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Sunday, September 26, 2010
Title: Finding Solutions: Comparison of Paper and Electronic Fetal Heart Rate Documentation
Discipline: Professional Issues (PI), Childbearing (CB), Advanced Practice (AP)
Learning Objectives:
Submission Description:- Compare the reliability and consistency between two systems of fetal monitoring documentation.
- Identify the incidence and reasons for missing data in both electronic and paper fetal monitoring.
- Describe the nursing implications of moving towards an electronic documentation and storage system for fetal monitoring.
Problem: Current provider clinical experience with electronic fetal monitoring archival systems and paper fetal monitoring archival systems indicate that both systems have missing data. Missing data may occur with paper monitoring strips due to lost strips during episodic care or during archive. Conversely, missing data may occur with the electronic archival system due to system network outages. It was hypothesized that electronic archival systems have significantly less missing data than paper tracing archival systems.
Literature Review: Although peer institutions have implemented an electronic fetal monitoring archival system and eliminated the paper documentation system, no data is available to compare the reliability and consistency between the electronic and paper fetal monitoring archival systems. It is unknown whether one system has less missing data than the other.
Sample: A convenient, stratified sample of fetal monitoring archival records (N=403) of patients presenting for monitoring during the 3rd fiscal quarter 2008, 403 were reviewed. Included records were those who had electronic fetal monitoring at >24 weeks gestation, any indication, and had a singleton pregnancy. Based on quality improvement initiatives, the sample size was estimated at 10% of the targeted population. Methodology: The study design was a retrospective, descriptive, comparative study of 403 case records. The sample was stratified into 2 groups; L&D subject records (n=111) and PEC subject records (n=292). From this data set, a subset of records were stratified by the timing and day of fetal monitoring initiation so that 1/3 of the records were randomly selected from each of the following time zones including 7AM-2:59PM; 3PM-10:59PM; 11:00PM-6:59AM. Each tracing episode was reviewed for missing fetal monitoring data.
Data Analysis & Interpretation: Descriptive and comparative statistical analyses were performed. In N=403 case records, the frequency of retrievable paper fetal monitoring data during an entire fetal monitoring episode was 80% (n=324). Therefore, 1 in 5 times, paper fetal monitoring tracings were not available for record review. When paper tracings were retrievable (n=324), paper loss time occurred in 125 cases, with the mean being 21.5 minutes/case. The most frequent reasons for paper loss time were missing or unlabeled tracings (68%) and the monitor running out of paper (12%). Conversely, in N=403 case records, the frequency of retrievable electronic fetal monitoring data during an entire fetal monitoring episode was 100% (n=403). Therefore, no electronic fetal monitoring records were irretrievable. When paper tracings were retrievable (n=324), the concomitant electronic fetal monitoring episodes showed an electronic loss record time in 81 cases, with the mean being 5.0minutes/case. System and network downtime accounted for 12% of electronic missing fetal monitoring records. Between the two methods, a significant difference was observed in retrievable tracings, p<.0001 (McNemar’s test) and mean number of minutes of loss record time episodes, ,p<.0001(paired T-test). Practice Implications: This study demonstrates that an electronic documentation and storage system is more reliable system than a paper documentation and storage system. During the fetal monitoring data capturing period, the electronic record proved to me more reliable. Importantly, missing data and irretrievable data may have significant health and legal consequences.
Literature Review: Although peer institutions have implemented an electronic fetal monitoring archival system and eliminated the paper documentation system, no data is available to compare the reliability and consistency between the electronic and paper fetal monitoring archival systems. It is unknown whether one system has less missing data than the other.
Sample: A convenient, stratified sample of fetal monitoring archival records (N=403) of patients presenting for monitoring during the 3rd fiscal quarter 2008, 403 were reviewed. Included records were those who had electronic fetal monitoring at >24 weeks gestation, any indication, and had a singleton pregnancy. Based on quality improvement initiatives, the sample size was estimated at 10% of the targeted population. Methodology: The study design was a retrospective, descriptive, comparative study of 403 case records. The sample was stratified into 2 groups; L&D subject records (n=111) and PEC subject records (n=292). From this data set, a subset of records were stratified by the timing and day of fetal monitoring initiation so that 1/3 of the records were randomly selected from each of the following time zones including 7AM-2:59PM; 3PM-10:59PM; 11:00PM-6:59AM. Each tracing episode was reviewed for missing fetal monitoring data.
Data Analysis & Interpretation: Descriptive and comparative statistical analyses were performed. In N=403 case records, the frequency of retrievable paper fetal monitoring data during an entire fetal monitoring episode was 80% (n=324). Therefore, 1 in 5 times, paper fetal monitoring tracings were not available for record review. When paper tracings were retrievable (n=324), paper loss time occurred in 125 cases, with the mean being 21.5 minutes/case. The most frequent reasons for paper loss time were missing or unlabeled tracings (68%) and the monitor running out of paper (12%). Conversely, in N=403 case records, the frequency of retrievable electronic fetal monitoring data during an entire fetal monitoring episode was 100% (n=403). Therefore, no electronic fetal monitoring records were irretrievable. When paper tracings were retrievable (n=324), the concomitant electronic fetal monitoring episodes showed an electronic loss record time in 81 cases, with the mean being 5.0minutes/case. System and network downtime accounted for 12% of electronic missing fetal monitoring records. Between the two methods, a significant difference was observed in retrievable tracings, p<.0001 (McNemar’s test) and mean number of minutes of loss record time episodes, ,p<.0001(paired T-test). Practice Implications: This study demonstrates that an electronic documentation and storage system is more reliable system than a paper documentation and storage system. During the fetal monitoring data capturing period, the electronic record proved to me more reliable. Importantly, missing data and irretrievable data may have significant health and legal consequences.
