Representation of research synthesis-derived clinical data elements for patients at risk for ICU delirium in a real-time practice documentation system

The primary purpose of this study was to explore the current use, metadata and availability of delirium data elements in an electronic health record (EHR) and clinical data repository (CDR). The investigation explored the domain-specific ontology of ICU delirium by comparing the delirium data elements representing nursing practice at one clinical agency with a Synthesis of evidence-based practice recommendations for adult patients at risk for delirium in the intensive care unit (ICU) developed for the Knowledge-Based Nursing Initiative (KBNI). The analysis provided a detailed understanding of the representation of data elements in one clinical setting and the availability of data for re-use in a clinical decision support system (CDSS). The KBNI conceptual framework guided the study methodology.;The descriptive and exploratory study used retrospective analysis of secondary data. Descriptive statistics and frequencies were be used to describe data elements identified through queries of the clinical agency's EHR and CDR. Content analysis was used to categorize the instance-level data from the convenience sample of 1,714 patients.;Forty-one data element categories were derived from the Synthesis based on nursing process components. These categories were matched to 160 data elements identified in the clinical agency's EHR. The matched data elements were primarily text-based, entered by registered nurses using flow sheets and care planning documentation. Although all but two data elements from the Synthesis were initially matched to data elements at the clinical agency, there was low use and availability for many of these data elements. ICD-9 codes were the only standardized terminology identified and had low data availability. Crossover element matches were found for many of the data elements which could create integration challenges when selecting the best data elements for reuse.;The findings of the study supported the importance of representing nursing practice electronically in a standardized manner in order to meet information needs of nurses. Future research is needed to identify level of risk for delirium and to determine the best preventative interventions. Policy implications of the study include a need to continue the inclusion of nursing quality measures, EHR interoperability and utilization of standardized nursing terminologies.