School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China (Hong Kong).
Accident and Emergency Department, Tuen Mun Hospital, Hong Kong, China (Hong Kong).
JMIR Mhealth Uhealth. 2024 Jan 5;12:e46744. doi: 10.2196/46744.
Complete documentation of critical care events in the accident and emergency department (AED) is essential. Due to the fast-paced and complex nature of resuscitation cases, missing data is a common issue during emergency situations.
This study aimed to evaluate the impact of a tablet-based resuscitation record on documentation completeness during medical resuscitations and nurses' perceptions of the use of the tablet app.
A mixed methods approach was adopted. To collect quantitative data, randomized retrospective reviews of paper-based resuscitation records before implementation of the tablet (Pre-App Paper; n=176), paper-based resuscitation records after implementation of the tablet (Post-App Paper; n=176), and electronic tablet-based resuscitation records (Post-App Electronic; n=176) using a documentation completeness checklist were conducted. The checklist was validated by 4 experts in the emergency medicine field. The content validity index (CVI) was calculated using the scale CVI (S-CVI). The universal agreement S-CVI was 0.822, and the average S-CVI was 0.939. The checklist consisted of the following 5 domains: basic information, vital signs, procedures, investigations, and medications. To collect qualitative data, nurses' perceptions of the app for electronic resuscitation documentation were obtained using individual interviews. Reporting of the qualitative data was guided by Consolidated Criteria for Reporting Qualitative Studies (COREQ) to enhance rigor.
A significantly higher documentation rate in all 5 domains (ie, basic information, vital signs, procedures, investigations, and medications) was present with Post-App Electronic than with Post-App Paper, but there were no significant differences in the 5 domains between Pre-App Paper and Post-App Paper. The qualitative analysis resulted in main categories of "advantages of tablet-based documentation of resuscitation records," "challenges with tablet-based documentation of resuscitation records," and "areas for improvement of tablet-based resuscitation records."
This study demonstrated that higher documentation completion rates are achieved with electronic tablet-based resuscitation records than with traditional paper records. During the transition period, the nurse documenters faced general problems with resuscitation documentation such as multitasking and unique challenges such as software updates and a need to familiarize themselves with the app's layout. Automation should be considered during future app development to improve documentation and redistribute more time for patient care. Nurses should continue to provide feedback on the app's usability and functionality during app refinement to ensure a successful transition and future development of electronic documentation records.
在急症部门（AED）中完整记录重症监护事件至关重要。由于复苏病例节奏快且复杂，因此在紧急情况下，数据缺失是常见问题。
本研究旨在评估基于平板电脑的复苏记录对医疗复苏过程中记录完整性的影响，以及护士对使用平板电脑应用程序的看法。
采用混合方法研究。为了收集定量数据，采用随机回顾性方法，对平板电脑应用程序实施前的纸质复苏记录（应用前纸质记录；n=176）、平板电脑应用程序实施后的纸质复苏记录（应用后纸质记录；n=176）和基于电子平板电脑的复苏记录（应用后电子记录；n=176）进行评估，使用记录完整性检查表。该检查表由 4 名急诊医学领域的专家进行了验证。采用量表 CVI（S-CVI）计算内容有效性指数（CVI）。通用一致 S-CVI 为 0.822，平均 S-CVI 为 0.939。检查表包括以下 5 个领域：基本信息、生命体征、程序、检查和药物。为了收集定性数据，采用个人访谈方式获取护士对电子复苏记录应用程序的看法。使用 CONSORT 声明报告定性数据，以增强严谨性。
与应用后纸质记录相比，应用后电子记录在所有 5 个领域（即基本信息、生命体征、程序、检查和药物）的记录率显著更高，但应用前纸质记录和应用后纸质记录在 5 个领域之间没有显著差异。定性分析产生了主要类别，包括“基于平板电脑的复苏记录的优势”、“基于平板电脑的复苏记录的挑战”和“基于平板电脑的复苏记录的改进领域”。
本研究表明，与传统纸质记录相比，基于电子平板电脑的复苏记录可实现更高的记录完成率。在过渡期间，护士记录员在复苏记录方面面临着一般的多任务处理问题，以及独特的挑战，如软件更新和需要熟悉应用程序的布局。在未来的应用程序开发中应考虑自动化，以改善文档记录并重新分配更多时间用于患者护理。在应用程序细化过程中，护士应继续提供对应用程序可用性和功能的反馈，以确保电子文档记录的成功过渡和未来开发。
