Pinheiro Joaquim M B, Fisher Marilyn, Munshi Upender K, Khalak Rubia, Tauber Kate A, Cummings James J, Cerone Jennifer B, Monaco-Brown Meredith, Geis Gina, Chowdhry Rehman, Fay Mary, Paul Anshu A, Levine Carolyn, Pan Phillip, Horgan Michael J
Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA.
Neonatology, Ellis Hospital, Schenectady, NY 12308, USA.
Children (Basel). 2024 Feb 8;11(2):217. doi: 10.3390/children11020217.
Continuous improvement in the clinical performance of neonatal intensive care units (NICU) depends on the use of locally relevant, reliable data. However, neonatal databases with these characteristics are typically unavailable in NICUs using paper-based records, while in those using electronic records, the inaccuracy of data and the inability to customize commercial data systems limit their usability for quality improvement or research purposes. We describe the characteristics and uses of a simple, neonatologist-centered data system that has been successfully maintained for 30 years, with minimal resources and serving multiple purposes, including quality improvement, administrative, research support and educational functions. Structurally, our system comprises customized paper and electronic components, while key functional aspects include the attending-based recording of diagnoses, integration into clinical workflows, multilevel data accuracy and validation checks, and periodic reporting on both data quality and NICU performance results. We provide examples of data validation methods and trends observed over three decades, and discuss essential elements for the successful implementation of this system. This database is reliable and easily maintained; it can be developed from simple paper-based forms or used to supplement the functionality and end-user customizability of existing electronic medical records. This system should be readily adaptable to NICUs in either high- or limited-resource environments.
新生儿重症监护病房(NICU)临床绩效的持续提升依赖于使用与当地相关的可靠数据。然而,具有这些特征的新生儿数据库在使用纸质记录的NICU中通常无法获取,而在使用电子记录的NICU中,数据的不准确以及无法定制商业数据系统限制了它们在质量改进或研究目的方面的可用性。我们描述了一个简单的、以新生儿科医生为中心的数据系统的特征和用途,该系统已成功维持30年,资源极少且具备多种功能,包括质量改进、行政管理、研究支持和教育功能。在结构上,我们的系统包括定制的纸质和电子组件,而关键功能方面包括基于主治医生的诊断记录、融入临床工作流程、多级数据准确性和验证检查,以及定期报告数据质量和NICU绩效结果。我们提供了数据验证方法的示例以及三十年来观察到的趋势,并讨论了成功实施该系统的基本要素。这个数据库可靠且易于维护;它可以从简单的纸质表格发展而来,也可用于补充现有电子病历的功能和终端用户可定制性。该系统应易于适应高资源或资源有限环境中的NICU。