The implementation and acceptance of an intra-operative anesthesia information management system

A survey of user acceptance of electronic patient anesthesia records

Background

An anesthesia information management system (AIMS), although not widely used in Korea, will eventually replace handwritten records. This hospital began using AIMS in April 2010. The purpose of this study was to evaluate users' attitudes concerning AIMS and to compare them with manual documentation in the operating room (OR).

Methods

A structured questionnaire focused on satisfaction with electronic anesthetic records and comparison with handwritten anesthesia records was administered to anesthesiologists, trainees, and nurses during February 2011 and the responses were collected anonymously during March 2011.

Results

A total of 28 anesthesiologists, 27 trainees, and 47 nurses responded to this survey. Most participants involved in this survey were satisfied with AIMS (96.3%, 82.2%, and 89.3% of trainees, anesthesiologists, and nurses, respectively) and preferred AIMS over handwritten anesthesia records in 96.3%, 71.4%, and 97.9% of trainees, anesthesiologists, and nurses, respectively. However, there were also criticisms of AIMS related to user-discomfort during short, simple or emergency surgeries, doubtful legal status, and inconvenient placement of the system.

Conclusions

Overall, most of the anesthetic practitioners in this hospital quickly accepted and prefer AIMS over the handwritten anesthetic records in the OR.

The value proposition of anesthesia information management systems

Anesthesia information management systems add value to the anesthesiologist and the hospital above that which is provided by manual anesthesia records. The more complete documentation and less biased recording of vital signs in this system, relative to manual records, provide data needed for quality initiatives and operating room management and for clinical research. The system can improve the ability to increase anesthesia charge capture, meet the requirements of pay-for-performance programs, and assist in the defense of malpractice allegations. Realization of value from the anesthesia information management systems requires additional expenditures of resources to adapt the systems to meet specific institutional requirements.

A survey of anesthesiologists' and nurses' attitudes toward the implementation of an Anesthesia Information Management System on a labor and delivery floor

BACKGROUND

An anesthesia information management system (AIMS) is most frequently used in the operating room, but not on labor and delivery (L&D). The purpose of this study is to describe the implementation of an AIMS on L&D and the attitudes of practitioners (anesthesiologists and nurses) toward the system.

METHODS

The anesthesiology survey focused on satisfaction with the L&D AIMS, comparison of the L&D AIMS with a handwritten anesthesia record, and comparison of the L&D AIMS with the operating room AIMS. The nursing survey focused on nursing satisfaction with the L&D AIMS and comparison of the L&D AIMS with a handwritten anesthesia record.

RESULTS

Most anesthesiologists (76%) were satisfied with the L&D AIMS and 73% would not want to revert back to the paper record. However, most anesthesiologists felt the operating room AIMS was either superior or equal to the L&D AIMS. Although few nurses (4%) preferred the anesthesiologists revert back to the handwritten record overall, the nurses were neutral in their assessment of the AIMS. Most of the criticism related to the location of the system; 56% believed it was not in a convenient location and 74% thought the AIMS equipment "got in their way".

CONCLUSIONS

Overall, the anesthesiologists and nurses are satisfied with the L&D AIMS and would not want to switch back to a handwritten record. We conclude that AIMS should not be limited to the operating room setting and can successfully be used in L&D.

The implementation of an anesthesia information management system

BACKGROUND AND OBJECTIVE

Anaesthesia information management systems, though still not used widely, will inevitably replace handwritten records and may eventually serve as a core for the development of computerized decision support. We investigated staff expectations and the accuracy of data entry in a recently implemented commercially available anaesthesia information management system.

METHODS

A structured questionnaire was administered to the staff before and 1 week and 3 months after implementation in order to assess their opinion. The quality of manual data entry, and of automatic data record was evaluated by looking for missing data and the prevalence of artefacts.

RESULTS

Despite initial fears the users quickly accepted the system. Both automatic and manual data entry were found to be accurate and reliable while the prevalence of artefacts was relatively low.

CONCLUSIONS

A commercially available anaesthesia information management system can be easily implemented and used instead of paper charts.

Neuroprotection is associated with beta-adrenergic receptor antagonists during cardiac surgery: evidence from 2,575 patients

OBJECTIVE

To determine the impact of perioperative beta-adrenergic receptor (betaAR) antagonist administration on neurologic complications.

DESIGN

Observational database analysis.

SETTING

A clinical investigation at a single tertiary academic medical center.

PARTICIPANTS

Elective coronary artery bypass graft surgical patients operated on in the period 1994-1996.

INTERVENTIONS

Patients were divided into 2 groups: (1) patients given betaAR antagonist-blocking drugs in the perioperative period, including during operation, and (2) patients not given betaAR antagonists.

MEASUREMENTS AND MAIN RESULTS

betaAR antagonist use in 2,575 consecutive patients undergoing coronary artery bypass graft surgery (1994-1996) was determined using the Cardiovascular Database and Anesthesia Information System Database. Outcome variables were postoperative stroke, coma, and transient ischemic attack. Of patients, 113 (4.4%) had postoperative neurologic complications, including stroke (n = 44), coma (n = 12), and transient ischemic attack (n = 3). Of patients, 2,296 (89%) received perioperative betaAR antagonist therapy, and 279 (11%) did not. Adverse neurologic events occurred in 3.9% (n = 90) of patients who received perioperative betaAR antagonists and 8.2% (n = 23) of patients who did not receive betaAR antagonists (odds ratio, 0.45; 95% confidence interval, 0.28 to 0.73; p = 0.003, unadjusted.) Severe neurologic outcomes (stroke and coma) occurred in 1.9% (n = 44) of patients who received betaAR antagonists and 4.3% (n = 12) of patients who did not receive betaAR antagonists (odds ratio, 0.43; 95% confidence interval, 0.23 to 0.83; p = 0.016).

CONCLUSION

Use of beta-adrenergic antagonists was associated with a substantial reduction in the incidence of postoperative neurologic complications. A prospective randomized trial is needed to verify this potentially important neuroprotective strategy in cardiac surgery.

Intraoperative physiologic variables and outcome in cardiac surgery: Part I. In-hospital mortality

BACKGROUND

Risk stratification schemes have been developed to predict outcome of coronary artery bypass grafting (CABG) procedures, which are predominately based upon unalterable preoperative patient characteristics. The purpose of this study was to determine if minimum intraoperative hematocrit, maximum glucose concentration, mean arterial pressure on cardiopulmonary bypass, or duration of bypass influence risk-adjusted in-hospital mortality after CABG.

METHODS

Outcome data from 2,862 CABG patients were merged with intraoperative physiologic data. A preoperative mortality risk index was calculated for each patient. Variables found significant (p<0.05) by univariate logistic regression were tested in a multiple variable model to determine risk-adjusted association with mortality.

RESULTS

Overall mortality rate was 1.85%. The preoperative risk index was significantly associated with mortality (p = 0.0001). No significant association was present between mortality and intraoperative variables. Preexisting hypertension was an independent predictor of mortality after controlling for risk index and bypass duration.

CONCLUSIONS

Preexisting hypertension proved to be an independent predictor of mortality in our patient population. This study found no evidence to support the hypothesis that mean arterial pressure less than 50 mm Hg, lower hematocrit, or elevated glucose while on bypass increases in-hospital mortality.

Intraoperative physiologic variables and outcome in cardiac surgery: Part II. Neurologic outcome

BACKGROUND

The impact of alterable physiologic variables on neurologic outcome after coronary artery bypass grafting procedures is unknown. The purpose of this study was to determine whether minimum intraoperative hematocrit, maximum glucose concentration, or mean arterial pressure during cardiopulmonary bypass influences risk-adjusted neurologic outcome after coronary artery bypass grafting.

METHODS

Outcome data from 2,862 patients undergoing coronary artery bypass grafting were merged with intraoperative physiologic data. A preoperative stroke risk index was calculated for each patient. Variables found significant by univariate logistic regression were tested in a multivariable model to determine association with outcome.

RESULTS

The incidence of stroke or coma in the study population was 1.3%. After controlling for stroke risk and bypass time, only an index of low mean arterial pressure during bypass retained a significant inverse association with outcome (p = 0.0304).

CONCLUSIONS

This study found no evidence that glucose concentration or minimum hematocrit are associated with major adverse neurologic outcome. The association between lower pressure during bypass and decreased incidence of stroke or coma persisted in all risk groups. This points to mechanisms other than hypoperfusion as the primary cause of neurologic injury associated with cardiac surgery.

Ergonomic automated anesthesia recordkeeper using a mobile touch screen with voice navigtion

OBJECTIVE

To develop an ergonomically designed computerized recordkeeping tool for anesthesiologists that allows the clinician to maintain visual contact with the patient while performing recordkeeping.

METHODS

To simplify the human interface software, we developed two general use software components. All purpose menu type 1 (APM1) was used for entering events using a tree structured menu. APM1 was designed to adapt to the limits of human memory, by using Miller's rule of 7 to guide the input process. APM1 can be considered to be a three-dimensional table list consisting of 7 vertical and 7 horizontal choices, which has further 5 tree-structured divergences. APM1 is also completely configurable by the user. All purpose menu 2 (APM2) was used to implement the system-initiated human interface where the system will prompt the user by voice for each entry. When users touch a key on APM1 and APM2, the system was designed to respond with a voice prompt. A touch-screen was also utilized and designed to fit the anesthesia machine. The screen is equipped with a small speaker for voice response and a microphone for voice recognition. The positions of the screen are adjustable supported by a long flexible limb (85 cm).

RESULTS

After improving the design, systems were assembled for 10 operating rooms. Of the multiple features of the VOCAAR user interface, the following were well accepted by users and employed daily: touch-screen input, and voice response. The noncompulsory use rate was 87% during the initial 2 weeks, increased to 94% after 2 weeks and 100% after two months. The mean sound emission by voice response (n = 10, mean +/- SD) was 8.2 +/- 2.3 dB at the main anesthetist site (35 cm from the speaker mounted on the touch-screen), 2.2 +/- 1.3 dB at the staff site (1.5 m from the touch-screen), which was only audible for anesthesiologist but for surgeon.

DISCUSSION

An EARK system was designed to allow the user to maintain visual contact with the patient while performing recordkeeping tasks. The combination of a mobile touch screen and voice response/recognition facilitated the design goals of the system. Although the system has enjoyed universal clinical acceptance, the voice functions remain too limited to satisfy the needs of a completely handsfree user interface. Enhancements to voice recognition technology will offer the potential for improved functionality. Additional research is also needed to better define the relationship between vigilance and visual contact with the patient.

Use of an automated anesthesia information system to determine reference limits for vital signs during cesarean section

INTRODUCTION

We evaluated whether automated anesthesia information systems can be used to calculate reference limits (population-based "normal values") for vital signs. We considered four populations of women undergoing cesarean section: healthy under spinal anesthesia, healthy under general anesthesia, pre-eclamptic/eclamptic under spinal anesthesia, and pre-eclamptic/eclamptic under general anesthesia.

METHODS

Reference limits were calculated for each of the study populations by determination of percentiles for: minimum heart rate, maximum heart rate, minimum arterial oxyhemoglobin saturation (SaO2), minimum mean arterial pressure (MAP), maximum MAP, decrease in MAP, and increase in MAP.

RESULTS

There was one adverse anesthetic outcome among the 1,300 women in the study; the woman sustained a post-dural puncture headache. The 5th percentiles of SaO2 were at least 95% saturation under spinal versus 90% under general. Under spinal anesthesia, 95th percentiles for decreases in MAP from baseline were 63 mmHg for healthy and 75 mmHg for pre-eclamptic/eclamptic women. Under general anesthesia, the 95th percentiles for maximum MAP were 161 and 177 mmHg, respectively. Two women of the 1,300 patients experienced simultaneously a minimum SaO2 < 92% and minimum MAP < 50 mmHg.

DISCUSSION

Automated anesthesia information systems can be used to determine reference limits for vital signs during anesthesia. Reference limits may play a role in malpractice cases when an expert claims that care by an anesthesiologist was sub-standard as shown by vital signs that were not maintained within the normal range during the critical portions of an anesthetic. Automated anesthesia information systems may enhance expert witnesses' clinical judgment.