Evaluation of an interdisciplinary minimal dataset for intensive care documentation

Objectives

The Austrian working group for the Standardization of a Documentation System for Intensive Care (ASDI) has defined a minimal dataset (MDS) for a national, interdisciplinary documentation standard for intensive care. Goal of the study was to evaluate the concordance between the contents of the defined dataset and actual needs.

Design

Thirteen ICUs participated in a trial, using the provided program for documentation of all admitted patients during a period of 4 weeks. In addition, a questionnaire, including a printout of the dataset, was distributed to the unit coordinators to evaluate documentation needs.

Results

Three hundred and seventy-six patients were documented in 1591 patient days. Valid SAPS II scores were found in 29% of discharged patients [39.1 ± 15.5 points (mean ± SD)]. Seven out of 122 MDS parameters (5.7%) were found superfluous. Several items, necessary for cost calculation and performance analysis were found to be missing. Moreover, documentation effort exceeded preset limits (10 min per patient and day) in 38% of the cases.

Conclusions

The contents of the ASDI dataset fitted existing needs closely. However, the questionnaires uncovered the need for structural changes to reduce documentation effort to the default limits. Moreover, the low number of valid SAPS II scores indicates that several ICUs have not enough resources to evaluate all data items for all patients on a daily base. The MDS was revised according to these results. It now represents a broad-based consensus, which seems to be qualified as a foundation for the national documentation system.