Nursing Documentation and Activities when Using a Clinical Decision Support System for Sepsis and Clinical Deterioration Management

Abstract

The role of nurses in the management of sepsis and clinical deterioration, and the potential use of Clinical Decision Support Systems to identify patients' undesired outcomes are well recognized. In order to verify the association of such a system adoption in the compliance of a hospital sepsis protocol on the nurses' workflow and documentation, a three-stage study was conducted. Main findings show that there is no statistically significant difference between the sepsis protocol compliance data from before and after the system implementation; that nursing caring-related activities are a priority over documentation and time spent using the system; and that it was possible to validate a proposal of nursing documentation for sepsis and clinical deterioration. This contributes to the improvement of nurses' awareness of their engagement in nursing informatics issues in the era of big data.