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首页> 外文期刊>BMC Pediatrics >Current practice of neonatal resuscitation documentation in North America: a multi-center retrospective chart review
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Current practice of neonatal resuscitation documentation in North America: a multi-center retrospective chart review

机译：北美新生儿复苏文献的当前实践：多中心回顾性图表审查

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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. 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. 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. 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.
机译：确定新生儿复苏文献的全面性，并确定各种患者，提供者和机构因素与新生儿文献完整性的关联。对2013年出生的极低出生体重婴儿的连续样本进行多中心回顾性图表审查。评估了每个婴儿记录中的复苏说明，其中包含29个复苏数据项，并为每个记录分配了记录的项数。确定了与此评估相关的协变量。回顾了263名婴儿的图表。平均胎龄为28.4周，平均出生体重1050克。在这些婴儿中，有69％为单胎，而74％是通过剖宫产分娩的。每个出生的29个复苏数据项中的平均值为13.2（SD 3.5）。最常出现的物品是;回顾产科史（98％），Apgar评分（96％），耗氧量（77％），吸痰（71％）和刺激（62％）。在我们针对测量的协变量进行调整的模型中，机构与文档显着相关。新生儿复苏文件尚未标准化，并且存在很大差异。文件的变化主要取决于体制因素，而不是婴儿或提供者的特征。了解这种变化可能会导致努力使新生儿复苏的文献标准化。

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