Electronic Health Record Documentation: Is it an accurate indicator of quality of care for mechanically ventilated patients?
Background: Ventilator associated pneumonia is one of the leading hospital acquired infections associated with increased mortality and lengths of stay in mechanically ventilated patients.
Hypothesis: It is hypothesized that the introduction of chlorhexidine gluconate will show reduction in the incidences of ventilator associated pneumonia and a greater reduction with tooth brushing vs oral swabbing. It is also hypothesized that the electronic health record will provide more evidence of quality of care than an external EHR sources.
Methods: The non-randomized, non-sampled population included 98 patient records that met the inclusion criteria. The external tool, Automated Vent Bundle tool provided information as to which patients were mechanically ventilated in the Surgical Intensive Care Unit during years 2011 and 2012 day to day during each month. Each EHR was searched for the documentation of CHG during periods of mechanical ventilation.
Results: There was not any significant difference noted in the reduction of VAP during years 2008 and 2009 in which swabs and tooth brushing were utilized. In 2010, significant decrease was noted in the rate of VAP from years 2009 and 2010 with a reduction of VAP by 27% from 4.1 in 2009 to 1.1 in 2010.
Conclusion: VAP rates and ventilator days were reduced as a direct result of implementation of CHG. External data sources provided more information than the data collected from the EHR. More research is needed in the evaluation of quality of care concerning electronic clinical documentation.
Powell, JoEtta, "Electronic Health Record Documentation: Is it an accurate indicator of quality of care for mechanically ventilated patients?" (2014). Applied Research Projects. 36. . https://doi.org/10.21007/chp.hiim.0041
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