Center for Data Science, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, United States.
Department of Computer Science, College of Arts and Sciences, Emory University, Atlanta, Georgia, United States.
Appl Clin Inform. 2021 Aug;12(4):897-909. doi: 10.1055/s-0041-1735179. Epub 2021 Sep 29.
This study aimed to compare the concordance of pressure injury (PI) site, stage, and count documented in electronic health records (EHRs); explore if PI count during each patient hospitalization is consistent based on PI site or stage count in the diagnosis or chart event records; and examine if discrepancies in PI count were associated with patient characteristics.
Hospitalization records with the International Classification of Diseases ninth edition (ICD-9) codes, chart events from two systems (CareVue, MetaVision), and clinical notes on PI were extracted from the Medical Information Mart for Intensive Care (MIMIC)-III database. PI site and stage counts from individual hospitalization were computed. Hospitalizations with the same or different counts of site and stage according to ICD-9 codes (site and stage), CareVue (site and stage), or MetaVision (stage) charts were defined as consistent or discrepant reporting. Chi-squared, independent -, and Kruskal-Wallis tests were examined if the count discrepancy was associated with patient characteristics. ICD-9 codes and charts were also compared for people with one site or stage.
A total of 31,918 hospitalizations had PI data. Within hospitalizations with ICD-9-coded sites and stages, 55.9% reported different counts. Within hospitalizations with CareVue charts on PI, 99.3% reported the same count. For hospitalizations with stages based on ICD-9 codes or MetaVision chart data, only 42.9% reported the same count. Discrepancies in counts were consistently and significantly associated with variables including PI recording in clinical notes, dead/hospice at discharge, more caregivers, longer hospitalization or intensive care unit stays, and more days to first transfer. Discrepancies between ICD-9 code and chart values on the site and stage were also reported.
Patient characteristics associated with PI count discrepancies identified patients at risk of having discrepant PI counts or worse outcomes. PI documentation quality could be improved with better communication, care continuity, and integrity. Clinical research using EHRs should adopt systematic data quality analysis to inform limitations.
本研究旨在比较电子病历（EHR）中记录的压疮（PI）部位、分期和数量的一致性；根据诊断或图表事件记录中的 PI 部位或分期计数，探索每次住院期间 PI 计数是否一致；并检查 PI 计数的差异是否与患者特征相关。
从医疗信息监护 III 数据库（MIMIC-III）中提取带有国际疾病分类第九版（ICD-9）代码的住院记录、来自两个系统（CareVue、MetaVision）的图表事件和 PI 的临床记录。计算了单个住院患者的 PI 部位和分期计数。根据 ICD-9 代码（部位和分期）、CareVue（部位和分期）或 MetaVision（分期）图表将具有相同或不同部位和分期计数的住院患者定义为一致或不一致报告。如果计数差异与患者特征相关，则检查卡方检验、独立样本 t 检验和 Kruskal-Wallis 检验。还比较了具有一个部位或分期的患者的 ICD-9 代码和图表。
共有 31918 例住院患者有 PI 数据。在具有 ICD-9 编码部位和分期的住院患者中，有 55.9%报告了不同的计数。在具有 PI CareVue 图表的住院患者中，有 99.3%报告了相同的计数。对于基于 ICD-9 代码或 MetaVision 图表数据的住院患者，只有 42.9%报告了相同的计数。计数差异与包括 PI 记录在临床记录中、出院时死亡/临终关怀、更多护理人员、更长的住院或 ICU 停留时间以及更多天的首次转移在内的变量一致且显著相关。还报告了 ICD-9 代码和图表值在部位和分期上的差异。
与 PI 计数差异相关的患者特征确定了存在差异 PI 计数或更差结局风险的患者。通过更好的沟通、护理连续性和完整性，可以提高 PI 文档的质量。使用 EHR 的临床研究应采用系统的数据质量分析来告知局限性。
