Current practice of neonatal resuscitation documentation in North America: a multi-center retrospective chart review

BMC Pediatrics

Gautham Suresh⁷  Carrie-Ellen Briere²  Mariann Pappagallo²  Ipsita Goswami⁴  Sandesh Shivananda⁴  Katie Satrom¹  Kari D. Roberts¹  Michael H. Goodstein⁵  Pradeep Alur⁵  Prakash Kabbur⁶  Matthew S. Braga³ 

[1] University of Minnesota Masonic Children’s Hospital, Neonatology, 2450 Riverside Ave, Minneapolis 55454, MN, USA;University of Connecticut Health Center, Connecticut Children’s Medical Center, Neonatology, 282 Washington St., Farmington 06106, CT, USA;Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Children’s Hospital at Dartmouth, One Medical Center Drive, Lebanon 03756, NH, USA;McMaster University, McMaster Children’s Hospital, Neonatology, 1200 Main St W, Hamilton L8N 3Z5, ON, Canada;Wellspan Health, York Hospital, Neonatology, 1001 S. George St., York 17403, NY, USA;Kapi’olani Medical Center for Women and Children, Neonatology, 1319 Punahou St, Honolulu 96826, HI, USA;Texas Children’s Hospital, Baylor College of Medicine, Neonatology, 6621 Fannin St, Houston 77030, TX, USA

关键词: Documentation;    Code documentation;    Neonatal resuscitation program;    Neonatal documentation;    Neonatal resuscitation;   

Others  :  1234531
DOI  :  10.1186/s12887-015-0503-8

 received in 2015-07-26, accepted in 2015-11-09,  发布年份 2015

【 摘 要 】

Background

To determine the comprehensiveness of neonatal resuscitation documentation and to determine the association of various patient, provider and institutional factors with completeness of neonatal documentation.

Methods

Multi-center retrospective chart review of a sequential sample of very low birth weight infants born in 2013. The description of resuscitation in each infant’s record was evaluated for the presence of 29 Resuscitation Data Items and assigned a Number of items documented per record. Covariates associated with this Assessment were identified.

Results

Charts of 263 infants were reviewed. The mean gestational age was 28.4 weeks, and the mean birth weight 1050 g. Of the infants, 69 % were singletons, and 74 % were delivered by Cesarean section. A mean of 13.2 (SD 3.5) of the 29 Resuscitation Data Items were registered for each birth. Items most frequently present were; review of obstetric history (98 %), Apgar scores (96 %), oxygen use (77 %), suctioning (71 %), and stimulation (62 %). In our model adjusted for measured covariates, the institution was significantly associated with documentation.

Conclusions

Neonatal resuscitation documentation is not standardized and has significant variation. Variation in documentation was mostly dependent on institutional factors, not infant or provider characteristics. Understanding this variation may lead to efforts to standardize documentation of neonatal resuscitation.

【 授权许可】

   
2015 Braga et al.

【 图 表 】

Fig. 1.

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