Abstracting ICU Nursing Care Quality Data From the Electronic Health Record. (September 2017)

• Record Type: Journal Article
• Authors: Seaman, Jennifer B.; Evans, Anna C.; Sciulli, Andrea M.; Barnato, Amber E.; Sereika, Susan M.; Happ, Mary Beth
• Is Part Of: Western journal of nursing research. Volume 39:Number 9(2017)
• Page Start: 1271
• Page End: 1288
• Publication Date: 2017-09
• Subjects: critical care -- tool development -- data collection tool -- nursing practice -- quality indicators -- electronic health record -- intervention testing; Nursing -- Research -- Periodicals; Nursing -- Periodicals; Nursing -- Research -- West (U.S.) -- Periodicals; Nursing -- West (U.S.) -- Periodicals; Nursing -- Periodicals; Nursing Research -- Periodicals; Soins infirmiers -- Recherche -- Périodiques; Soins infirmiers -- Périodiques; Soins infirmiers -- Recherche -- États-Unis (Ouest) -- Périodiques; Soins infirmiers -- États-Unis (Ouest) -- Périodiques; Soins infirmiers; Recherche; États-Unis (Ouest); Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); 610.730702
• DOI: 10.1177/0193945916665814
• Languages: English
• ISSNs: 0193-9459

Abstract

The electronic health record is a potentially rich source of data for clinical research in the intensive care unit setting. We describe the iterative, multi-step process used to develop and test a data abstraction tool, used for collection of nursing care quality indicators from the electronic health record, for a pragmatic trial. We computed Cohen's kappa coefficient (κ) to assess interrater agreement or reliability of data abstracted using preliminary and finalized tools. In assessing the reliability of study data ( n = 1, 440 cases) using the finalized tool, 108 randomly selected cases (10% of first half sample; 5% of last half sample) were independently abstracted by a second rater. We demonstrated mean κ values ranging from 0.61 to 0.99 for all indicators. Nursing care quality data can be accurately and reliably abstracted from the electronic health records of intensive care unit patients using a well-developed data collection tool and detailed training.