Azaouagh A, Stausberg J
Medizinische Klinik I, Sankt Marien-Hospital Mülheim.
Pneumologie. 2008 May;62(5):273-8. doi: 10.1055/s-2008-1038099. Epub 2008 Feb 13.
The aim of the study was to check the validity of the electronic patient records for hospital-acquired pneumonia and to estimate their reliability.
On reviewing 23,356 inpatients with admission from 1st April 2005 and discharge up to the 30th September 2005, we identified 211 cases with hospital-acquired pneumonia in the electronic patient records whereby 70 cases taken at random were included in the calculation of the positive predictive value. A second random sample of 130 cases under risk was used to calculate its sensitivity. Positive predictive value and sensitivity were combined to estimate the true rate of hospital-acquired pneumonia.
In 64.3 % of the cases hospital-acquired pneumonia was confirmed in the paper-based patient records (45 cases, 95 % confidence interval 51.9 - 75.4 %). Sensitivity was calculated as 42.9 % and specificity as 99.0 %. Estimation for the University Clinics Essen revealed a true rate of hospital-acquired pneumonia of 1.32 %. The estimated true rate was higher than the measured rate of 0.90 % which is covered, nevertheless, by the 95 % confidence interval.
Results from electronic and paper-based patient records are similar for hospital-acquired pneumonia, in spite of relevant differences on the level of the individual cases. However, data quality is not sufficient for special claims of supervision, clinical hygiene and prevention, for which a further optimisation is required.
本研究旨在检验医院获得性肺炎电子病历的有效性并评估其可靠性。
在回顾2005年4月1日入院至2005年9月30日出院的23356例住院患者时,我们在电子病历中识别出211例医院获得性肺炎病例,其中随机抽取70例用于计算阳性预测值。另一个由130例有风险的病例组成的随机样本用于计算其敏感性。将阳性预测值和敏感性相结合以估计医院获得性肺炎的真实发生率。
在纸质病历中,64.3%的病例确诊为医院获得性肺炎(45例,95%置信区间51.9 - 75.4%)。计算得出敏感性为42.9%,特异性为99.0%。埃森大学诊所的估计显示医院获得性肺炎的真实发生率为1.32%。估计的真实发生率高于测量值0.90%,不过该测量值仍在95%置信区间内。
尽管个别病例层面存在显著差异,但医院获得性肺炎的电子病历和纸质病历结果相似。然而,数据质量不足以满足监测、临床卫生和预防方面的特殊要求,为此需要进一步优化。