Related Experiment Video
Updated: Aug 5, 2026
19:15
Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale
Published on: August 25, 2014
When documentation changes but behaviour persists: de-implementation in a neonatal intensive care unit
Mohammad Adawi1, Matthew Garber1, Padma Nandula2
1Departmenf of Pediatrics, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA.
BMJ Quality & Safety
|July 29, 2026
Summary
De-implementing routine gastric residual checks in neonatal intensive care units showed zero documented checks but 29% of nurses continued the practice secretly. True behavior, not just documentation, is key for successful de-implementation.
Area of Science:
- Neonatal Medicine
- Quality Improvement Science
- Healthcare Behavior Analysis
Background:
- De-implementation of low-value care is crucial but challenging.
- Documentation may not reflect actual clinical practice.
- Routine gastric residual checks are a common low-value practice in neonatal intensive care units (NICUs).
Purpose of the Study:
- To de-implement routine gastric residual (GR) checks in infants <1500g birth weight in a NICU.
- To assess the impact of a multifaceted quality improvement initiative on documentation and actual practice.
- To evaluate clinician behavior and associated factors during de-implementation.
Main Methods:
- A quality improvement initiative using education, EMR workflow changes, and symptom-based feeding assessment.
- De-implementation of routine gastric residual checks in infants <1500g birth weight.
- Secondary analysis of an anonymous nursing survey to assess behavioral adoption and associated factors.
Main Results:
- Documented GR checks decreased to zero, with no adverse impact on necrotising enterocolitis, feeding intolerance, or time to full feeds.
- 29% of surveyed nurses reported continuing GR checks without documentation.
- Nurses expressed anxiety, particularly less-experienced ones, and perceived increased adverse events despite stable outcomes.
Conclusions:
- Documentation alone can overestimate de-implementation fidelity.
- A significant discordance exists between documented and actual clinical practice.
- Measurement strategies must capture true bedside behavior for effective de-implementation.
Related Concept Videos
01:29Documentation in Long-Term and Home Healthcare Setting
Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Long-Term Care Facilities
01:23Methods of Documentation V: CBE
Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
01:30Guidelines for Nursing Documentation I
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:15Methods of Documentation VI: Case Management Model
The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic illness...
For example, a patient with a chronic illness...
01:26Guidelines for Nursing Documentation II
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:06Legal Guidelines for Documentation
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here: