Korean J Adult Nurs.  2019 Oct;31(5):496-506. 10.7475/kjan.2019.31.5.496.

Emergency Department Nursing Activities: Retrospective Study on Data from Electronic Nursing Records

• Baik SY
• Cho E
• Kim YA
• Choi M

• KMID: 2461065
• DOI: http://doi.org/10.7475/kjan.2019.31.5.496

Abstract

PURPOSE
This study aimed to identify the type and frequency of nursing activities targeting emergency department patients by analyzing electronic nursing records.
METHODS
This retrospective study identified the characteristics of and nursing activities for adult patients who visited a university hospital emergency department for 6 months from January to June 2018 by analyzing the hospital's electronic nursing records. Descriptive statistics and one-way analysis of variance were used to analyze the characteristics of patients and the nursing records.
RESULTS
A total of 36,435 patients, with an average age of 52.82±19.91 years and a male-to-female ratio of 1:1.16, participated in the study. The number of patients with Korean Triage and Acuity Scale levels 4 (less urgent) and 5 (non-urgent) were 24,403 (67% of the total number). Referrals were requested 1.21±0.54 times per patient. The most frequent NANDA diagnosis and Nursing Intervention Classification intervention were "Risk for unstable blood glucose level" (858, 28.4%), and "Surveillance" (83,131, 23.9%). The most frequent Clinical Care Classification action type was "Assess or Monitor" (313,729, 38.5%). The higher the severity level and the number of referrals, the more the recorded numbers of nursing diagnoses, interventions, and care activities.
CONCLUSION
This study demonstrated the possibility of nursing task analysis by identifying the type and frequency of nursing activities based on the data from electronic nursing records. Further research on electronic nursing records would contribute to the usefulness of these records for nursing workload analysis and effective workforce management.

MeSH Terms

Adult
Blood Glucose
Classification
Diagnosis
Electronic Health Records
Emergencies*
Emergency Service, Hospital*
Humans
Nursing Diagnosis
Nursing Records*
Nursing Services
Nursing*
Referral and Consultation
Retrospective Studies*
Triage
Blood Glucose

Reference

1. Gil M-R, Choi CG. Exploring the factors of selecting national and public hospitals of emergency service users. The Korean Association for Policy Studies. 2017; 26(3):23–50.

2. Kim BJ, Lee EN, Kang KH, Kim SS, Kim SA, Sung YH, et al. A study of job analysis of the emergency room nurse. Journal of Korean Clinical Nursing Research. 2006; 12(1):81–95.

3. Park JG. Statistical yearbook of emergency medicine. 9th ed. Seoul: National Emergency Medical Center;2011. p. 121–31.

4. Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. The American Journal of Emergency Medicine. 2010; 28(3):304–9. https://doi.org/10.1016/j.ajem.2008.12.014.

5. Lee EN, Kim BJ, Kim SS, Kang KH, Kim YS. Development of an in-service education program for emergency room nurses according to their career ladders. Journal of Korean Clinical Nursing Research. 2008; 14(1):99–111.

6. DeCola PR, Riggins P. Nurses in the workplace: expectations and needs. International Nursing Review. 2010; 57(3):335–42. https://doi.org/10.1111/j.1466-7657.2010.00818.x.

7. Cole FL, Ramirez E. Activities and procedures performed by nurse practitioners in emergency care settings. Journal of Emergency Nursing. 2000; 26(5):455–63. https://doi.org/10.1067/men.2000.110585.

8. Kim MH. Actual condition of caring emergency department nurses working [master's thesis]. Seoul: Hanyang University;2004.

9. Jones T, Shaban RZ, Creedy DK. Practice standards for emergency nursing: an international review. Australasian Emergency Care. 2015; 18(4):190–203. https://doi.org/10.1016/j.aenj.2015.08.002.

10. Lucchini A, De Felippis C, Elli S, Schifano L, Rolla F, Pegoraro F, et al. Nursing activities score (NAS): 5 years of experience in the intensive care units of an Italian university hospital. Intensive and Critical Care Nursing. 2014; 30(3):152–8. https://doi.org/10.1016/j.iccn.2013.10.004.

11. Somensi RM, Caregnato RCA, Cervi GH, Flores CD. Workload: a comparison between the online and observational methods. Revista Brasileira de Enfermagem. 2018; 71(4):1850–1857. https://doi.org/10.1590/0034-7167-2017-0313.

12. Adomat R, Hicks C. Measuring nursing workload in intensive care: an observational study using closed circuit video came-ras. Journal of Advanced Nursing. 2003; 42(4):402–12. https://doi.org/10.1046/j.1365-2648.2003.02632.x.

13. Choi HW, Park HA. Needs for nursing information system according to the level of nursing informatization in general hospitals. Journal of Korean Society of Medical Informatics. 2008; 14(4):405–16. https://doi.org/10.4258/jksmi.2008.14.4.405.

14. Cho I, Choi WJ, Choi WH, Kim MK. The adoptions and use of electronic nursing records in Korean hospitals: findings of a nationwide survey. Journal of Korean Clinical Nursing Research. 2013; 19(3):345–56.

15. Ahn M, Choi M, Kim YA. Factors associated with the time-liness of electronic nursing documentation. Healthcare Informatics Research. 2016; 22(4):270–6. https://doi.org/10.4258/hir.2016.22.4.270.

16. Zhao S, Chen H, Feng L. Using hospital information system data to capture nurse workload. Nursing Informatics 2016. 2016. 822–3.

17. Liljamo P, Kinnunen U-M, Saranto K. Assessing the relation of the coded nursing care and nursing intensity data: towards the exploitation of clinical data for administrative use and the design of nursing workload. Health Informatics Journal. 2018. Forthcoming.https://doi.org/10.1177/1460458218813613.

18. American Nurses Association. ANA's principles for nursing documentation: guidance for registered nurses. Silver Spring, MD: ANA, Nursebook;2010.

19. Urquhart C, Currell R, Grant MJ, Hardiker NR. Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Database of Systematic Reviews. 2009. 1.

20. The Korean Society of Emergency Medicine KTAS Committee. Korean triage and acuity scale - Provider training manual version 3. Paju: Koonja;2017. 16-9.

21. Herdman HT, Kamitsuru S. editors. NANDA international nursing diagnoses: definitions & classification 2018-2020. 11th ed.New York: Thieme;2017.

22. Butcher HK, Bulechek GM, Dochterman JMM, Wagner CM. Nursing interventions classification (NIC). Maryland. Elsevier Health Sciences;2018.

23. Saba VK. Clinical care classification (CCC) system version 2.5: user's guide. 2nd ed.New York: Springer Publishing Com-pany;2012.

24. Lee KS. Research about chief complaint and principal diagnosis of patients who visited the university hospital emergency room. Journal of Digital Convergence. 2012; 10(10):347–52. https://doi.org/10.14400/JDPM.2012.10.10.347.

25. Jung SH, Yoon HD, Na BJ. Characteristics of non-emergent patients at emergency departments. Health Policy and Management. 2006; 16(4):128–46. https://doi.org/10.4332/kjhpa.2006.16.4.128.

26. Atenstaedt R, Gregory J, Price-Jones C, Newman J, Roberts L, Turner J. Why do patients with nonurgent conditions present to the emergency department despite the availability of alter-native services? European Journal of Emergency Medicine. 2015; 22(5):370–3. https://doi.org/10.1097/MEJ.0000000000000224.

27. Kim JY, Lee YW, Chung MK. Differences of upgrading nurse staffing in nursing care activity, work performance outcomes, and job satisfaction. Korean Journal of Adult Nursing. 2016; 28(3):256–65. https://doi.org/10.7475/kjan.2016.28.3.256.

28. Schilder M. To represent needs of nursing care using nursing diagnoses: potentials and restrictions of the NANDA classification and ICNP. Pflege Zeitschrift. 2005; 58(3):2–8.

29. Johnson KD, Mueller L, Winkelman C. The nurse response to abnormal vital sign recording in the emergency department. Journal of Clinical Nursing. 2017; 26(1-2):148–56. https://doi.org/10.1111/jocn.13425.

30. Song KJ. Analysis of the nursing practice in a medical ICU based on an electronic nursing record. Journal of Korean Academy of Nursing. 2007; 37(6):883–90. https://doi.org/10.4040/jkan.2007.37.6.883.