Park Hyeoun-Ae, Cho Insook, Chung Eunja
College of Nursing, Seoul National University, Seoul, South Korea.
Comput Inform Nurs. 2011 Jul;29(7):419-26. doi: 10.1097/NCN.0b013e3181f9dc6e.
To determine the usefulness of a clinical data repository for nursing, we conducted two studies (1) investigating the gaps between required nursing care time based on patient classification and actual nursing care time based on nurse staffing level and (2) exploring the practice variations of nurses by comparing nursing interventions documented to prevent and treat pressure ulcers. We reviewed the nursing records of 124,416 patients discharged from 2005 to 2007 to identify the gaps in nursing care time. We also reviewed records of 41,891 patients discharged in 2007 to identify those who had pressure ulcers or were at risk of pressure ulcers and analyzed the nursing interventions documented to prevent and treat pressure ulcers. The pediatric and geriatric units showed relatively high staffing needs and the trends of understaffing over time. For pressure ulcer care, nursing interventions vary by nursing unit. Position change was the most common nursing intervention documented except in the maternity unit, followed by ulcer wound care, use of devices, and nutritional assessment. This study showed that data in a clinical data repository can provide nurse managers and nurses with valuable information about nurse staffing and patient care.
为了确定临床数据存储库对护理工作的实用性，我们开展了两项研究：（1）调查基于患者分类的所需护理时间与基于护士人员配备水平的实际护理时间之间的差距；（2）通过比较为预防和治疗压疮而记录的护理干预措施，探索护士的实践差异。我们查阅了2005年至2007年出院的124,416名患者的护理记录，以确定护理时间方面的差距。我们还查阅了2007年出院的41,891名患者的记录，以确定那些患有压疮或有压疮风险的患者，并分析了为预防和治疗压疮而记录的护理干预措施。儿科和老年科显示出相对较高的人员配备需求以及随着时间推移人员不足的趋势。对于压疮护理，不同护理单元的护理干预措施有所不同。除产科外，记录最常见的护理干预措施是更换体位，其次是溃疡伤口护理、使用设备和营养评估。本研究表明，临床数据存储库中的数据可为护士管理人员和护士提供有关护士人员配备和患者护理的宝贵信息。
