CLINICAL DATA READINESS IN INFECTION-RELATED SURGICAL ICU ADMISSIONS: A RETROSPECTIVE EVALUATION OF ROUTINE DOCUMENTATION RETRIEVABILITY
DOI:
https://doi.org/10.67214/br8hh628Keywords:
intensive care unit, clinical documentation, data retrievability, sepsis, medical recordsAbstract
Background: We evaluated the completeness and retrievability of core clinical and laboratory treatment, and outcome variables from routine records of infection-related surgical ICU admissions and explored documentation gaps relevant to clinical evaluation and secondary data use.
Material and Methods: We performed a retrospective, single-center, record-based evaluation of infection-related ICU admissions during 2025. The predefined data sources comprised the ICU paper record, admission documentation, clinical progress notes, and laboratory reports physically available in the reviewed patient file. Variables were grouped into bedside physiological/neurological data, laboratory data, organ-support and treatment data, and administrative/outcome data. As an exploratory functional assessment, we evaluated whether the retrieved variables enabled complete retrospective reconstruction of qSOFA, conventional SOFA, NEWS, and MEWS, and conducted a respiratory-rate-based feasibility assessment of SIRS.
Results: Among 196 included patients, supplemental oxygen status, heart rate, systolic blood pressure, and SpO₂ were retrievable in 98.5%, 98.0%, 95.9%, and 93.9% of records, respectively. WBC and platelet count were each retrievable in 77.0%, creatinine in 76.5%, temperature in 67.9%, lactate in 52.6%, and an interpretable mental-status assessment in 52.0% of records. Bilirubin was retrievable in 18.4%, while the numerical respiratory rate was not retrievable within the predefined sources and assessment window. PaO₂ values were documented in arterial blood gas reports, but the corresponding FiO₂ was not routinely recorded in the reviewed paper documentation, preventing paired retrospective derivation of PaO₂/FiO₂.
Conclusions: Routine records of infection-related surgical ICU admissions contained substantial clinically relevant information, but retrievability varied markedly across documentation domains. The most prominent gaps involved structured bedside variables, particularly numerical respiratory rate and neurological assessment, while some laboratory and microbiological information may have been available outside the predefined paper sources. Improving the integration of existing data sources and standardizing a limited set of bedside fields may enhance ICU data readiness while reducing redundant documentation.
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Data Availability Statement
The data supporting the findings of this evaluation are available from the corresponding author (Marija Sekulovska) upon reasonable request, subject to institutional and ethical requirements.
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Copyright (c) 2026 Marija Sekulovska (Author)
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