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  • Measure Summary
  • NQMC:008526
  • Mar 2011

Nursing care: percentage of duly completed registers.

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in May 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of duly completed registers.

Rationale

The aim of intensive care medicine is to provide critical patients with the healthcare that they need, ensuring the quality and safety of care. Intensive care medicine is one of the principal components of modern healthcare systems. There is an increasing demand for this resource, which involves high costs.

The quality of care has gradually come to be the central focus of healthcare, and in recent years patient safety has come to represent one of the key aspects of quality. In the case of intensive care medicine, this interest in quality is even more evident, not only because of its social and economic impact, but also because some of the dimensions involved in the quality of care of critical patients take on greater importance: critical patients are more vulnerable, access to critical care is more limited so efforts to distribute resources equitably are more important, scant scientific evidence is available, and the efficiency is limited.

Nursing registers form part of the patient's clinical records. They assure the quality and continuity of care. They help to avoid errors and repetition of procedures. They provide a record of the activity planned and carried out by the nursing staff and all the information generated in the nursing staff's relations with the patient. Nursing registers improve interdisciplinary communication. Nursing registers are legal documents.

Evidence for Rationale

del Olmo-Núñez SM, Casasde la Cal L, Mejías-Delgado A. [The nursing register: a communication system]. Enfermeria Clin. 2007 May-Jun;17(3):142-5. PubMed External Web Site Policy

Donati A, Gabbanelli V, Pantanetti S, Carletti P, Principi T, Marini B, Nataloni S, Sambo G, Pelaia P. The impact of a clinical information system in an intensive care unit. J Clin Monit Comput. 2008 Feb;22(1):31-6. PubMed External Web Site Policy

González Sánchez JA, Cosgaya García O, Simón García MJ, Blesa Malpica AL. [Nursing records: conventional versus computerized. Critical care unit]. Enferm Intensiva. 2004 Apr-Jun;15(2):53-62. PubMed External Web Site Policy

Perpiñá Galvan J. Análisis de los registros de enfermería del Hospital General Universitario de Alicante y pautas para mejorar su cumplimentación. Enfermeria Clin. 2005;15:95-102.

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Primary Health Components

Nursing care; nursing register

Denominator Description

Number of registers evaluated (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of duly completed registers (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Hospital Inpatient

Intensive Care Units

Professionals Involved in Delivery of Health Services

Nurses

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Institutionalization

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of registers evaluated

Note:

  • Nursing registers: Computerized or paper charts where all pertinent information about the patient are registered (from admission to discharge from the critical care department) as well as all annexed documents accepted by the hospital's clinical documentation commission
  • Population: All registers of patients discharged to the critical care department during the period reviewed.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of duly completed registers

Duly completed:

  • Containing all data specified in the regulations for the use of clinical records at each hospital
  • Brief summary of the patient's condition during each shift and registry of all activities planned and executed by the nursing staff, duly signed by the registered nurse responsible for the patient

Exclusions
Unspecified

Numerator Search Strategy

Institutionalization

Data Source

Electronic health/medical record

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Prescriptive standard

Prescriptive Standard

Standard: 100%

Evidence for Prescriptive Standard

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Original Title

Nursing registries in the ICU.

Measure Collection Name

Quality Indicators in Critically Ill Patients

Measure Set Name

Nursing Care

Submitter

Spanish Society of Intensive and Critical Care and Units Coronary - Clinical Specialty Collaboration

Developer

Spanish Society of Intensive and Critical Care and Units Coronary - Clinical Specialty Collaboration

Funding Source(s)

Boehringer Laboratories

Composition of the Group that Developed the Measure

Work Group for Nursing (SEEIUC)

  • Rosa García Díez
  • Mar Sánchez Sánchez
  • Juan Carlos Muñoz Camargo
  • Mónica Vázquez Calatayud
  • Rosa Jam Gatell
  • Rosana Goñi Viguria
  • Emilia Romero de San Pío
  • Susana Arias Rivera
  • Alicia Robas Gómez
  • Juan Ángel Hernández
  • Susana Arias Rivera

Scientific Coordination:

  • Maria Cruz Martín Delgado
  • Jesús Blanco Varela
  • Lluís Cabré Pericas
  • Pedro Galdos Anuncibay
  • Federico Gordo Vidal

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2011 Mar

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

2016 Jul

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in May 2016.

Source(s)

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Measure Availability

Source available in English External Web Site Policy and Spanish External Web Site Policy from the Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC) Web site.

For more information, contact SEMICYUC at Paseo de la Reina Cristina, 36, 4o D, Madrid, Spain; Phone: +34-91-502-12-13; Fax: +34-91-502-12-14; Web site: www.semicyuc.org External Web Site Policy; E-mail: secretaria@semicyuc.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on March 20, 2014. The information was verified by the measure developer on April 25, 2014.

The information was reaffirmed by the measure developer on May 10, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

The Quality Indicators in Critically Ill Patients update 2011 can be used by any private or public body only for the purposes of research, clinical management, teaching and education, and will not be used for any other purpose. In all cases, full credit to the Spanish Society of Intensive Care Medicine (SEMICYUC) will be granted. The commercial use of the Quality Indicators in Critically Ill Patients update 2011 is explicitly forbidden.

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