CONGRESS ABSTRACT

Introduction . Standardization of information flows is increasingly essential in the context of rapid digitalization and global e-Health initiatives, supporting personalization, continuity, safety, and quality of care. The use of codified terminology helps reduce data fragmentation by enabling consistent communication and making clinical practice more explicit and measurable. A single-specialty healthcare organization in Tuscany has acquired and implemented the ICNP™ coding system, developing a Cardiovascular Area Catalogue Subset, implementing a digitalized Integrated Nursing Process (INP) module for the adult population. Objective . Identify the most prevalent nursing diagnoses in the cardiovascular area and the nursing interventions implemented. Methods. An outcome monitoring dashboard was developed to allow retrospective data extraction over a 12-month period starting from July 2024 in adults, while the INP is still under development in the pediatric-neonatal setting. Results. Data extraction for the 12 months yielded 5,294 patients accessing the hospital, 65,6% was male, the mean duration of hospital stay was 5.76 days (SD ± 6.10). The mean age was 68,1 years (SD 14.5), with 71 as median. 2,639 of the patients had at least a nursing diagnosis with a total of 102,028 nursing assessments recorded. The most prevalent medical diagnosis was coronary atherosclerosis of native coronary artery (14,2%), disorders of the aortic valve (10,4%), atrial fibrillation (8%); while the prevalent nursing diagnoses, a median of 4 per each, included impaired respiratory function (n.19,199), followed by impaired self-care ability (n.18,013), impaired gait (n.16,200), and bedridden, confined to bed (n.13,889). Impaired urinary function (n.8,628) and adherence to fluid intake recommendations, compliance (n.5117) were also frequently identified. There was a moderate to strong positive correlation between the number of nursing diagnoses and length of hospital stay (Spearman’s ρ = 0.594, p < .001). Conclusions . A document model supported by standardized language and data interoperability ensures information consistency and security, data traceability, comprehensive data extraction, outcome monitoring for secondary analyses, and the development of reporting models to support decision-making, enhancing staff empowerment and accountability.