Bürkle T, Michel A, Horch W, Schleifenbaum L, Dudeck J
Institute for Medical Informatics, University of Giessen, Germany.
Int J Med Inform. 1998 Oct-Dec;52(1-3):71-80. doi: 10.1016/s1386-5056(98)00126-9.
New functions have been integrated in the Giessen Hospital Information System WING to support the classification of all intensive care patients into the Therapeutic Intervention Scoring System (TISS). The use of those functions has been pushed when health insurance bodies demanded evidence for the correct classification of ICU beds. This article presents an overview on this development from the start in just one intensive care unit to the complete coverage of six intensive care units and three intensive monitoring units with a total of 109 beds. For those units complete TISS data has been documented for more than a year now at a detailed level. On average 14 interventions have been recorded per patient and day, accumulating to a database with more than a million entries. We describe the experiences made during introduction and the different front-end applications we used to achieve the goal. Results gained from the huge database and their implications for our future work are discussed. TISS documentation is now an established routine on every intensive care unit of our University hospital. It has been implemented without major financial or manpower investments and no specific intensive care information system has been needed. Establishing this type of basic care documentation made nurses aware of their activities, so that now they consider electronic care documentation to be in their very own interest. The next goal has been set by nurses themselves, they want to establish intervention based care documentation on normal wards as well. We think that step by step we will thus be able to achieve a more complete electronic patient record.
吉森医院信息系统WING已集成新功能，以支持将所有重症监护患者分类到治疗干预评分系统（TISS）中。当健康保险机构要求提供重症监护病床正确分类的证据时，这些功能的使用得到了推动。本文概述了这一发展历程，从最初仅在一个重症监护病房开始，到六个重症监护病房和三个重症监测病房（共109张床位）的全面覆盖。对于这些病房，详细的TISS数据已记录了一年多。平均每位患者每天记录14项干预措施，积累了一个超过100万条记录的数据库。我们描述了引入过程中的经验以及为实现目标所使用的不同前端应用程序。讨论了从庞大数据库中获得的结果及其对我们未来工作的影响。TISS文档记录现已成为我们大学医院每个重症监护病房的既定常规工作。它的实施无需大量资金或人力投入，也不需要特定的重症监护信息系统。建立这种基本护理文档让护士们意识到了自己的活动，所以现在他们认为电子护理文档符合他们自身的利益。护士们自己设定了下一个目标，他们希望在普通病房也建立基于干预的护理文档。我们认为，通过逐步努力，我们将能够实现更完整的电子病历。
