STANDARDIZATION AND EVALUATION OF A DOCUM ENTATION SYSTEM FOR INTENSIVE-CARE - THE ASDI PROJECT

Objectives: A comparison of data from different intensive care units ( ICUs) needs standardized documentation. In this study the ASDI documen tation standard for intensive care was tested in clinical practice. Go al of the study was to evaluate parameters and functionality required for a national, interdisciplinary documentation system for intensive c are. Desgin: 13 ICUs participated in a 4-week trial using the provided program for documentation of all admitted patients during the observa tion period. In addition, a questionnaire was distributed to the unit coordinators. Results. 376 patients were documented in 1591 patient da ys. Valid SAPS II scores were found in only 29% of the discharged pati ents (39.1 +/- 15.5 points). Time needed for data entry exceed ed pres et limits (ten minutes per patient and day) in 38% of the cases. All p articipants affirmed the necessity of a documentation standard for int ensive care, giving quality control and cost analysis as the most impo rtant reasons. Conclusion: The ASDI data set fitted existing needs ver y closely. Only 7 out of 122 parameters (5.7%) were found to be superf luous and thus removed. Measures to reduce documentation effort to the default limits were a) a new, date orientated concept for manual reco rding, b) redesign of the user interface with new, user friendly data entry possibilites, and c) the integration of statistical analysis and reports in the documentation system. The revised data set represents a broad-based consensus, which seems to be well-suited as foundation f or the national quality assurance program.