Collaborating to Create a Comprehensive Neonatal Resuscitation Form

Abstract

Poster Presentation Purpose for the Program High‐quality care of the newborn at birth is critically important in obstetrics. To assess response to newborns who require extra assistance at birth, a newborn code review committee was formed in July 2012. Newborn resuscitation documentation was audited for 3 months, and it was determined the current form was a barrier to accurate documentation and care. Of the 16 indicators audited, documentation was found to be 0% to 67% complete in seven categories. The code committee searched the literature, Internet, and area hospitals to find a better documentation form. Forms found were either equal to or less comprehensive than the current form. Proposed Change To create a new form that follows the guidelines of the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program to increase documentation adherence and provide documentation prompts to perform correct actions during a newborn code. The American Heart Association (AHA) Get with the Guidelines neonatal resuscitation form was used as a starting point. Content was added and removed based on team experience with newborn codes and AAP guidelines. Implementation, Outcomes, and Evaluation The new form, completed in October 2012, was taken to delivery team nurses and neonatologists for review. After suggested changes were made, the code team approved the final form, and staff members involved in newborn resuscitation were taught to use it. Health care providers began using the new form in May 2013. Neonatal resuscitation records from July through October 2013 were reviewed to identify trends and improvements after implementation of the new form. Of 16 categories audited, adherence scores increased from 88% to 100%. Nursing and medical staff expressed satisfaction and acceptance of the new form, noting ease of use and guidance through code documentation and prompts for needed actions. Audits continue to show improvement in documentation after the implementation of the form. Implications for Nursing Practice Teams should review current neonatal resuscitation forms for documentation accuracy and adherence. Revisions may be necessary to help guide practitioners through resuscitation and assist with accurate documentation.