13^th World Pediatric Congress

Neonatal resuscitation is required in approximately 7% of births in the UK. One in 2000 deliveries requires both ventilation and chest compressions. Documentation during resuscitation is vital for delivering good patient care as well as for medicolegal reasons. We conducted a retrospective review of documentation within paper notes and a neonatal electronic database. We reviewed all babies admitted to NICU in a district general hospital in the UK over a 4 month period with an APGAR score of ≤7 at 5 minutes. We excluded babies resuscitated in NICU and ex utero transfers. We reviewed 5 domains: Demographics, APGARS, airway and breathing, circulation and transfer to NICU. We had a total of 23 babies in this study. 17 babies required inflation breaths, 4 required intubation, 2 required chest compressions and 1 required access and drugs. Not all demographic data relating to the resuscitation was complete. In written notes, only 70% of APGAR scores were documented. Where airway interventions were used, this was only documented in approximately 40% of cases. Only 1 out of 2 cases requiring chest compressions were documented fully. In only 40% of cases clinical state on transfer to NICU was documented. To improve documentation and reduce errors we have developed and implemented a pro forma to use within neonatal resuscitation.