Evaluation of comprehensiveness and reliability of electronic health records concerning resuscitation efforts within academic intensive care units: a retrospective chart analysis

BMC Emergency Medicine

Dirk Lunz¹  Marcus Creutzenberg¹  Martin Kieninger¹  Bernhard M. Graf¹  Diane Bitzinger¹  Michael S. Dittmar¹  Sabrina Zimmermann²  Sylvia Bele³ 

[1] Department of Anesthesiology, Regensburg University Medical Center, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany;Department of Anesthesiology, Regensburg University Medical Center, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany;Department of Forensic Psychiatry, Bezirksklinikum Regensburg, Universitätsstraße 84, 93053, Regensburg, Germany;Department of Neurosurgery, Regensburg University Medical Center, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany;

关键词: Quality management;    Cardiopulmonary resuscitation;    Intensive care unit;    Medical documentation;    Patient data management systems;   

DOI  :  10.1186/s12873-021-00462-y

来源: Springer

【 摘 要 】

BackgroundAccording to the literature, the validity and reliability of medical documentation concerning episodes of cardiopulmonary resuscitation (CPR) is suboptimal. However, little is known about documentation quality of CPR efforts during intensive care unit (ICU) stays in electronic patient data management systems (PDMS). This study analyses the reliability of CPR-related medical documentation within the ICU PDMS.MethodsIn a retrospective chart analysis, PDMS records of three ICUs of a single university hospital were searched over 5 y for CPR check marks. Respective datasets were analyzed concerning data completeness and data consistency by comparing the content of three documentation forms (physicians’ log, nurses’ log, and CPR incident form), as well as physiological and therapeutic information of individual cases, for missing data and plausibility of CPR starting time and duration. To compare data reliability and completeness, a quantitative measure, the Consentaneity Index (CI), is proposed.ResultsOne hundred sixty-five datasets were included into the study. In 9% (n = 15) of cases, there was neither information on the time points of CPR initiation nor on CPR duration available in any data source. Data on CPR starting time and duration were available from at least two data sources in individual cases in 54% (n = 90) and 45% (n = 74), respectively. In these cases, the specifications of CPR starting time did differ by a median ± interquartile range of 10.0 ± 18.5 min, CPR duration by 5.0 ± 17.3 min. The CI as a marker of data reliability revealed a low consistency of CPR documentation in most cases, with more favorable results, if the time interval between the CPR episode and the time of documentation was short.ConclusionsThis study reveals relevant proportions of missing and inconsistent data in electronic CPR documentation in the ICU setting. The CI is suggested as a tool for documentation quality analysis and monitoring of improvements.

【 授权许可】

CC BY