July and August of 2016. The study involved 31 observations of 18 nurses, with 392 patients admitted. The variables were: shift, working methodology, 'round' time, time taken to write up data, total time, number of patients admitted and time spent per patient. Each nurse was asked how they worked and why. The average total time was 59,16 min (DT:16,6), and 12.65 (DT:1,11) patients admitted. Time spent per patient was 4,65 min (DT:1,15) and was lower during the afternoon shift [M:4,14; [DT: 0.84] than during the night shift [M: 5.47; DT: 1,12]. The night shift always used the same method of work, whereas different systems were used during the afternoon. The nurses expressed the need for a lightweight record system that would enable them to record information in real time near the patient without having to go elsewhere, and which would make it easy to consult and exchange information. The two working methods used in the observation unit do not satisfy the needs of nurses, are slow and cumbersome and make it difficult for nurses to access and record information. The adoption of tablets could reduce these problems and meet nurses’ expectations and thus opens a new line of research

Evaluación del Informe de Cuidados de Enfermería en un hospital universitario / Assessment of nursing care reports in a university hospital

OBJETIVO: valorar la calidad de los Informes de Cuidados de Enfermería (ICE) realizados en las unidades de hospitalización de un complejo hospitalario universitario y determinar su mejoría en 2016 respecto a 2015. MÉTODO: se llevó a cabo un estudio descriptico longitudinal retrospectivo, con dos cortes en periodos similares, mayo de 2015 y mayo de 2016, en el Complejo Asistencial Universitario de Burgos. Para la recogida de datos se utilizó el programa de gestión de cuidados GACELA Care. Se analizó la calidad de los ICE en función a criterios estandarizados y consensuados por el equipo. Se realizó un análisis descriptivo de la calidad de los ICE. Para valorar los cambios entre 2015 y 2016 en su calidad global y de sus variables, se utilizó la prueba de Chi cuadrado o el test exacto de Fisher. RESULTADOS: se analizaron 666 informes. Los ICE efectuados aumentaron en el 2016 de 316 (79%) a 350 (85%). Los informes con calidad muy buena ascendieron del 1% (n= 4) al 17% (n= 60), disminuyendo los de calidad mala, del 53% (n= 169) al 42% (n= 146) con p< 0,00. Globalmente, las varibles de Observaciones (resumen) y Observaciones (dipositivos/continuidad de cuidados) mejoraron significativamente en 2016 respecto a 2015. La variable de Valoración activa alcanzó el 75% de cumplimentación, mientras que en el 13% de los ICE no se incluyeron recomendaciones al alta que precisaba el paciente CONCLUSIONES: la cumplimentación del ICE es bastante elevada, mejorando de un año a otro, aunque solo en el 25% de ellos se realiza con una calidad buena o muy buena. Sería recomendable planificar una intervención con el objeto de mejorar la calidad en la cumplimentación de estos informes

OBJECTIVE: to assess the quality of Nursing Care Reports (NCR) completed in the hospitalization units of a university hospital, and to determine their improvement in 2016 vs. 2015. METHOD: a retrospective longitudinal descriptive study was conducted, with two cut-off dates in similar periods: May, 2015 and May, 2016, in the Complejo Asistencia Universitario de Burgos. The care management program GACELA-Care was used for data collection. The quality of NCRs was analyzed based on standard criteria that were agreed upon by consensus of the team. There was a descriptive analysis of NCR quality. Chi-Square Test or Fisher's Exact Test was used in order to assess the changes between 2015 and 2016 in terms of overall quality and variables. RESULTS: there was an analysis of 666 reports. There was an increase in the number of NCRs conducted: from 316 (79%) to 350 (85%) in 2016. The reports with very good quality increased from 1% (n= 4) to 17% (n= 60), and there was a reduction in the number of reports with poor quality, from 53% (n= 169) to 42% (n= 146) with p< 0.00. Overall, the variables Observations (summary) and Observations (devices, continuity of care) improved significantly in 2016 vs. 2015. The Active Assessment variable reached 75% compliance, while 13% of NCRs did not include recommendations needed by the patient at discharge. CONCLUSIONS: NCR compliance is quite high, and improving from one year to another, though only 25% of these reports presented Good or Very Good quality. It would be advisable to plan an intervention with the aim to improve the quality in the completion of these reports

Análisis de las complicaciones del decúbito prono en el síndrome de distrés respiratorio agudo: estándar de calidad, incidencia y factores relacionados / Analysis of complications of prone position in acute respiratory distress syndrome: quality standard, incidence and related factors

Introducción: El sistema de monitorización mediante indicadores de calidad permite evaluar y mejorar la calidad asistencial. Atendiendo a los indicadores recomendados por la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias y dada la importancia del tratamiento postural en decúbito prono (DP) de pacientes con síndrome de distrés respiratorio agudo, resulta crucial el registro de las complicaciones que puedan producirse durante el procedimiento y su posterior análisis. Objetivos: Determinar el grado de cumplimiento del estándar de calidad recomendado por la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias en relación con el registro de complicaciones graves. Identificar la incidencia de complicaciones graves registradas y posibles factores relacionados. Método: Estudio descriptivo retrospectivo transversal, UCI polivalente (16 camas). Población: Pacientes con síndrome de distrés respiratorio agudo tratados con DP (enero 2012-diciembre 2013). Variables: Registros DP, extubaciones accidentales, retiradas de catéteres, úlceras por presión (UPP), obstrucción del tubo endotraqueal, urgencia procedimiento, horas DP, aporte nutricional, tipo de sonda alimentaria, regurgitación, retención alimentaria, uso de procinéticos y/o relajantes musculares. Resultados: La muestra del estudio fue de 38 casos habiéndose encontrado un registro adecuado de las complicaciones en un 92,1% de los casos. La única complicación grave registrada fueron las UPP con una incidencia del 25,7%. Posibles factores relacionados con UPP: horas en DP superior en pacientes que desarrollaron UPP (p=0,067); menor incidencia de UPP cuando el aporte nutricional ha sido adecuado (p=0,577). El 82,9% de los pacientes pronados no recibieron aporte nutricional adecuado. Conclusiones: El porcentaje de registros adecuadamente cumplimentados es muy elevado. Destaca la aparición de UPP (grado 1-2 mayoritariamente). No hay significación estadística, aunque sí tendencia, entre UPP y horas DP (AU)

Introduction: The monitoring system based on standards of quality allows clinicians to evaluate and improve the patient's care. According to the quality indicators recommended by Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias, and due to the importance of prone position (PP) as a treatment in patients with acute respiratory distress syndrome, it is fundamental to keep accurate record of serious adverse events occurring during the prone position procedure and its posterior analysis. Objectives: To establish fulfilment of the Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias standards of quality according to the register of serious complications. To identify the incidence of serious complications registered as well as to identify possible factors related to these complications. Method: Retrospective, cross-sectionsl descriptive study, polyvalent ICU (16 beds). Study population Patients with acute respiratory distress syndrome treated with PP (January 2012-December 2013). Study variables PP recording, accidental extubation, removal of catheters, decubitus ulcers (DU), ETT obstruction, urgency of the procedure, hours in PP, nutritional intake, type of feeding tube, food regurgitation/retention and use of prokinetics/muscle relaxant. Results: The study sample comprised 38 cases, with an adequate record of complications in 92.1% of the cases. DU were the only serious complication recorded, with a 25.7% incidence. Possible factors related to DU: more hours in PP in patients developing DU (p= .067). Less incidence of DU in well-nourished patients (p= .577). 82.9% of patients were not appropriately nourished. Conclusions: The percentage of records duly completed is very high. The presence of DU (grade 1-2 mostly) is to be noted. There is no stastistical significance, although a trend is obversed, between DU and hours in PP (AU)

Blood pressure documentation in the emergency department.

Objective: To analyze the frequency of blood pressure documentation performed by nursing professionals in an emergency department. Methods: This is a cross-sectional, observational, descriptive, and analytical study, which included medical records of adult patients admitted to the observation ward of an emergency department, between March and May 2014. Data were obtained through a collection instrument divided into three parts: patient identification, triage data, and blood pressure documentation. For statistical analysis, Pearson's correlation coefficient was used, with a significance level of α<0.05. Results: One hundred fifty-seven records and 430 blood pressure measurements were analyzed with an average of three measurements per patient. Of these measures, 46.5% were abnormal. The mean time from admission to documentation of the first blood pressure measurement was 2.5 minutes, with 42 minutes between subsequent measures. There is no correlation between the systolic blood pressure values and the mean time interval between blood pressure documentations: 0.173 (p=0.031). Conclusion: The present study found no correlation between frequency of blood pressure documentation and blood pressure values. The frequency of blood pressure documentation increased according to the severity of the patient and decreased during the length of stay in the emergency department.

Objetivo: Analisar a frequência de registros da pressão arterial realizados por profissionais de enfermagem em uma unidade de emergência. Métodos: Estudo transversal, observacional, descritivo e analítico, que incluiu registros de pacientes adultos admitidos em leitos de observação de uma unidade de emergência no período de março a maio de 2014. Os dados foram obtidos por meio de um instrumento de coleta de dados dividido em três partes: identificação do paciente, dados de triagem e registro da pressão arterial. Para a análise estatística, foi utilizado o coeficiente de correlação de Pearson, com nível de significância de α<0,05. Resultados: Foram analisados 157 prontuários e realizadas 430 medidas da pressão arterial, com média de três aferições por paciente; 46,5% dos valores obtidos estavam alterados. O tempo médio de admissão até o registro da primeira pressão arterial foi de 2,5 minutos, e de 42 minutos entre as medidas subsequentes. Não foi encontrada correlação entre os valores de pressão arterial sistólica e o intervalo médio de tempo entre os registros da pressão arterial: 0,173 (p=0,031). Conclusão: O presente estudo não encontrou correlação entre frequência de verificação da pressão arterial e os valores de pressão arterial. A frequência do registro da pressão arterial aumentou de acordo com a gravidade do paciente e diminuiu durante seu tempo de permanência no serviço de emergência.

Blood pressure documentation in the emergency department / Registro da pressão arterial em unidade de emergência

ABSTRACT Objective To analyze the frequency of blood pressure documentation performed by nursing professionals in an emergency department. Methods This is a cross-sectional, observational, descriptive, and analytical study, which included medical records of adult patients admitted to the observation ward of an emergency department, between March and May 2014. Data were obtained through a collection instrument divided into three parts: patient identification, triage data, and blood pressure documentation. For statistical analysis, Pearson’s correlation coefficient was used, with a significance level of α<0.05. Results One hundred fifty-seven records and 430 blood pressure measurements were analyzed with an average of three measurements per patient. Of these measures, 46.5% were abnormal. The mean time from admission to documentation of the first blood pressure measurement was 2.5 minutes, with 42 minutes between subsequent measures. There is no correlation between the systolic blood pressure values and the mean time interval between blood pressure documentations: 0.173 (p=0.031). Conclusion The present study found no correlation between frequency of blood pressure documentation and blood pressure values. The frequency of blood pressure documentation increased according to the severity of the patient and decreased during the length of stay in the emergency department.

RESUMO Objetivo Analisar a frequência de registros da pressão arterial realizados por profissionais de enfermagem em uma unidade de emergência. Métodos Estudo transversal, observacional, descritivo e analítico, que incluiu registros de pacientes adultos admitidos em leitos de observação de uma unidade de emergência no período de março a maio de 2014. Os dados foram obtidos por meio de um instrumento de coleta de dados dividido em três partes: identificação do paciente, dados de triagem e registro da pressão arterial. Para a análise estatística, foi utilizado o coeficiente de correlação de Pearson, com nível de significância de α<0,05. Resultados Foram analisados 157 prontuários e realizadas 430 medidas da pressão arterial, com média de três aferições por paciente; 46,5% dos valores obtidos estavam alterados. O tempo médio de admissão até o registro da primeira pressão arterial foi de 2,5 minutos, e de 42 minutos entre as medidas subsequentes. Não foi encontrada correlação entre os valores de pressão arterial sistólica e o intervalo médio de tempo entre os registros da pressão arterial: 0,173 (p=0,031). Conclusão O presente estudo não encontrou correlação entre frequência de verificação da pressão arterial e os valores de pressão arterial. A frequência do registro da pressão arterial aumentou de acordo com a gravidade do paciente e diminuiu durante seu tempo de permanência no serviço de emergência.

Registros de enfermagem em um hospital de ensino: estudo quase-experimental / Nursing records at a teaching hospital: a quasi-experimental study / Registros de enfermería en un hospital de educación: estudio casi-experimenta

OBJETIVO: avaliar os registros da equipe de enfermagem quanto ao cumprimento da legislação específica em um hospital de ensino considerando-se o setor da instituição, o turno de trabalho, a categoria profissional e o número de infrações por registro antes e após intervenção educativa. MÉTODO: estudo quase-experimental do tipo pré-teste e pós-teste com um único grupo. RESULTADO: foram avaliados 826 registros de enfermagem. O maior número de registros foi feito na Unidade de Terapia Intensiva, pelos técnicos de enfermagem e no turno noturno. Houve um aumento na quantidade de registros feitos pelos auxiliares de enfermagem nos setores clínica masculina e cirurgia feminina. Houve redução quanto à ocorrência de três infrações ou mais. A intervenção foi eficaz para os itens presença de data, hora, assinatura e carimbo. DISCUSSÃO: anotações incompletas podem dificultar a assistência individualizada, prejudicar a continuidade da assistência e implicar riscos para a segurança do paciente. CONCLUSÃO: intervenções educativas podem contribuir para melhorias nos registros de enfermagem.

AIM: to evaluate the records of the nursing staff for compliance with the specific legislation in a teaching hospital considering the institution sector, work shift, the professional category and the number of offenses per registration before and after educational intervention. METHOD: a quasi-experimental study of pre-test and post-test type with a single group. RESULT: 826 nursing records were evaluated. The largest number of records was made in the Intensive Care Unit by the practical nurses and the night shift. There was an increase in the number of records made by nursing assistants, in male clinical sectors and female surgery sector. There was a reduction in the occurrence of three or more offenses. The intervention was effective for items such as presence of date, time, signature and professional identification stamp. DISCUSSION: incomplete notes can hamper individual care, undermine the continuity of care and imply risks to patient safety. CONCLUSION: educational interventions can contribute to improvements in nursing records.

OBJETIVO: Evaluar los registros del equipo de enfermería cuanto alcumplimiento de la legislación específica en un hospital de educación considerándose el sector de la institución, el turno de trabajo, la categoría profesional y el número de infracciones por registro antes y después de la intervención educativa. MÉTODO: estudio casi-experimental del tipo pre-teste y pos-teste con un único grupo. RESULTADO: fueron evaluados 826 registros de enfermería. El mayor número de registros fue hecho en la Unidad de Terapia Intensiva, por los técnicos de enfermería y en el turno nocturno. Hubo un aumento en la cantidad de registros hechos por los auxiliares de enfermería en los sectores clínica masculina y cirugía femenina. Hubo reducción cuanto a la ocurrencia de tres infracciones o más. La intervención fue eficaz para los ítems presencia de fecha, hora, firma y sello. DISCISIÓN: anotaciones incompletas pueden dificultar la asistencia individualizada, perjudicar la continuidad de la asistencia e implicar riesgos para la seguridad del paciente. CONCLUSIÓN: intervenciones educativas pueden contribuir para mejorías en los registros de enfermería.

Post-Implementation Study of a Nursing e-Chart: How Nurses Use Their Time.

Nursing documentation is a significant component of electronic health records nevertheless integrating a new chart into nursing activities required multiples strategies to ensure adherence. Current literature demonstrates that nurses spend part of their time performing activities no related with patients' direct care and sometimes even does not fall under their purview. Thus it is important to quantify the effect that a new system could have in the proportion of time dedicated to documentation. The objective of this work was to determine the time dedicated to different activities including those related to electronic documentation after the implementation of a renewed nurse chart in an Electronic Health Record at Hospital Italiano de Buenos Aires. An observational, cross sectional and work sampling study was performed. During the study 2396 observations were made in 3 wards. Nurses' activities included 36.09% of direct care, 28.9% of indirect care, 0.67% support tasks, 22.99% non related to patient tasks, 11.32% personal activities and documenting on EHR 17.43%. The comparison with the previous study shows indirect care activities decreased 12.28% and non-related to patients increased 11.85%. The results demonstrate that the new nurses' e-chart did not increase documentation time.

Evaluation of Acceptance of Nursing Information System in a German and American Hospital.

Nursing Information Systems (NIS) are not well-adopted and accepted in Germany. The evaluation of a NIS deployment in a German University Hospital supports this assumption. A second side study in the US should point out the differences regarding the technical and organizational differences. We use a questionnaire including standardized instruments like the Unified Theory of Acceptance (UTAUT). Results indicated that nurses in Germany compared to in the US do not use nursing process documentation to the same extent. The main reasons behind the low usage in comparison with the US are deficits in ease-of-use, system performance and the high expenditure of time and paper work for charting nursing plans.

Functionality of Triggers for Epilepsy Patients Assessed by Text and Data Mining of Medical and Nursing Records.

A trigger is a powerful tool for identifying adverse events to measure the level of any kind of harm caused in patient care. Studies with epilepsy patients have illustrated that using triggers as a methodology with data mining may increase patient well-being. The purpose of this study is to test the functionality and validity of the previously defined triggers to describe the status of epilepsy patient's well-being. In both medical and nursing data, the triggers described patients' well-being comprehensively. The narratives showed that there was overlapping in triggers. The preliminary results of triggers encourage us to develop some reminders to the documentation of epilepsy patient well-being. These provide healthcare professionals with further and more detailed information when necessary.