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Documentation and feedback after neonatal emergency transport

from Section 2 - Basics in cardiopulmonary resuscitation of newborn infants

Published online by Cambridge University Press:  05 March 2012

Georg Hansmann
Affiliation:
Children's Hospital Boston
Georg Hansmann
Affiliation:
Children's Hospital Boston, Harvard Medical School
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Summary

Neonatal resuscitation and transfers are always documented in written form, and obstetricians, nursery/NICU and NETS are provided with a copy of the transport chart. Aside from the hand-written form, a detailed report may be faxed to the admitting team (nursery, NICU) after completion of the transport and verbal sign-out of the patient. Usually, all specifications mentioned in chronological order on p. 182 belong to documentation of both the standard initial care/resuscitation in the delivery room and NETS (resuscitation, stabilization, transport). In particular, the Apgar score, initial UA pH value and at least one blood gas analysis and one blood glucose value (D-stix), together with total transport time, must be documented in a transport protocol (legal backup). The original, labeled blood gas analysis printout should be stapled to the protocol. Further mandatory information should be documented: maternal HBsAg status, HIV status and blood type, perinatal drugs/medication/antibiotic prophylaxis/maternal signs of infection, and, if performed, hepatitis B vaccination and vitamin K administration. The admitting team also needs full prenatal laboratory test results, which can be faxed by the birth hospital, but is better provided as a photocopy. The complete physical examination after birth should also be documented, as should additional data such as the time of the emergency call, time of arrival at the delivery site, and time of arrival at the admitting children's hospital/NICU. Also, the most important vital signs obtained in the delivery room, during the transport and those obtained upon arrival in the NICU (HR, MAP, SaO2, blood gas, blood glucose, core temperature; see pp. 131–2) must be documented.

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Publisher: Cambridge University Press
Print publication year: 2009

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