Int J Med Inform - Model development for EHR interdisciplinary information exchange of ICU common goals.

Tópicos

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Resumo

RPOSE: Effective interdisciplinary exchange of patient information is an essential component of safe, efficient, and patient-centered care in the intensive care unit (ICU). Frequent handoffs of patient care, high acuity of patient illness, and the increasing amount of available data complicate information exchange. Verbal communication can be affected by interruptions and time limitations. To supplement verbal communication, many ICUs rely on documentation in electronic health records (EHRs) to reduce errors of omission and information loss. The purpose of this study was to develop a model of EHR interdisciplinary information exchange of ICU common goals.METHODS: The theoretical frameworks of distributed cognition and the clinical communication space were integrated and a previously published categorization of verbal information exchange was used. 59.5h of interdisciplinary rounds in a neurovascular ICU were observed and five interviews and one focus group with ICU nurses and physicians were conducted.RESULTS: Current documentation tools in the ICU were not sufficient to capture the nurses' and physicians' collaborative decision-making and verbal communication of goal-directed actions and interactions. Clinicians perceived the EHR to be inefficient for information retrieval, leading to a further reliance on verbal information exchange.CONCLUSION: The model suggests that EHRs should support: (1) information tools for the explicit documentation of goals, interventions, and assessments with synthesized and summarized information outputs of events and updates; and (2) messaging tools that support collaborative decision-making and patient safety double checks that currently occur between nurses and physicians in the absence of EHR support.

Resumo Limpo

rpose effect interdisciplinari exchang patient inform essenti compon safe effici patientcent care intens care unit icu frequent handoff patient care high acuiti patient ill increas amount avail data complic inform exchang verbal communic can affect interrupt time limit supplement verbal communic mani icus reli document electron health record ehr reduc error omiss inform loss purpos studi develop model ehr interdisciplinari inform exchang icu common goalsmethod theoret framework distribut cognit clinic communic space integr previous publish categor verbal inform exchang use h interdisciplinari round neurovascular icu observ five interview one focus group icu nurs physician conductedresult current document tool icu suffici captur nurs physician collabor decisionmak verbal communic goaldirect action interact clinician perceiv ehr ineffici inform retriev lead relianc verbal inform exchangeconclus model suggest ehr support inform tool explicit document goal intervent assess synthes summar inform output event updat messag tool support collabor decisionmak patient safeti doubl check current occur nurs physician absenc ehr support

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