Enhancing Sepsis Collaborative: Computer Documentation

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Table of Contents

Introduction
Nursing Informatics Project
Stakeholders
Project Priority
Success Evaluation
Reporting the Results: To Whom?
Conclusion
References

Introduction

Preventing and treating the life-threatening infection that is sepsis requires one of the most rapid reactions from healthcare professionals regarding time. Thus, identifying and documenting sepsis cases becomes another critical step in the patient’s healing process, requiring a specific set of skills and ultimate collaboration from doctors and nurses alike. Despite paper-based databases remaining the traditional way of going about protocol, using advanced and modern means of documentation presents newer, undiscovered aspects of utility. Hence, the presented Nursing Informatics (NI) project at Northwell Health will focus on the ways a shift from paper to computer databases can be achieved, as well as the benefits of this within treating sepsis.

Nursing Informatics Project

The need for a computer-based documentation approach within Northwell Health was identified based on multiple factors, concerned not only with modernizing the attitude of healthcare professionals towards the documentation process. A study by Perez (2013) states that the “results of adopting innovation and the improvements effected by its implementation go beyond the adoption process” (p. 89). While the mentioned study deals mainly with educative nursing systems, their apperceived benefits may transfer well onto the presented documentation procedures. Considering all this, along with the fact that Northwell Health does not have a computer-based sepsis protocol, creates the need for a project that will construct the possibility of such a changeover.

The project objectives will include:

The creation of a sustainable computer-based sepsis documentation protocol to be used within Northwell Health.
The identification of those who would benefit from such computerization of the documentation process.
An establishment of the project’s priority within Northwell Health and, thus, the need for its timely implementation within the organization.
The codification of specific values of success evaluation by using a devised rubric.
The determining of those responsible for the project’s implementation.

An argument should be made about the need for a computer-based protocol, as it is often associated with unnecessary costs rooted in equipment and software prices, as well as the required staff training. However, computerization allows for an enhanced response time, which becomes vital in life-threatening cases, and electronic documentation has been found to surpass hand-written protocol in speed (Schachner et al., 2016). This fact alone may be enough to give computerization an advantage over slower, paper-based methods, as the positive effects on patient’s health far outweigh the negative repercussions related to cost.

Stakeholders

The effect of decreasing the so-called paper trail on sepsis identification has already been identified as having a positive impact on patients’ health. The influences of inopportune sepsis treatment result in “long hospital stays (median = 10 days), discharge to long-term care settings (20%), and death (25%)” (Novosad et al., 2016, p. 867). Expediting sepsis treatment through its rapid documentation, thus, allows for faster patient recovery through not only its identification but also the collaboration of healthcare professionals in its treatment. Therefore, both actors and seekers of aid within the healthcare system may be identified as those benefiting directly and indirectly from sepsis protocol computerization.

Project Priority

The importance of this project should not be underestimated in comparison to other attempts to improve the healthcare system mechanism. A study by Clynch and Kellett (2015) focused on the impact of human error in medicine has shown that documentation takes up a significant portion of doctors’ time, which may be combatted by developments in computerized protocols. Thus, the issue of incident codification becomes one of the most important and most requiring solving, especially considering that there is no necessity for a complete revamping of the system bus, only its remodeling.

Success Evaluation

Attainment of success should not just focus on reaching the goals set systematically in the presented research but should rely on the creation of a rubric to measure that, which is quantitative. Of such calculable values, it is possible to highlight two, with one of them being the percentage of implementation of the devised computer-based sepsis documentation protocol throughout Northwell Health.

The second measurable quantity would be that of sepsis treatment time through a comparison of the speed of reaction before/after implementation, calculated in time per aided patient. Factors relating to project priority and stakeholders may be effectively extrapolated from doctor-nurse opinion questionnaires about the subject. However, the success of this project should be defined not only through its perceived utility but also through an assessment of the implementation effort against positive results, to be calculated from the suggested above metrics.

Reporting the Results: To Whom?

The institution of a separate group, or multiple ones, with a defined group leader, may seem necessary for the success of such a project, which will help achieve ultimate collaboration between system-developers and healthcare professionals. Equally as important remains the assignment of those responsible for the assessment of the results and thus playing a role in the evaluation of the advantageousness of the project. Thus, the creation of such a system of group collaboration within Northwell Health becomes vital to the success of the project, as without appropriate evaluation, no outcome may be devised. It would seem practical to place this project under the responsibility of the Taming Sepsis Education Program at Northwell Health, due to the perceived goal alignment.

Conclusion

The partnership instituted between healthcare professionals through the development of a computer-based system of documentation can ultimately lead to faster response time to life-threatening cases, such as sepsis. Through the establishment of appropriate software, training, and a decrease of the infamous paper trail, which slows down aid administration, patients’ health may be positively affected. The highlighted in this research goals and suggested rubrics of evaluation could be implemented to appropriately develop and modernize the health care system by creating efficient ways of communication between doctors, nurses, and patients alike.

References

Clynch, N., & Kellett, J. (2015). Medical documentation: Part of the solution, or part of the problem? A narrative review of the literature on the time spent on and value of medical documentation. International Journal of Medical Informatics, 84(4), 221-228. Web.

Novosad, S., Sapiano, M., Grigg, C., Lake, J., Robyn, M., Dumyati, G…. Epstein, L. (2016). Vital signs: Epidemiology of sepsis: Prevalence of health care factors and opportunities for prevention. Morbidity and Mortality Weekly Report, 65(33), 864-869. Web.

Perez, G. (2013). The adoption of information systems innovation: Study of a learning support system and its adoption in the medical education field. International Journal of Auditing Technology, 1(1), 75-90. Web.

Schachner, M., Gonzalez, Z., Sommer, J., Recondo, F., Gassino, F., Luna, D., & Benitez, S. (2016). Computerization of a nursing chart according to the nursing process. In W. Sermeus, P. Procter & P. Weber (Eds.), Nursing Informatics 2016: EHealth for all: Every level collaboration – from project to realization (pp. 133-137). Washington, DC: IOS Press.

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