Krakau Karolina, Andersson Helene, Dahlin Åsa Franzén, Egberg Louise, Sterner Eila, Unbeck Maria
Department of Rehabilitation Medicine, Danderyd Hospital, Danderyd, Sweden.
Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Solna, Sweden.
BMC Nurs. 2021 Apr 9;20(1):58. doi: 10.1186/s12912-021-00577-4.
In-hospital fall incidents are common and sensitive to nursing care. It is therefore important to have easy access to valid patient data to evaluate and follow-up nursing care. The aim of the study was to validate the nursing documentation, using a specific term in the registered nurses´ (RNs´) discharge note, regarding inpatient falls according to the outcome of a digitalized data extraction tool and the discharge note itself.
At a teaching hospital, 31,571 episodes of care were eligible for inclusion in this retrospective cohort study. A stratified sampling including five groups was used, two with random sampling and three with total sampling. In total, 1232 episodes of care were reviewed in the electronic patient record using a study-specific protocol. Descriptive statistics were used.
In total, 590 episodes of care in the study cohort included 714 falls. When adjusted for the stratified sampling the cumulative incidence for the study population was 1.9%. The positive predictive value in total for the data extraction tool regarding the presence of any fall, in comparison with the record review, was 87.4%. Discrepancies found were, for example, that the RNs, at discharge, stated that the patient had fallen but no documented evidence of that could be detected during admission. It could also be the opposite, that the RNs correctly had documented that no fall had occurred, but the data extraction tool made an incorrect selection. When the latter had been withdrawn, the positive predictive value was 91.5%. Information about minor injuries due to the fall was less accurate. In the group where RNs had stated that the patient had fallen without injury, minor injuries had actually occurred in 28.3% of the episodes of care.
The use of a specific term regarding fall in the RNs´ discharge note seems to be a valid and reliable data measurement and can be used continuously to evaluate and follow-up nursing care.
住院期间跌倒事件很常见，且对护理工作很敏感。因此，能够轻松获取有效的患者数据对于评估和跟踪护理工作很重要。本研究的目的是根据数字化数据提取工具的结果和出院小结本身，使用注册护士（RN）出院小结中的特定术语来验证关于住院患者跌倒的护理记录。
在一家教学医院，31571例护理事件符合纳入这项回顾性队列研究的条件。采用了包括五组的分层抽样，两组采用随机抽样，三组采用全样本抽样。总共使用特定的研究方案在电子病历中回顾了1232例护理事件。使用了描述性统计方法。
研究队列中总共590例护理事件包括714次跌倒。经分层抽样调整后，研究人群的累积发病率为1.9%。与记录审查相比，数据提取工具关于任何跌倒情况的总体阳性预测值为87.4%。发现的差异包括，例如，注册护士在出院时表示患者跌倒，但入院期间未发现该情况的记录证据。也可能相反，注册护士正确记录未发生跌倒，但数据提取工具做出了错误选择。排除后者后，阳性预测值为91.5%。关于跌倒导致的轻伤的信息不太准确。在注册护士表示患者跌倒但未受伤的组中，实际有28.3%的护理事件发生了轻伤。
在注册护士的出院小结中使用关于跌倒的特定术语似乎是一种有效且可靠的数据测量方法，可用于持续评估和跟踪护理工作。
