Cesare Manuele, D'agostino Fabio, Maurici Massimo, Zega Maurizio, Zeffiro Valentina, Cocchieri Antonello
Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
Unicamillus, Saint Camillus International University of Health Sciences, Rome, Italy.
SAGE Open Nurs. 2023 Feb 20;9:23779608231158157. doi: 10.1177/23779608231158157. eCollection 2023 Jan-Dec.
In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs.
The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes.
A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs.
The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred.
NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes.
在电子健康记录（EHR）中，需要标准化护理术语（SNT），如护理诊断（ND），以证明护理对患者结局的影响。不幸的是，ND在临床实践中并不常用，尤其是在手术环境中，并且很少包含在EHR中。
本研究的目的是通过分析ND与医院结局之间的关系，描述医院手术环境中ND的患病率和趋势。
进行了一项回顾性研究。纳入了意大利一家大学医院15个外科住院单元之一连续1年收治的所有成年住院患者。数据，包括专业评估工具和医院出院登记册，是从医院的EHR中回顾性收集的。
样本包括5027名外科住院患者。每位患者平均有6.3±4.3个ND。ND的平均分布全年呈稳定趋势。最具代表性的北美护理诊断协会国际（NANDA-I）护理诊断领域是安全/保护。住院时间较长的患者入院时ND的总数显著更高。入院时ND的数量与院内患者转科数量之间存在统计学显著相关性。此外，与未转科的患者相比，后来转入重症监护病房的患者入院时ND的平均数量更高。
ND是理解护士在手术环境中贡献的关键。入院时收集的ND可以代表与医院关键结局相关的预后因素。
