Exploring the Documentation of Delirium in Patients After Cardiac Surgery

被引:0
|
作者
Poikajarvi, Satu [1 ,2 ,3 ,10 ,11 ]
Peltonen, Laura-Maria [1 ]
Siirala, Eriikka [4 ]
Heimonen, Juho [5 ]
Moen, Hans [6 ]
Salantera, Sanna [1 ,7 ]
Junttila, Kristiina [1 ,8 ,9 ]
机构
[1] Univ Turku, Fac Med, Dept Nursing Sci, Turku, Finland
[2] Univ Helsinki, Dept Perioperat & Intens Care, Helsinki, Finland
[3] Helsinki Univ Hosp, Helsinki, Finland
[4] Turku Univ Hosp, Res Serv, Turku, Finland
[5] Univ Turku, Fac Technol, Dept Comp, Turku, Finland
[6] Aalto Univ, Sch Sci, Dept Comp Sci, Espoo, Finland
[7] Turku Univ Hosp, Turku, Finland
[8] Helsinki Univ Hosp, Nursing Res Ctr, Helsinki, Finland
[9] Univ Helsinki, Helsinki, Finland
[10] Univ Helsinki, Dept Perioperat & Intens Care, HUS, Karvasmaentie 8,POB 800, FI-00029 Espoo, Finland
[11] Helsinki Univ Hosp, HUS, Karvasmaentie 8,POB 800, FI-00029 Espoo, Finland
关键词
Cardiac surgery; Delirium; Documentation; EHRs; Nursing;
D O I
10.1097/CIN.0000000000001039
中图分类号
TP39 [计算机的应用];
学科分类号
081203 ; 0835 ;
摘要
Delirium is a common disorder for patients after cardiac surgery. Its manifestation and care can be examined through EHRs. The aim of this retrospective, comparative, and descriptive patient record study was to describe the documentation of delirium symptoms in the EHRs of patients who have undergone cardiac surgery and to explore how the documentation evolved between two periods (2005-2009 and 2015-2020). Randomly selected care episodes were annotated with a template, including delirium symptoms, treatment methods, and adverse events. The patients were then manually classified into two groups: nondelirious (n = 257) and possibly delirious (n = 172). The data were analyzed quantitatively and descriptively. According to the data, the documentation of symptoms such as disorientation, memory problems, motoric behavior, and disorganized thinking improved between periods. Yet, the key symptoms of delirium, inattention, and awareness were seldom documented. The professionals did not systematically document the possibility of delirium. Particularly, the way nurses recorded structural information did not facilitate an overall understanding of a patient's condition with respect to delirium. Information about delirium or proposed care was seldom documented in the discharge summaries. Advanced machine learning techniques can augment instruments that facilitate early detection, care planning, and transferring information to follow-up care.
引用
收藏
页码:27 / 34
页数:8
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