[Validity of clinical register of pressure ulcers]. / La validez de un registro clínico de úlceras por presión.

BACKGROUND: To compare pressure ulcers (PU) found in this prospective observational study with PU recorded in the Electronic Medical Record (EHR). METHOD: We use a prospective observational study to record PU, with daily monitoring by an observer in the medical-surgical units of hospitalization, as well as a clinical record review of PU tracking. Patient monitoring was conducted between December 2008 and March 2009 at Fuenlabrada University hospital. We calculated the absolute and relative frequency of PU in the patients followed, as well as the association among qualitative variables and the validity of the registration in the EHR with regard to the reference standard, the observational study. RESULTS: Among the 1,001 patients followed-up in this study, 42 of them showed PU (4.2% of the total patients), compared to 25 (2.5%) patients who had registered PU in the Electronic Health Record, which means a statistically significant difference (p<0.001). The record of PU presents a Kappa index of 0.548, with a sensitivity of 47.62 % and a specificity of 99.48 %, with regard to the reference standard, the observational study. CONCLUSION: The number of patients with pressure ulcers almost doubled if the observational data collection is done by an expert nurse compared to what was recorded in the EHR.

La validez de un registro clínico de úlceras por presión / Validity of clinical register of pressure ulcers

Objetivos: Comparar las úlceras por presión (UPP) encontradas en este estudio observacional prospectivo con las registradas en la historia clínica electrónica (HCE). Método: Estudio observacional prospectivo para registrarlas UPP, con seguimiento diario por una observadora en las unidades de hospitalización médico-quirúrgicas y revisión del registro clínico de seguimiento de UPP. El seguimiento de los pacientes se realizó entre diciembre de 2008 y marzo de 2009 en el hospital Universitario de Fuenlabrada. Se ha calculado la frecuencia absoluta y relativa de UPP en los pacientes seguidos, la asociación entre variables cualitativas y la validez del registro en la HCE con respecto al patrón de referencia, el estudio observacional. Resultados: Se ha completado un seguimiento a 1.001 pacientes encontrando 42 pacientes con UPP frente a los 25 pacientes que tenían registrada UPP en la HCE, siendo estadísticamente significativa la diferencia (p<0,001). El registro de la UPP en la HCE presenta un índice Kappa de 0,584 con una sensibilidad de 47,62% y una especificidad de 99,48% con respecto a la observación directa. Conclusión: El número de pacientes que presentan UPP prácticamente se duplica si la recogida de datos es observacional por una enfermera experta frente a lo registrado en la HCE (AU)

Background: To compare pressure ulcers (PU) found in this prospective observational study with PU recorded in the Electronic Medical Record (EHR). Method: We use a prospective observational study to record PU, with daily monitoring by an observer in the medical-surgical units of hospitalization, as well as a clinical record review of PU tracking. Patient monitoring was conducted between December 2008 and March 2009 at Fuenlabrada University hospital. We calculated the absolute and relative frequency of PU in the patients followed, as well as the association among qualitative variables and the validity of the registration in the EHR with regard to the reference standard, the observational study. Results: Among the 1,001 patients followed-up in this study, 42 of them showed PU (4.2% of the total patients), compared to 25 (2.5%) patients who had registered PU in the Electronic Health Record, which means a statistically significant difference (p<0.001). The record of PU presents a Kappa index of 0.548, with a sensitivity of 47.62 % and a specificity of 99.48 %, with regard to the reference standard, the observational study. Conclusion: The number of patients with pressure ulcers almost doubled if the observational data collection is done by an expert nurse compared to what was recorded in the EHR (AU)