Abstract
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.
Highlights
Recording reliable and valid data on resuscitation efforts during in-hospital cardiac arrest serves the interests of patients as well as legal, quality assurance, and scientific purposes
Case numbers The search for cardiopulmonary resuscitation (CPR) patients revealed 245 hits
Twentytwo cases were removed from the study since the CPR mentioning had been deleted after false documentation
Summary
Recording reliable and valid data on resuscitation efforts during in-hospital cardiac arrest serves the interests of patients as well as legal, quality assurance, and scientific purposes. The quality of electronic patient records concerning the documentation of CPR in intensive care units (ICU) is largely unknown. In this retrospective study, we assessed the comprehensiveness and reliability of CPR documentation in the PDMS of three ICUs of a single academic center. We assessed the comprehensiveness and reliability of CPR documentation in the PDMS of three ICUs of a single academic center For this purpose, we analyzed whether the time point and duration of resuscitation measures, the cardiac rhythm, and cardiac defibrillations were represented plausibly and consistently within the PDMS. 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
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