Agreement between common goals discussed and documented in the ICU

Objective: Meaningful use of electronic health records (EHRs) is dependent on accurate clinical documentation. Documenting common goals in the intensive care unit (ICU), such as sedation and ventilator management plans, may increase collaboration and decrease patient length of stay. This study analyzed the degree to which goals stated were present in the EHR. Design: Descriptive correlational study of common goals verbally stated during daily ICU interdisciplinary rounds compared with the presence of those goals, and actions related to those goals, documented in the EHR over the subsequent 24 h for 28 patients over 15 days. The study setting was a neurovascular ICU with a fully implemented electronic nursing and physician documentation system. Measurements: Descriptive statistics and ?2 analyses were used to assess differences in EHR documentation of stated goals and goal-related actions. Inter-coder reliability was performed on 16 (13%) of the 127 stated goals. Results: One-quarter of the stated goals were not documented in the EHR. If a goal was not documented, actions related to that goal were 60% less likely to be documented. The attending physician note contained 81% of the stated ventilator weaning goals, but only 49% of the sedation weaning goals; additionally, sedation goals were not part of the structured nursing documentation. Inter-coder reliability (?) was greater than 0.82. Limitations: Observations in a single ICU setting at a large academic medical center using a commercial EHR. Conclusion: The current documentation tools available in EHRs may not be sufficient to capture common goals of ICU patient care.6 page(s

Working Together Toward a Common Goal: A Grounded Theory of Nurse-Physician Collaboration

Purpose: Effective collaboration has been identified as essential to quality patient care processes and outcomes. Yet, the conceptual and theoretical basis for understanding and practicing collaboration remains underdeveloped and imprecise. These factors may hamper the study of collaboration and therefore the optimization of care processes and outcomes. The purpose of this study was to understand the social processes associated with collaboration between nurses and physicians, with the intention of theory development. Background: Collaboration, or a lack thereof, has been shown to impact both provider and patient satisfaction and outcomes. JCAHO now requires proof of collaboration for accreditation. Many organizations state that their providers collaborate for the betterment of patient care. However, a thorough literature search determined that a theory of nurse-physician collaboration based in healthcare has yet to be published. Without theoretical support it is difficult to devise precise measurement instruments to truly understand the current level of collaboration and develop strategies for improvement. Method: A grounded theory study was conducted with the intent of developing a theory to support nurse-physician collaboration. Sample: Data were collected from 15 nurses and 7 physicians with a wide range of experience and training from a variety of units thus allowing the theory to be applicable to a range of professionals. Research Question: The purpose, or main concern, of this study was to conceptually understand if and how nurse-physician collaboration takes place with the intention of theory development. Results: Results indicated that the process of nurse physician collaboration involves 9 stages: something needs our attention; knowing who to talk to; finding the right perso; coming together; exchanging ideas and information; developing the plan; getting everybody on the right page; making it happen; and monitoring progress. The core category of working together toward a common goal describes how nurses and physicians collaborate for patient care. It is anticipated that this theory will add to the body of knowledge and contribute to the understanding of collaboration between these two disciplines