Statistical Information Collection In The Clinical Setting

INTRODUCTION

Prevention and Safety is very important in the clinical setting. Mounds of data are collected everyday on patients in all clinical areas, by clinicians of all disciplines for the purposes of creating preventative measures and safety protocols. Baptist Health Systems is a corporation of clinicians working toward outstanding medical practice with decreased negative outcomes. There are several ways that information is collected in this facility to reach this goal.

The list as follows is examples of the types of statistical information gathered for the purposes of increased quality of patient care and safe medical management.

1. Pain Management

2. Fall Risk Assessment

3. Skin Integrity Assessment

4. Patient Satisfaction

There is also statistical information that is not placed at the forefront of information gathering that should be included in this list such as incidence of proper hand washing, proper use of universal precautions, and incidence of infection in wounds both surgical and non-surgical.

This paper will discuss each type of statistical data and data collection methods and then briefly discuss why other listed information should be included in the data collection process.

TYPES OF INFORMATION COLLECTED

PAIN MANAGEMENT DATA

Proper management of pain in the clinical setting has no longer taken a back seat to patient safety. Although patient safety will always be important, it has been determined that pain management is just as important when determining the quality of patient care in hospitals. Since the level of pain is subjective, the hospital determines how treatment is provided, by requiring that each nurse assess the level of pain throughout the patients hospital stay. It has also been determined, through statistical studies that a patient who has proper pain management will heal faster, thus decreasing the risk for other medical complications and lengthy hospital stays. Each nurse must complete a medical assessment form as needed throughout the shift, and when treatment for pain is provided, then the nurse must complete a follow up assessment to determine if the treatment was effective. Whatever steps are necessary to provide patient relief, according to standards set by the patient, must be taken. The information gathered is placed in a data bank to be reviewed by management and eventually by Joint Commission to determine if the clinical measures for pain management are effective or need to be altered. In order to keep the patient focused on healing it is important to manage pain control responsibly while caring for patients.

FALL RISK ASSESSMENT DATA

The Fall Risk Assessment Form is completed every two hours on patients at risk for falls by nursing or ancillary staff during their shift. For those patients who have not demonstrated a safety risk, then the form must be completed at the beginning and end of shift. If there has been a change in patient status and an assessment must be completed more often then the two protocols must be followed. Patients who have been placed in restraints should also be check according to hospital policies and procedures to prevent injury to patient and staff. In the event that a fall is not prevented, a quality assurance report must be completed and the physician, family of the patient and house supervisor notified of the event. Patient safety and fall risk work concurrently to prevent injury to patients, the data collected when a patient has suffered an injury is compared to the nursing records of how safety protocols are followed.

SKIN INTEGRITY ASSESSMENT DATA

The nurse assesses skin integrity of a patient every two hours in an effort to prevent breakdown of healthy skin and decrease the risk of infection in compromised patients. A form discussing how the skin looks and what type of skin care was provided is included in the nursing assessment. Independent patients are still at risk for skin breakdown if there is a decrease in patient activity. Patient activity is also included in the skin integrity to help determine the score. Patients who are at risk for skin breakdown or have compromised skin, it is important to document upon admission any pressure ulcers or other evidence of skin breakdown and monitor the patient throughout their hospital stay. Hospitals have been involved in litigation because of pressure ulcers that have developed during their hospital stay and this creates a huge deficit in the hospital budget. There is monthly evaluation of Skin Integrity Assessment Data.

PATIENT SATISFACTION

It is enforced and reinforced in staff meetings and monthly reports what type of care patients are expecting. This information is provided through patient surveys by either phone or mail after each patient encounter with the medical and ancillary staff of the facility. Patients are consumers, and like every other serviced based industry, it is important to provide quality customer service. The only way to determine if quality service has been provided is to talk with the consumers. It is important for each employee to take this seriously and read the reports and comments made by patients. Loss of consumers is a direct result of the patient’s interpretation of how their medical encounter was handled.

WHAT DATA IS NOT COLLECTED BUT SHOULD BE

Although the hospitals have created a host of data collection topics and methods for prevention and safety, a few other topics should be included in the statistical studies to enhance prevention of the spread of infection and safety for hospital staff and patients.

1. Hand washing. The hospitals have provided clinics, posters and other informational forums about how important hand washing is in the reduction of the spread of germs and infection. There are no quantitative or qualitative studies on how well the staff and patients are utilizing this data. There has been a constant increase