NR 361 Week 7 Wound Measurement Informatics Proposal Example

Moving Pressure Injury Measurements Out of the Note and Into Coded Fields: An Informatics Project Proposal

Student Name

College of Nursing, Chamberlain University

NR 361: RN Information Systems in Healthcare

Instructor Name

Month Day, Year

Moving Pressure Injury Measurements Out of the Note and Into Coded Fields: An Informatics Project Proposal

The Problem, Stated as Data

On a composite 36-bed medical unit, nurses document pressure injury length, width and depth in a free-text wound note, usually as a phrase such as sacral wound 3 by 2.5 by 0.5, slightly smaller. The electronic record has structured wound fields in the Lines, Drains, Airways and Wounds section, including numeric fields for each dimension, but the unit's habit, carried over from paper documentation, is to type the measurements in the note. The problem is therefore data that is present but unstructured. Because the measurements sit in prose, the record cannot graph a wound over time, the wound care nurse cannot run a report of wounds that are not healing, and the unit's quality report cannot count how many pressure injuries were measured at least weekly as the unit's policy requires.

The size of the problem is known from one review. The wound care nurse reviewed the records of 20 patients with pressure injuries on the unit last quarter and found measurements in structured fields for 4 and in free text only for 13; 3 had no measurements at all for at least one week. International guidance recommends measuring pressure injuries regularly to monitor healing and to prompt reassessment of the treatment plan when a wound is not improving (European Pressure Ulcer Advisory Panel et al., 2019), and that monitoring depends on measurements being comparable over time.

The Change, in One Sentence

Every pressure injury measurement on the unit will be entered in the existing structured wound fields, and the free-text wound note will be shortened to a description of appearance and treatment with no measurements in it.

Why Structure Matters Here

Rosenbloom et al. (2011) describe a tension in clinical documentation between structured data, which computers can count, compare and report, and narrative text, which captures nuance and context but is hard to reuse. They argue that the right balance depends on how the information will be used. Wound measurements are a clear case for structure: they are numbers, they are compared over time, and their main uses are trend graphs and reports. Wound appearance, odor and the patient's pain are better suited to narrative. The proposal keeps each kind of information where it works best rather than moving all wound documentation into fields.

Stakeholders, With What They Will Do and What It Costs

Staff nurses: Will enter measurements in three numeric fields instead of typing them in the note. Cost: about 30 seconds more per wound at first, because the fields sit in a different part of the record from the note; after a few weeks, perhaps no difference.

Wound care nurse: Will build and run a monthly report of wounds whose area has not decreased in two weeks and review those patients. Gain: a list she currently cannot produce. Cost: about two hours a month.

Nurse manager: Will approve the change and include the percentage of wounds measured weekly in the unit quality report. Gain: a measure the unit is already expected to meet.

Clinical informatics analyst: Will add the wound measurement fields to the unit's shift assessment navigator so nurses see them next to the note, and build the report. Cost: about six hours.

Providers: Will see a trend graph of wound size in the record. Gain: faster recognition of wounds that are not healing.

Plan and Timeline

In weeks 1 and 2, the informatics analyst moves the wound measurement fields into the shift assessment navigator for the unit and the wound care nurse drafts the report. In week 3, the wound care nurse teaches the change at four huddles, five minutes each, using one example of a wound graph built from structured data. In week 4, the change goes live and the free-text wound note template is edited to prompt for appearance and treatment only. For the first month, the wound care nurse checks every new wound entry weekly and gives nurses same-day feedback. Carayon et al. (2006) describe how changes to documentation tools succeed when they are designed around how the work is actually done; placing the fields next to the note, where nurses already are, is the design choice that makes the change likely to hold.

How Success Will Be Measured

The primary measure is the percentage of pressure injuries with length, width and depth entered in structured fields at least weekly, calculated from a report of structured wound entries against the list of patients with pressure injuries, monthly. The baseline from the review is 4 of 20, or 20 percent; the target is 80 percent at three months. A secondary measure is whether the wound care nurse's monthly report identifies nonhealing wounds and leads to a change in treatment, recorded as the number of treatment changes following the report. The proposal does not promise faster wound healing, which depends on many factors and would take far longer to show.

Risks and Responses

Three risks could undermine the change. The first is duplication: nurses may enter measurements in the fields and keep typing them in the note out of habit, which doubles the work and leaves two versions that may disagree. The response is the edited note template, which no longer prompts for measurements, and the wound care nurse's feedback in the first month. The second risk is inconsistent measurement technique, which structured fields do not fix: a wound measured head to toe by one nurse and side to side by another will produce a misleading trend even when every number is in a field. The huddle teaching therefore includes the unit's measurement convention, length as the longest head-to-toe dimension and width perpendicular to it, and the fields will carry a short reminder of that convention. The third risk is that the report produces a list nobody acts on. The response is to assign the report to the wound care nurse by name, with the nurse manager reviewing the number of nonhealing wounds identified and acted on each month.

If the change works on this unit, the same fields and report could be offered to the other medical units without new build work, since the fields already exist hospital-wide. That makes the proposal inexpensive to extend, which is a point worth making to the nurse manager when approval is requested.

References

Carayon, P., Schoofs Hundt, A., Karsh, B.-T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 15(Suppl. 1), i50-i58. https://doi.org/10.1136/qshc.2005.015842

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. The international guideline (E. Haesler, Ed.). EPUAP/NPIAP/PPPIA.

Rosenbloom, S. T., Denny, J. C., Xu, H., Lorenzi, N., Stead, W. W., & Johnson, K. B. (2011). Data from clinical notes: A perspective on the tension between structure and flexible documentation. Journal of the American Medical Informatics Association, 18(2), 181-186. https://doi.org/10.1136/jamia.2010.007237