Romero-Brufau Santiago, Gaines Kim, Nicolas Clara T, Johnson Matthew G, Hickman Joel, Huddleston Jeanne M
Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA.
Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA.
JAMIA Open. 2019 Aug 28;2(4):465-470. doi: 10.1093/jamiaopen/ooz033. eCollection 2019 Dec.
Identification of hospitalized patients with suddenly unfavorable clinical course remains challenging. Models using objective data elements from the electronic health record may miss important sources of information available to nurses.
We recorded nurses' perception of patient potential for deterioration in 2 medical and 2 surgical adult hospital units using a 5-point score at the start of the shift (the Worry Factor [WF]), and any time a change or an increase was noted by the nurse. Cases were evaluated by three reviewers. Intensive care unit (ICU) transfers were also tracked.
31 159 patient-shifts were recorded for 3185 unique patients during 3551 hospitalizations, with 169 total outcome events. Out of 492 potential deterioration events identified, 380 (77%) were confirmed by reviewers as true deterioration events. Likelihood ratios for ICU transfer were 17.8 (15.2-20.9) in the 24 hours following a WF > 2, and 40.4 (27.1-60.1) following a WF > 3. Accuracy rates were significantly higher in nurses with over a year of experience (68% vs 79%, = 0.04). The area under the receiver operator characteristic curve (AUROC) was 0.92 for the prediction of ICU transfer within 24 hours.
This is a higher accuracy than most published early warning scores.
Nurses' pattern recognition and sense of worry can provide important information for the detection of acute physiological deterioration and should be included in the electronic medical record.
识别临床病程突然恶化的住院患者仍然具有挑战性。使用电子健康记录中的客观数据元素的模型可能会遗漏护士可获得的重要信息来源。
我们在两个内科和两个外科成人医院科室，于轮班开始时使用5分制记录护士对患者病情恶化可能性的感知（担忧因素[WF]），以及护士注意到任何变化或病情加重的时刻。病例由三名评审员进行评估。还对重症监护病房（ICU）的转诊情况进行了跟踪。
在3551次住院期间，为3185名独特患者记录了31159个患者轮班，共有169个总结局事件。在确定的492个潜在恶化事件中，380个（77%）被评审员确认为真正的恶化事件。WF>2后24小时内ICU转诊的似然比为17.8（15.2 - 20.9），WF>3后为40.4（27.1 - 60.1）。经验超过一年的护士的准确率显著更高（68%对79%，P = 0.04）。受试者工作特征曲线下面积（AUROC）在预测24小时内ICU转诊方面为0.92。
这一准确率高于大多数已发表的早期预警评分。
护士的模式识别和担忧感可为检测急性生理恶化提供重要信息，应纳入电子病历。
