SCIitelsafe Prefect Series: The Supplemental Cursing Taxonomy

Abstract

Context: Spinal cord injury (SCI) rehabilitation nurses document the occurrence of educational and care management efforts in traditional nursing documentation methods but not the intensity (or dose) of such interactions. This article describes a process to capture these nursing interventions. Methods: Nurses at 6 US inpatient SCI centers used 2 in-person meetings and weekly telephone calls over 9 months to develop a taxonomy of nursing patient education efforts and care management. Results: This was subsequently incorporated into a point-of-care documentation system and used to capture details of nursing care for 1,500 SCI rehabilitation patients enrolled in the SCIRehab study. The taxonomy consists of 10 education and 3 care management categories. The point-of-care system includes time spent on each category along with an indication of whether the patient and/or family received the education/care management. In addition, a subjective measure of patient participation in nursing activities is included. Conclusions: Creation of a SCI rehabilitation nursing taxonomy is feasible, and its use has had an impact on nursing practice. It also has implications for future clinical documentation, because greater accuracy and details of patient education and care management will be a permanent practice in the participating systems at the conclusion of the study.

New Approach to Study the Contents and Outcomes of Spinal Cord Injury Rehabilitation: The SCIRehab Project

“…The paper by Gassaway et al (4) in this issue describes the electronic data capture applications and methods, along with the process that was used to develop the discipline-specific POC documentation (4). Specifics for each discipline's POC are described in the remaining papers in this series (5)(6)(7)(8)(9)(10)(11).…”

“…The second article in this series by Gassaway et al (4) describes how representatives of rehabilitation disciplines at 6 centers developed a taxonomy for categorizing rehabilitation interventions and a documentation system suitable for capturing detailed treatment information prospectively and provides information on documentation elements that are common to the information collected by most disciplines. The remaining papers in the series describe the interventional taxonomies developed by 7 disciplines and the unique elements of their documentation; they also place the information collected on SCI rehabilitation against the background of issues in the disciplines involved (5)(6)(7)(8)(9)(10)(11).…”

Nursing bedside education and care management time during inpatient spinal cord injury rehabilitation

“…Nurses at the SCIRehab project sites entered details of bedside education and care management interactions with each study patient into either (1) a handheld personal digital assistant (PDA; Hewlett Packard PDA hx2490b, Palo Alto, CA) containing a modular custom application (PointSync Pro version 2.0, MobileDataforce, Boise, ID, USA) of the SCIRehab point-of-care documentation system, which incorporates the supplemental nursing taxonomy, or (2) a supplemental electronic page that included the taxonomy added to the existing electronic health record of the hospital. This taxonomy has been described in detail previously 7 and included education topics and care management processes. Education topics included bladder management, bowel management, medical complications, medication, nutrition, pain, respiratory, safety, skin, and therapy carryover (reinforcing techniques learned during therapy sessions).…”

“…[5][6][7] For the nursing component of this study, nursing leaders from six SCI rehabilitation centers hypothesized that patient outcomes are influenced by the amount of nursing education and care management that is provided to the patient and/or designated family caregivers during the acute rehabilitation period. The ultimate aim of the SCIRehab project is to test this hypothesis by examining details of specific components (interventions) provided within the rehabilitation nursing process.…”

“…This paper is the second in a series of reports by clinical nursing leaders involved in the SCIRehab research project. [5][6][7] SCIRehab is a multi-center, 5-year study that will enroll approximately 1400 acute SCI inpatient rehabilitation patients, record and analyze details of the rehabilitation process, and determine whether type and quantity of nursing interventions (along with interventions provided by other rehabilitation care providers) are predictive of first-year post-injury outcomes.…”