Session S42.3

Electronic Nursing Record System: Experience in a Large Cardiac Rehabilitation Department

C Marcassa*, A Terazzi, D Brovelli, A Zappia, P Giannuzzi

S. Maugeri Foundation
Veruno, Italy

Our cardiac rehabilitation department consists of 95 beds. From Jan 1st to Sept 30th 2007, 1355 patients (pts) were admitted for a residential cardiac rehabilitation program (mean age 67y, 26% aged>75y; 70% male; 57% after cardiac surgery). A nursing record system (NRS) may have a positive impact on nurse practice and improve pts management.
Aim: Implement an electronic NRS, integrated in the Hospital Information System, to plan individual pts care and interventions, limit the error risk, document nurses workloads, and verify the efficacy of the rehabilitation process (outcome).
Description: The electronic NRS has a modular structure, with different sections: 1) a core component (clinical data collection at pts admission, including Barthel score), 2) the nursing diagnoses scores according to NANDA classification, with the automatic generation of individual care plans and daily planning of related nursing activities (e.g. vital signs measurement, surgical wound medications, therapy administration, specimen collection), 3) scheduling labs analyses, 4) generation of a discharge summary (including scores on admission and discharge, a summary of interventions, and instruction to caregivers for home care when indicated). The NRS is accessible through a personal account (login&password) on all desktops; laptops connected via a protected WLAN are also available for data collection and scoring at pts’ bed.
Results: Complete data were available in 99.7% pts. A cumulative workload of 69342 activities was recorded (average 51/pt); workload was higher in the 77 pts (6%) admitted to ICU (250 activities/pt) than the remaining 94% pts (39 activities/pt, p<0.00001), and in pts with >75y (67 vs 47 activities/pt, p<0.0001). As outcome measure, Barthel score (87.9 and 94.2 on admission and discharge, p<0.001)) and NANDA score (from 3.1 to 1.3, p<0.001) improved.
Conclusions: The electronic NRS had a positive impact on nursing management. The automatic generation of individual pts’ daily workplan reduced both the risk of error during therapeutical interventions and to miss activities due to lack in communication among operators. The possibility to have a detailed workload may be useful for better resources utilization. Finally, the automatic generation of a nursing discharge summary may be effective to improve the integration with the home care health system.

(Abstract Control Number: 357)