Automated Anesthesia Record Research Articles

Automated anaesthesia record system - Expensive toy or a change whose time has come?

Automated anaesthesia record system - Expensive toy or a change whose time has come?

Strong and Weak Areas of Automated Anesthesia Record Systems

Strong and Weak Areas of Automated Anesthesia Record Systems

A Comparison of Electronic and Handwritten Anaesthetic Records for Completeness of Information

Complete documentation in anaesthetic records is important for patient management, research and quality assurance and has medicolegal implications. This study compares the completeness of information contained in electronic versus handwritten intraoperative anaesthetic records. A sample of 70 handwritten records was randomly selected from anaesthesia performed in the month prior to implementation of the Integrated Injectable Drug Administration and Automated Anaesthesia Record System and compared to a similar sample of electronic records generated eight months later. A comprehensive scoring system, based on the Australian and New Zealand College of Anaesthetists' guideline PS6, was used to compare the completeness of information throughout the entire intraoperative record. There was no significant difference in the total score for completeness between electronic (78%) and handwritten (83%) records (P = 0.16). Handwritten records were more complete with respect to weight (P < 0.0001), American Society of Anesthesiologists' physical status score (P < 0.0001), the size and type of artificial airway used (P = 0.003) and a record of the surgeons involved (P = 0.0004). Electronic records were more complete with respect to a record of drug administration including intravenous drugs (P < 0.0001), vapour (P = 0.0001) and nitrous oxide/oxygen (P < 0.0001), a record of end-tidal carbon dioxide monitoring (P = 0.006) and the level of trainee supervision (P = 0.0002). There was no overall difference in the completeness of electronic versus handwritten records. Several differences did exist however, highlighting both clinically important advantages and deficiencies in the electronic system. Records from both systems sometimes lacked important information.

Evaluation of a Computerized Anesthesia Report

In Brazil, the use of information systems that allows filling out anesthesia reports automatically is still in its initial stages. The objective of this study was to validate an automated anesthesia record. This study was approved by the Ethics Commission of the institution; an industry-university partnership (Dixtal, São Paulo, Brazil and Universidade de São Paulo) was developed, and the study received a grant from FINEP (Financiadora de Estudos e Projetos do Ministério de Ciência e Tecnologia). The integration of hospital information systems for recovery of data regarding identification, preoperative evaluation, and laboratorial exams was the premise of this study. The applicability of the final version of the prototype of the automated system was evaluated by applying a semi-structured tool to 33 physicians, residents, and/or anesthesiologists during surgery procedures in 66 patients. Descriptive evaluation of the data was undertaken. The computerized system was considered reliable even for large surgeries by 81% of the participants. The majority of the anesthesiologists considered the prototype of great value for future studies and capable of meeting the requirements of anesthesia reports, bringing benefits for anesthesiologists, patients, and hospitals. The full use of the system requires training and some of its aspects can be improved. Validation of this prototype of a computerized system for elaboration of anesthesia reports showed the viability of this type of solution to help anesthesiologists in their daily tasks, increasing the reliability of the data. Besides, when evaluating the applicability, anesthesiologists considered that the prototype could be useful for patients, physicians, and hospitals.

The Medicolegal Importance of Enhancing Timeliness of Documentation When Using an Anesthesia Information System and the Response to Automated Feedback in an Academic Practice

Documentation should ideally occur in real time immediately after completion of a service. Although electronic records often do not print the time that documentation notes were entered on the medical record, automated anesthesia record keeping systems store an audit trail that time stamps events entered by all anesthesia providers. As more lawyers become aware of this fact and requisition audit trails, prospective charting of necessary documentation may undermine the integrity of an anesthesia care team accused of malpractice, with potentially significant medicolegal consequences. We changed existing documentation practices of a large academic practice via a three-step process. Educational sessions increased the percentage of cases with correct timing of emergence documentation from 25% to 60% over a 2-mo period. Automated email performance feedback further increased correct note timing to 70%. When combined with personal contact by a member of the billing office and email copy notification of the chair, the percentage increased to >99.5%. The behavioral change was seen in all individuals, as 95% of attendings had < or = 2 records/mo with untimely documentation at the end of the study period. Once the habits were ingrained, further input was rarely necessary over the next 9 mo. This suggests physician behavioral change related to work process flow, unlike that related to patient care, is easily sustained.

Failure to Recognize Loss of Incoming Data in an Anesthesia Record-Keeping System May Have Increased Medical Liability

Automated anesthesia record-keeping systems (AARKs) are increasingly being used. There is a perception that AARKs may limit medical liability. We report a case in which our AARK may have increased our medical liability exposure. Nine months after a patient suffered a serious intraoperative complication, the anesthesiologist was named (as one of several defendants) in a claim alleging failure to properly monitor anesthetic care. One reason why the anesthesiologist was named related to a gap of 93 min in which no vital signs were documented in the anesthesia record. Relying on the physiological monitors to assess the patient's condition, the anesthesiologist did not recognize the interruption of data transmission, because the "active" medication window obscured the graphical display of the vital sign window.

The training of the automated anaesthesia record keeper with high fidelity human patient simulator for novice residents

The training of the automated anaesthesia record keeper with high fidelity human patient simulator for novice residents

The electronic pre-anesthesia form: An integral component of a new anesthesia information management system

g g o l w early a decade ago, we set out to establish an anesthesia information management system AIMS) for our hospital. Anesthesia information anagement systems are a form of clinical inforation system (CIS) that is designed to manage linical information pertaining to the patient’s periperative experience. Such systems vary in their cope and features, but we saw little added value in cquiring a discrete, automated anesthesia record eeper. Instead, we sought out a comprehensive ystem that would record, process, and manage the ntire perioperative process. An important compoent of the perioperative CIS is the Pre-Anesthesia valuation Form, hereafter referred to as the aneshesia “preoperative form” or “preop” for short. his article describes our experience in developing nd implementing an electronic “preop” form for n anesthesia CIS. Traditionally, the anesthesia preoperative asessment has differed from the ubiquitous history nd physical used by other specialties. The form ontains a variety of information, including demoraphic information, surgical diagnosis, procedure, edications, allergies, past surgical history, exanded review of systems, abbreviated physical xam, listing of labs and tests, overall assessment, nd anesthetic plan. The electronic preoperative form embodies ore than a simple electronic record of a patient’s reoperative condition. The electronic form is the ynch pin for an electronic system that manages the erioperative workflow process. Information enered in the form is the basis of the manual and utomated decision-making processes and largely etermines the management of the patient’s aneshetic care. Theoretically, the computer could proess information contained in the form and use redetermined rules and algorithms to suggest any aspects of the patient’s perioperative care “rules-based logic”). An electronic form has numerous advantages ver its paper cousin, but these advantages may be ifficult to exploit and costly to develop. Furtherore, the benefits of an electronic system may be

Prediction of tracheal tube size in children using multiple variables.

Tracheal tube (TT) size selection in children is important to avoid complications. Formulae utilizing age and physical characteristics to predict appropriate tube size are not entirely predictive. Using an automated anaesthesia record keeper database, the anaesthetic records of 8504 children, aged up to 7 years, who required tracheal intubation, were reviewed. Age, height and weight data were related to TT size. The total number of patients whose age, height and weight were independently available was 8396, 3929 and 7823, respectively. The number having all three variables was 3814. A linear regression analysis was performed for patients with all three variables and for each variable individually. Tracheal tube size is best predicted using multivariate analysis and, for any child aged up to 7 years, is represented by the formula: 2.44 + (age x 0.1) + (height x 0.02) + (weight x 0.016). Formulae utilizing these variables individually are also reviewed. Prediction of TT size is best accomplished using multiple variables. Further prospective study is suggested.

A New, Safety-Oriented, Integrated Drug Administration and Automated Anesthesia Record System

Medication errors are an important cause of patient morbidity and mortality and excessive costs, including in anesthesia. Conventional methods of injectable drug administration in anesthesia make little use of technology to support manual checking and are idiosyncratic and relatively error prone. Similarly, conventional anesthesia records are handwritten, time-consuming to make, and often unreliable. There are automated record systems, but they do not provide support for checking drugs. Therefore, by using a multifaceted approach based on established principles of systems design and human factors psychology, we have developed a system that includes trays that promote a well-organized anesthetic workspace, color- and bar-coded labeling of syringes, and automatic visual and auditory verification of the syringe labels by computer just before each drug administration. In addition, documentation of drugs administered and a traditional anesthetic case record are generated automatically. The system has been successfully deployed for 25 mo and has been used by 35 anesthesiologists in 1148 diverse cases, including cardiopulmonary bypass procedures, heart and lung transplants, and orthopedic and otorhinolaryngologic operations. It is in daily use in a tertiary teaching center and in a private hospital.

A new, safety-oriented, integrated drug administration and automated anesthesia record system.

Medication errors are an important cause of patient morbidity and mortality and excessive costs, including in anesthesia. Conventional methods of injectable drug administration in anesthesia make little use of technology to support manual checking and are idiosyncratic and relatively error prone. Similarly, conventional anesthesia records are handwritten, time-consuming to make, and often unreliable. There are automated record systems, but they do not provide support for checking drugs. Therefore, by using a multifaceted approach based on established principles of systems design and human factors psychology, we have developed a system that includes trays that promote a well-organized anesthetic workspace, color- and bar-coded labeling of syringes, and automatic visual and auditory verification of the syringe labels by computer just before each drug administration. In addition, documentation of drugs administered and a traditional anesthetic case record are generated automatically. The system has been successfully deployed for 25 mo and has been used by 35 anesthesiologists in 1148 diverse cases, including cardiopulmonary bypass procedures, heart and lung transplants, and orthopedic and otorhinolaryngologic operations. It is in daily use in a tertiary teaching center and in a private hospital. Traditional methods of drug administration and record keeping in anesthesia are relatively error prone. By using sound principles of systems design and human factors psychology, we have designed and deployed a system with the aim of improving patient safety by facilitating correct drug administration and accurate anesthesia record making.

The use of an anesthesia information management system for prediction of antiemetic rescue treatment at the postanesthesia care unit.

We used an anesthesia information management system (AIMS) to devise a score for predicting antiemetic rescue treatment as an indicator for postoperative nausea and vomiting (PONV) in the postanesthesia care unit (PACU). Furthermore, we wanted to investigate whether data collected with an AIMS are suitable for comparable clinical investigations. Over a 3-yr period (January 1, 1997, to December 31, 1999), data sets of 27,626 patients who were admitted postoperatively to the PACU were recorded online by using the automated anesthesia record keeping system NarkoData(R) (IMESO GmbH, Hüttenberg, Germany). Ten patient-related, 5 operative, 15 anesthesia-related, and 4 postoperative variables were studied by using forward stepwise logistic regression. Not only can the probability of having PONV in the PACU be estimated from the 3 previously described patient-related (female gender, odds ratio [OR] = 2.45; smoker, OR = 0.53; and age, OR = 0.995) and one operative variables (duration of surgery, OR = 1.005), but 3 anesthesia-related variables (intraoperative use of opioids, OR = 4.18; use of N(2)O, OR = 2.24; and IV anesthesia with propofol, OR = 0.40) are predictive. In implementing an equation for risk calculation into the AIMS, the individual risk of PONV can be calculated automatically. The aim of this study was to investigate predictors for postoperative nausea and vomiting by using online anesthesia records. With the help of computerized data evaluation, 7 of 34 variables could be detected as risk factors. By implementing an automatic score into the record keeping system, an individual risk calculation could be made possible.

COMPLIANCE WITH HCFA TERMINOLOGY; AN AUTOMATED SYSTEM FOR AUDIT OF ANESTHESIA DOCUMENTATION

S27 INTRODUCTION: Automated Anesthesia Record Keepers (AARK) provide a method of tracking compliance with Health Care Finance Administration (HCFA) required documentation. Documentation needs to be 100% complete and manual audit of charts is both tedious and expensive for support staff to perform. The Duke anesthesia information group developed a database analysis program designed to ensure both the completeness of the anesthesia record as well as 100% compliance with HCFA documentation. These notes detailed the presence and participation of the attending anesthesiologist, and staff, in those elements of each case and ancillary medical service as mandated by HCFA. METHODS: A prospective before and after comparison study was performed at a tertiary care medical center [1]. Documentation was assessed using our program before Documentation Guidelines (BDG) were instituted, after DG were suggested to Faculty as to what terms should be included in the record (ADG), and for three consecutive months 6 months after a $5.00 per complete record remuneration was started (AR1-3) [Months 1 through 3]. All incomplete records were returned to staff for completion. Penalties for failing to address incomplete documents were instituted. Those records that failed the automated compliance check were culled from the full list of records and returned to each attending for manual addenda. In the rare cases where the level of service did not meet HCFA requirements, bills were not submitted for those services. This ensured 100% compliance before records were submitted for payment and entry into the patients' charts. RESULTS: Median values of the compliance for the whole attending staff are shown in Table 1 below:Table 1These data show that compliance was fair after DG, then improved and was sustained after remuneration was instituted. CONCLUSIONS: AARK can be used to ensure timely, accurate and fully HCFA compliant records are produced and submitted. However, database analysis and feedback by itself was insufficient to fully change behavior. Additional behavioral change required incentives. In this case $5/case was sufficient to motivate the attending staff to fully document the services being provided in 90% of the cases, Continual database analysis gives the department the assurance that all necessary documentation is present. The absence of documentation can be wrongly interpreted as lack of service. Use of the AARK guarantees that all bills are submitted only where documentation exists of the service provided. The exact savings are hard to calculate, but, based upon the punitive and unreasonable settlements at other academic institutions for "fraudulent billing", savings could amount to millions of dollars.

An evolutionary solution to anesthesia automated record keeping.

In the course of five years the development of an automated anesthesia record keeper has evolved through nearly a dozen stages, each marked by new features and sophistication. Commodity PC hardware and software minimized development costs. Object oriented analysis, programming and design supported the process of change. In addition, we developed an evolutionary strategy that optimized motivation, risk management, and maximized return on investment. Besides providing record keeping services, the system supports educational and research activities and through a flexible plotting paradigm, supports each anesthesiologist's focus on physiological data during and after anesthesia.

Automated record-keeping in anesthesia

Implementation of electronic anesthesia documentation systems is increasing rapidly. This update reviews issues of system installation, and of interfacing to anesthesia equipment. Quality assurance, critical incident documentation, and management of hospital economics are discussed as the main rationale behind installing automated anesthesia record systems. Further topics of discussion are technical requirements, problems of the anesthetist's vigilance, and artifacts.

Automated anesthesia record systems

The introduction of electronic anaesthesia documentation systems was attempted as early as in 1979, although their efficient application has become reality only in the past few years. The advantages of the electronic protocol are apparent: Continuous high quality documentation, comparability of data due to the availability of a data bank, reduction in the workload of the anaesthetist and availability of additional data. Disadvantages of the electronic protocol have also been discussed in the literature. By going through the process of entering data on the course of the anaesthetic procedure on the protocol sheet, the information is mentally absorbed and evaluated by the anaesthetist. This information may, however, be lost when the data are recorded fully automatically-without active involvement on the part of the anaesthetist. Recent publications state that by using intelligent alarms and/or integrated displays manual record keeping is no longer necessary for anaesthesia vigilance. The technical design of automated anaesthesia records depends on an integration of network technology into the hospital. It will be appropriate to connect the systems to the internet, but safety requirements have to be followed strictly. Concerning the database, client server architecture as well as language standards like SQL should be used. Object oriented databases will be available in the near future. Another future goal of automated anaesthesia record systems will be using knowledge based technologies within these systems. Drug interactions, disease related anaesthetic techniques and other information sources can be integrated. At this time, almost none of the commercially available systems has matured to a point where their purchase can be recommended without reservation. There is still a lack of standards for the subsequent exchange of data and a solution to a number of ergonomic problems still remains to be found. Nevertheless, electronic anaesthesia protocols will be required in the near future. The advantages of accurate documentation and quality control in the presence of careful planning outweight cost considerations by far.

The successful implementation of pharmaceutical practice guidelines. Analysis of associated outcomes and cost savings. SWiPE Group. Systematic Withdrawal of Perioperative Expenses.

Although approximately 2,000 medical practice guidelines have been proposed, few have been successfully implemented and sustained. We hypothesized that we could develop and institute practice guidelines to promote more appropriate use of costly anesthetics, to generate and sustain widespread compliance from a large physician group, and to decrease costs without adversely affecting clinical outcomes. A prospective before and after comparison study was performed at a tertiary care medical center. Clinical outcomes data and times indicative of perioperative patient flow were collected on the first of two sets of patients 1 month before discussion of practice guidelines. Practice guidelines were developed by the physicians and their associated care team for the intraoperative use of anesthetic drugs. A drug distribution process was developed to aid compliance. Clinical outcomes data and times indicative of perioperative patient flow were collected on the second set of patients 1 month after institution of practice guidelines. Hospital drug costs and adherence to guidelines were noted throughout the study period and for each of the following 9 months by querying the database of an automated anesthesia record keeper. A total of 1,744 patients were studied. Drug costs decreased from 56 dollars per case to 32 dollars per case as a result of adherence to practice guidelines. Perioperative patient flow was minimally affected. Time (mean +/- SD) from end of surgery to arrival in the post-anesthesia care unit (PACU) increased from 11 +/- 7 min before the authors instituted practice guidelines to 14 +/- 8 min after practice guidelines (P < 0.0001). Admission of inpatients to the PACU receiving monitored anesthesia care increased from 6.5 to 12.9% (P < 0.02). Perioperative patient flow and clinical outcomes were not otherwise adversely affected. Compliance and cost savings have been sustained. This study is an example of a successful physician-directed program to promote more appropriate utilization of health care resources. Cost savings were obtained without any substantial changes in clinical outcomes. Institution of similar practice guidelines should result in pharmaceutical savings in the range of 50% at tertiary care centers around the country, with a slightly smaller degree of savings expected at institutions with more ambulatory surgery.

Detection of intraoperative incidents by electronic scanning of computerized anesthesia records. Comparison with voluntary reporting.

The use of a computerized anesthesia information management system provides an opportunity to scan case records electronically for deviations from specific limits for physiologic variables. Anesthesia department policy may define such deviations as intraoperative incidents and may require anesthesiologists to report their occurrence. The actual incidence of such events is not known. Neither is the level of compliance with voluntary reporting. Using automated anesthesia record-keeping with long-term storage, physiologic data were recorded every 15 s from 5,454 patients undergoing noncardiothoracic surgery. Recorded measurements of blood pressure, heart rate, arterial oxygen saturation, and temperature were electronically analyzed for deviations from defined limits. The computer system also was used by anesthesiologists to report voluntarily those deviations as intraoperative incidents. For each electronically detected incident: 1) the complete automated anesthesia record was examined by two senior anesthesiologists who, by consensus, eliminated case records with artifact or in which context suggested that the incident was not clinically relevant, and 2) the anesthesia information management system database was checked for voluntary reporting. In 473 automated anesthesia records, 494 incidents were found by electronic scanning of 5,454 automated anesthesia records. Sixty intraoperative incidents were eliminated, 25 due to artifact and 35 due to context. When the remaining 434 intraoperative incidents were checked for voluntary reporting, 18 (4.1%) matching voluntary reports were found. All intraoperative incidents that were reported voluntarily also were detected by electronic scanning. Based on a 10% sample, the sensitivity rate of electronic scanning was 97.2% (35/36), and the specificity rate was 98.4% (427/434). Among 413 cases with electronically detected intraoperative incidents, there were 29 deaths (7.0%), whereas there were only 79 deaths (1.6%) among 5,041 cases without incidents (chi 2 = 58.5, P < 0.001). The use of an anesthesia information management system facilitated analysis of intraoperative physiologic data and identified certain intraoperative incidents with high sensitivity and specificity. A low level of compliance with voluntary reporting of defined intraoperative incidents was found for all anesthesiologists studied. Finally, there was a strong association between intraoperative incidents and in-hospital mortality.

Comparison of automated and manual anaesthesia record keeping. A video observation study analysing anaesthesia related tasks

Automated anaesthetic records allow increased accuracy of data collection. Presumably, the automated anaesthesia record keeping (AARK) compared to the traditional pen and paper approach may change the way anaesthesia staff work. When Peijas Hospital decided to purchase a new anaesthesia documentation system, we were interested in analysing its influence on routine anaesthesia practice. We also wanted to compare the applicability of automated and manual anaesthesia records. After institutional approval and with informed consent, five nurse anaesthetists were selected for the study. The idea was to have both subjects who have had years of experience in the operating room and those who just recently had started their clinical practice. Each study subject performed one case with manual record keeping and one case with AARK. In order to standardize the case, only elective ASA 1-2 hysterectomies were included in the study. In the manual records group, a standard hospital record form was used. Automated records were created with AS/3 AM™ (Datex, Finland) multiparameter monitor including a record keeping software. It provided automated vital-signs collection and pre-configured record keeper menus which were designed according to the wishes of the staff. An independent observer was present in all cases. Each case was video recorded from the moment the patient was asleep until extubation and transport to the recovery area. The recordings were analysed post-operatively: each single task was selected, and its duration in seconds was measured. The data were later combined into five major categories representing typical task groups during anaesthesia (recording anaesthesia, direct patient care, supplementary activities, watching surgery and communication). For descriptive analysis of data, mean and median values with ranges were used. All hysterectomies were uneventful, there were no abnormal occurrences which might have influenced the way record keeping was performed. For this abstract, four manual and four automated cases have been analysed. Total duration of video recordings was 921 min. A total of 2451 entries were recorded in the database. Interestingly, the workload in recording anaesthesia seems to be less with AARK than with manual records (12.7% vs. 22.6% of the duration of general anaesthesia). On the contrary, more time can be allocated to direct patient care in the AARK group (34.5%) than in the manual records group (29.1%). Two of the major categories 'communication' and 'watching surgery' were selected as indicators of anaesthesia teamwork. The relative duration of both indicators seems to be independent of the way record keeping is used.

Effect of Automatic Record Keeping on Vigilance and Record Keeping Time

Comment This is interesting work. Some of us are frightened by automatic anesthetic record keeping. This paper attempts to look at both positive and negative aspects of such technology. The authors study error limits in recalled physiologic variables. As it happens, this does not differ significantly with or without the use of an automated anesthesia record keeper. One might question the value of reviewing such recall at all, however, unless the limits are great. What is the value of recall of a specific number unless that number is significant in its abnormality? The general change/progression is of greater importance. What this paper does do very well is to note the “nonchange” in total charting time between automated and manual systems. The authors suggest in their summary that automated systems require more time spent on the interface. However, the details of this are not clarified. Of special concern is the general finding that a significant period of time previously spent in “direct patient care” has now moved to the “unclassified”