Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
Department of Neurology, New York-Presbyterian Hospital, New York, NY, USA.
Neurocrit Care. 2022 Aug;37(Suppl 2):276-290. doi: 10.1007/s12028-022-01497-0. Epub 2022 Jun 10.
We evaluated the feasibility and discriminability of recently proposed Clinical Performance Measures for Neurocritical Care (Neurocritical Care Society) and Quality Indicators for Traumatic Brain Injury (Collaborative European NeuroTrauma Effectiveness Research in TBI; CENTER-TBI) extracted from electronic health record (EHR) flowsheet data.
At three centers within the Collaborative Hospital Repository Uniting Standards (CHoRUS) for Equitable AI consortium, we examined consecutive neurocritical care admissions exceeding 24 h (03/2015-02/2020) and evaluated the feasibility, discriminability, and site-specific variation of five clinical performance measures and quality indicators: (1) intracranial pressure (ICP) monitoring (ICPM) within 24 h when indicated, (2) ICPM latency when initiated within 24 h, (3) frequency of nurse-documented neurologic assessments, (4) intermittent pneumatic compression device (IPCd) initiation within 24 h, and (5) latency to IPCd application. We additionally explored associations between delayed IPCd initiation and codes for venous thromboembolism documented using the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) system. Median (interquartile range) statistics are reported. Kruskal-Wallis tests were measured for differences across centers, and Dunn statistics were reported for between-center differences.
A total of 14,985 admissions met inclusion criteria. ICPM was documented in 1514 (10.1%), neurologic assessments in 14,635 (91.1%), and IPCd application in 14,175 (88.5%). ICPM began within 24 h for 1267 (83.7%), with site-specific latency differences among sites 1-3, respectively, (0.54 h [2.82], 0.58 h [1.68], and 2.36 h [4.60]; p < 0.001). The frequency of nurse-documented neurologic assessments also varied by site (17.4 per day [5.97], 8.4 per day [3.12], and 15.3 per day [8.34]; p < 0.001) and diurnally (6.90 per day during daytime hours vs. 5.67 per day at night, p < 0.001). IPCds were applied within 24 h for 12,863 (90.7%) patients meeting clinical eligibility (excluding those with EHR documentation of limiting injuries, actively documented as ambulating, or refusing prophylaxis). In-hospital venous thromboembolism varied by site (1.23%, 1.55%, and 5.18%; p < 0.001) and was associated with increased IPCd latency (overall, 1.02 h [10.4] vs. 0.97 h [5.98], p = 0.479; site 1, 2.25 h [10.27] vs. 1.82 h [7.39], p = 0.713; site 2, 1.38 h [5.90] vs. 0.80 h [0.53], p = 0.216; site 3, 0.40 h [16.3] vs. 0.35 h [11.5], p = 0.036).
Electronic health record-derived reporting of neurocritical care performance measures is feasible and demonstrates site-specific variation. Future efforts should examine whether performance or documentation drives these measures, what outcomes are associated with performance, and whether EHR-derived measures of performance measures and quality indicators are modifiable.
我们评估了最近提出的神经重症监护临床绩效指标（神经重症监护学会）和创伤性脑损伤质量指标（欧洲合作神经创伤效应研究创伤性脑损伤；CENTER-TBI）从电子健康记录（EHR）流程表数据中提取的可行性和可区分性。
在合作医院存储库统一标准（CHoRUS）的三个中心内，我们检查了连续超过 24 小时的神经重症监护入院病例（2015 年 3 月至 2020 年 2 月），并评估了五项临床绩效指标和质量指标的可行性、可区分性和特定于站点的变化：（1）当需要时在 24 小时内进行颅内压（ICP）监测（ICP 监测），（2）在 24 小时内开始 ICP 监测时的潜伏期，（3）护士记录的神经评估频率，（4）在 24 小时内开始间歇性气动压缩装置（IPC），以及（5）IPC 应用的潜伏期。我们还探索了延迟开始 IPC 与使用国际疾病和相关健康问题第十次修订版（ICD-10）系统记录的静脉血栓栓塞症代码之间的关联。报告中位数（四分位距）统计数据。使用 Kruskal-Wallis 检验测量中心之间的差异，并用 Dunn 统计报告中心之间的差异。
共有 14985 例入院符合纳入标准。1514 例（10.1%）记录了 ICPM，14635 例（91.1%）记录了神经评估，14175 例（88.5%）记录了 IPC 应用。1267 例（83.7%）在 24 小时内开始 ICPM，站点 1-3 的潜伏期差异具有统计学意义，分别为 0.54 小时（2.82）、0.58 小时（1.68）和 2.36 小时（4.60）（p < 0.001）。护士记录的神经评估频率也因站点而异（17.4 次/天[5.97]、8.4 次/天[3.12]和 15.3 次/天[8.34]；p < 0.001）和昼夜差异（白天 6.90 次/天与夜间 5.67 次/天，p < 0.001）。符合临床资格的 12863 例（90.7%）患者在 24 小时内接受了 IPC，排除了 EHR 记录有局限性损伤、被明确记录为可活动或拒绝预防的患者。院内静脉血栓栓塞的发生率因站点而异（1.23%、1.55%和 5.18%；p < 0.001），与 IPC 潜伏期延长有关（总体而言，1.02 小时[10.4]与 0.97 小时[5.98]，p = 0.479；站点 1，2.25 小时[10.27]与 1.82 小时[7.39]，p = 0.713；站点 2，1.38 小时[5.90]与 0.80 小时[0.53]，p = 0.216；站点 3，0.40 小时[16.3]与 0.35 小时[11.5]，p = 0.036）。
从电子健康记录中提取神经重症监护绩效指标的报告是可行的，并且表现出特定于站点的变化。未来的研究应探讨是绩效还是文件记录推动了这些指标，哪些结果与绩效相关，以及电子健康记录中提取的绩效指标和质量指标是否可以修改。
