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

URN to cite this document:

urn:nbn:de:bvb:355-epub-447817 Copy

DOI to cite this document:

10.5283/epub.44781 Copy

Dittmar, Michael ; Zimmermann, Sabrina ; Creutzenberg, Marcus ; Bele, Sylvia ; Bitzinger, Diane ; Lunz, Dirk ; Graf, Bernhard M. ; Kieninger, Martin

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Date of publication of this fulltext: 10 Feb 2022 17:10

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Details

Item type:	Article
Open Access Type:	DEAL (Springer Gold)
Höhe Gebühr (aus OpenAPC):	1458.27
Institution der Zahlung:	Regensburg U
Journal or Publication Title:	BMC Emergency Medicine
Publisher:	BMC
Place of Publication:	LONDON
Volume:	2021
Number of Issue or Book Chapter:	21
Page Range:	pp. 1-10
Date:	10 June 2021
Institutions:	Medicine > Lehrstuhl für Anästhesiologie Medicine > Lehrstuhl für Neurochirurgie
Identification Number:	Value Type 10.1186/s12873-021-00462-y DOI
Keywords:	CARDIAC-ARREST; DOCUMENTATION; QUALITY; EVENTS; SYSTEM; COUNCIL; Quality management; Cardiopulmonary resuscitation; Intensive care unit; Medical documentation; Patient data management systems
Dewey Decimal Classification:	600 Technology > 610 Medical sciences Medicine
Status:	Published
Refereed:	Yes, this version has been refereed
Created at the University of Regensburg:	Yes
Item ID:	44781

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Abstract

Background According 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 ...

Abstract

Background According 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. Methods In 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. Results One 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. Conclusions This 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.

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Metadata last modified: 21 Feb 2022 14:59

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