Department of Trauma Surgery, Otto-von-Guericke University Magdeburg, D 39120, Magdeburg, Germany.
Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Bundeswehrhospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany.
BMC Health Serv Res. 2019 Aug 9;19(1):558. doi: 10.1186/s12913-019-4400-y.
Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. However, for multi-center evaluations, standardized documentation is necessary. The AKTIN project ("National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany") has used the "German Emergency Department Medical Record" (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry.
Until March 2016 the documentation standard in ED was the pen-and-paper version of the GEDMR. In April 2016 we implemented the GEDMR in a timeline-based EDIS. Related to this, we compared the availability of structured treatment information of traumatological patients between pen-and-paper-based and electronic documentation, with special focus on the treatment time.
All 796 data fields of the 6 modules (basic data, severe trauma, patient surveillance, anesthesia, council, neurology) were adapted for use with the existing EDIS configuration by a physician working regularly in the ED. Electronic implementation increased availability of structured anamnesis and treatment information. However, treatment time was increased in electronic documentation both immediately (2:12 ± 0:04 h; n = 2907) and 6 months after implementation (2:18 ± 0:03 h; n = 4778) compared to the pen-and-paper group (1:43 ± 0:02 h; n = 2523; p < 0.001).
We successfully implemented standardized documentation in an EDIS. The availability of structured treatment information was improved, but treatment time was also increased. Thus, further work is necessary to improve input time.
实施电子急诊信息系统（EDIS）的一些优势在于提高了数据可用性，并简化了对急诊（ED）治疗的统计评估。然而，对于多中心评估，需要标准化的文档记录。AKTIN 项目（“国家急诊登记处：改善德国急性医学卫生服务研究”）使用德国跨学科急救和重症监护协会发布的“德国急诊医疗记录”（GEDMR）作为其国家数据登记处的文档记录标准。
直到 2016 年 3 月，ED 的文档记录标准是 GEDMR 的纸笔版。2016 年 4 月，我们在基于时间线的 EDIS 中实施了 GEDMR。在此基础上，我们比较了纸笔版和电子文档记录中创伤患者结构化治疗信息的可用性，特别关注治疗时间。
6 个模块（基本数据、严重创伤、患者监测、麻醉、理事会、神经病学）的 796 个数据字段均由一位经常在 ED 工作的医生根据现有 EDIS 配置进行了调整。电子实施提高了结构化病史和治疗信息的可用性。然而，与纸笔组相比，电子文档记录的治疗时间立即增加（2:12±0:04 小时；n=2907），6 个月后也增加（2:18±0:03 小时；n=4778）（p<0.001）。
我们成功地在 EDIS 中实施了标准化文档记录。结构化治疗信息的可用性得到了提高，但治疗时间也增加了。因此，需要进一步改进输入时间。
