Impact of a computerized note template/checklist on documented adherence to institutional criteria for determination of neurologic death in a pediatric intensive care unit

Objective: Variability exists in the documentation of death by neurologic criteria in children. We hypothesized that the use of a note template/checklist, which included directive (educational) prompts based on institutional neurologic determination of death criteria, improved thoroughness of documentation within our institutional guidelines for the neurologic determination of death. Design: Retrospective chart review. Setting: Twenty-one bed pediatric intensive care unit in a freestanding pediatric teaching hospital. Patients: Children 0-18 yrs undergoing evaluation for cessation of neurologic function from May 2000 to June 2006. Interventions: Introduction of a computerized note template/checklist with educational prompts to document cessation of neurologic function. Measurements and Main Results: Documentation of 15 specific elements derived from our institution's neurologic determination of death guidelines was evaluated. Age, gender, primary diagnosis, observation interval between examinations, the use of appropriate ancillary testing, and apnea test element documentation were also studied. There were 490 deaths in the pediatric intensive care unit, of which 82 (16.7%) had at least one examination for cessation of neurologic function. Neurologic determination of death examination was performed 136 times in 78 patients (mean 1.74 examinations/patient); four charts were missing. Life support was withdrawn before the second examination in 14.1% of patients. Documentation was handwritten for 37.5% of the notes. The mean number of examination elements documented by handwritten note was 11.1 +/- 2.2 vs. 14.9 +/- 0.7 in the template/checklist group (p < .0001). Use of a template/checklist was associated with neurologic determination of death documentation of 98.6% of essential elements compared with 73.9% of the elements in handwritten notes (p < .0001). Compliance with intervals between examinations conformed to guidelines in 64.0% of cases. Documentation of apnea duration and pco(2) increase was significantly greater with the template/checklist (p <.025 and p < .001, respectively). Conclusions: Use of a note template/checklist to guide and document neurologic determination of death improved adherence to institutional criteria for assessment of cessation of neurologic function. (Pediatr Crit Care Med 2011; 12:271-276)