Exploring the Documentation of Delirium in Patients After Cardiac Surgery: A Retrospective Patient Record Study

Satu Poikajärvi, Laura-Maria Peltonen, Eriikka Siirala, Juho Heimonen, Hans Moen, Sanna Salanterä, Kristiina Junttila

Tutkimustuotos: ArtikkelijulkaisuArtikkeliTieteellinenvertaisarvioitu

Abstrakti

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.

Alkuperäiskielienglanti
LehtiComputers, informatics, nursing : CIN
Vuosikerta42
Numero1
Sivut27-34
Sivumäärä8
ISSN1538-2931
DOI - pysyväislinkit
TilaJulkaistu - 1 tammik. 2024
OKM-julkaisutyyppiA1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä, vertaisarvioitu

Lisätietoja

Publisher Copyright:
Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.

Tieteenalat

  • 3126 Kirurgia, anestesiologia, tehohoito, radiologia
  • 316 Hoitotiede

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