Neonatal electronic resuscitation app documentation (NeRD): Electronic documentation compared to written documentation

Abstract

At present, neonatal resuscitations are documented on the Neonatal Emergence Record, but thorough completion of this record in resuscitations, on average, is poor and less than adequate for proficient, safe and legal documentation. Failure of an accurate representation of a full resuscitation, in real time, can have a bearing on the clinical care given, for example in hypoxic infants. The objective is to improve documentation of resuscitation, ensuring accurate, contemporaneous and complete documentation of neonatal resuscitation in real time. A pilot study evaluated the feasibility, time, cost, adverse events and effect size (statistical variability) to predict an appropriate sample size and improve upon the study design prior to the performance of a full-scale study. Twenty neonatal participants were enrolled in the pilot study. The sequence of randomization was computer generated and blinded to each resuscitation team. The NeRD app achieved higher levels of task completion for majority of the audit criteria. Although only a small study the NeRD app allowed for more accurate and contemporaneous documentation when compared to the current paper-based documentation. In a time where litigation is high and all medical and nursing documentation are scrutinized, high quality, accurate, contemporaneous documentation will be of value. Therefore, the main pilot study is feasible without changes to the protocol. A larger randomized controlled trial is needed for more robust evidence in the use of the NeRD app in documenting neonatal resuscitation.