Assessing and Improving Documentation of Pediatric Brain Death Determination within an Electronic Health Record

Abstract

Background/Objective Pediatric brain death determination (BDD) can be subject to interprovider variability of documentation, resulting in diagnosis credibility. The aim of this study was to describe our approach to assessing pediatric BDD documentation and documentation variation in the electronic health record (EHR).

Methods This was a single institution cross-sectional review of pediatric patients younger than 18 years determined to meet brain death criteria. We assessed electronic documentation and evaluated for the presence of contributing factors that can interfere with the brain death documentation based on our institutional brain death evaluation policy (core body temperature, systolic blood pressure within an acceptable range, sedative/analgesic drug effects, and neuromuscular blockade).

Results In total, 33 pediatric brain death patients were identified. This review revealed pediatric BDD documentation consistency (n, %) as follows: performance of the first pediatric brain death clinical examination with temperature above 36°C (27, 81.8%), systolic blood pressure above the defined range (29, 87.9%), more than 24 hours following admission (28, 84.8%); performance of the second pediatric brain death clinical examination with temperature above 36°C (32, 97%), more than 12 hours following the first examination (26, 89.7%); and ensuring sedative infusions were discontinued within the recommended cutoff period prior to pediatric BDD (28, 84.8%). Clinical neurologic examinations were fully documented.

Conclusions Pediatric BDD is a rare process subject to documentation omissions and error. Our findings highlight the variability of pediatric BDD electronic documentation among different providers and specialties at our institution. An approach to improving pediatric BDD documentation may start with completing a standardized electronic brain death document.

Keywords

critical care - electronic health record - intensive care unit - patient care - pediatric brain death

Name of Institution Where the Study Performed

Penn State Health Children's Hospital.

Source of Support

None.

Author Contribution

Dr. Conrad Krawiec was the lead author who conceptualized and designed the study, drafted and completed the initial manuscript, and approved the final manuscript as submitted. Dr. Gary D. Ceneviva assisted with the study design and analysis of the data, reviewed critical portions of the manuscript, contributed to the completed manuscript, and approved the final manuscript as submitted. Dr. Neal Thomas mentored Dr. Krawiec during the course of the project, assisted with the study design, and reviewed and contributed to the completed manuscript. Dr. Thomas approved the final manuscript as submitted.

• References

• 1 Shemie SD, Dhanani S. Brain Death. In: Wheeler DS, Wong HR, Shanley TP. , ed. Pediatric Critical Care Medicine Textbook. 2nd ed. London: Springer-Verlag; 2014: 481-485
• 2 Burkle CM, Schipper AM, Wijdicks EF. Brain death and the courts. Neurology 2011; 76 (09) 837-841
• 3 Nakagawa TA, Ashwal S, Mathur M, Mysore M. ; Society of Critical Care Medicine, Section on Critical Care and Section on Neurology of American Academy of Pediatrics; Child Neurology Society. Clinical report—guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations. Pediatrics 2011; 128 (03) e720-e740
• 4 Hornby K, Shemie SD, Teitelbaum J, Doig C. Variability in hospital-based brain death guidelines in Canada. Can J Anaesth 2006; 53 (06) 613-619
• 5 Greer DM, Wang HH, Robinson JD, Varelas PN, Henderson GV, Wijdicks EF. Variability of brain death policies in the United States. JAMA Neurol 2016; 73 (02) 213-218
• 6 Truog RD. Defining death-making sense of the case of Jahi McMath. JAMA 2018; 319 (18) 1859-1860
• 7 Lewis A, Adams N, Varelas P, Greer D, Caplan A. Organ support after death by neurologic criteria: results of a survey of US neurologists. Neurology 2016; 87 (08) 827-834
• 8 No Authors. A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to examine the definition of brain death. JAMA 1968; 205 (06) 337-340
• 9 Sittig DF, Wright A, Meltzer S. , et al. Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records. BMC Med Inform Decis Mak 2011; 11: 13
• 10 Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspect Health Inf Manag 2013; 10: 1c
• 11 Singh H, Classen DC, Sittig DF. Creating an oversight infrastructure for electronic health record-related patient safety hazards. J Patient Saf 2011; 7 (04) 169-174
• 12 National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004; 114 (2, Suppl 4th Report): 555-576
• 13 Popernack ML, Thomas NJ, Lucking SE. Decreasing unplanned extubations: utilization of the Penn State Children's Hospital Sedation Algorithm. Pediatr Crit Care Med 2004; 5 (01) 58-62
• 14 Mathur M, Petersen L, Stadtler M. , et al. Variability in pediatric brain death determination and documentation in southern California. Pediatrics 2008; 121 (05) 988-993
• 15 Shappell CN, Frank JI, Husari K, Sanchez M, Goldenberg F, Ardelt A. Practice variability in brain death determination: a call to action. Neurology 2013; 81 (23) 2009-2014
• 16 Linder JA, Schnipper JL, Middleton B. Method of electronic health record documentation and quality of primary care. J Am Med Inform Assoc 2012; 19 (06) 1019-1024
• 17 Narayanan J, Dobrin S, Choi J. , et al. Structured clinical documentation in the electronic medical record to improve quality and to support practice-based research in epilepsy. Epilepsia 2017; 58 (01) 68-76
• 18 Reimschissel E, Dela Cruz B, Gonzalez M, Buitrago J, Goodman C, Johnston PA. Immunotherapy toxicities: a new electronic documentation template to improve patient care. Clin J Oncol Nurs 2017; 21 (2, Suppl): 41-44
• 19 Pellegrini DP, Raghu S, Waechter DK. Structured Electronic Documentation (SED) Cardiac Surgery and PowerNote: A Pilot Project. AMIA Annu Symp Proc 2005:1076
• 20 Carlson KL, McFadden SE, Barkin S. Improving documentation timeliness: a “brighter future” for the electronic medical record in resident clinics. Acad Med 2015; 90 (12) 1641-1645