Information technology and the anaesthetic workstation

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Chapter 22 Information technology and the anaesthetic workstation

Chris J. Barham

Chapter contents

Record keeping

Other information and communication systems

Anaesthetists perform the majority of their clinical work in the operating theatre: the anaesthetic machine therefore, acts as their desk and office as well as a device for delivering anaesthesia. It is essential that it is equipped with the tools to provide care, record activity, provide information and enable communication.

This chapter will consider not only how information technology can assist in maintaining a record of the anaesthetic, but also its wider use in the theatre environment.

Record keeping

The earliest anaesthetic records date from 1894, although over 80 years later 3.4% of records in the UK were still merely an entry in the operating theatre register. It is now a legal requirement that an anaesthetic record is kept.

Most anaesthetists in the United Kingdom still create a handwritten record, which is sometimes augmented by a printout from the monitoring systems. These are both only stored in paper format. Table 22.1 lists the advantages and disadvantages of manual records compared with computerized records. The report of the National Confidential Enquiry for Perioperative Deaths for 2000¹ showed that 5% of case notes were lost, and in 3% of those present the anaesthetic record was missing. There is no evidence that these figures have changed significantly since then. Nevertheless, the report concluded that ‘Improvements in Information Technology can make retrieval of patient information more, rather than less, difficult’. This must be viewed in the context of the time when records were all paper based, and the majority of information systems did not communicate with each other.

Table 22.1 Comparison of manual and computerized records

Functions of the anaesthetic record

In addition to the legal imperative for keeping an anaesthetic record there are many practical reasons for doing so.

Computerized anaesthetic records

Computerized anaesthetic record systems have been available for many years, but despite their benefits and the sophistication of modern systems they have yet to gain widespread acceptance. One of the major impediments to their introduction has been the lack of a ‘business case’ to prove their financial worth. This is despite the fact that anaesthetists are involved in 60% of inpatient hospital activity, and that many studies have shown the benefits of automated records.^2,³

One of the difficulties in providing a business case is that there is little, if any, evidence of cash savings from the introduction of a computerized record. However, electronic patient records have been shown to provide many ‘softer’ benefits, including improved patient safety (due to reliable and clear communication), better information about the patient and the clinical process at the point of care, and the ability to identify good and poor care by linking care to outcomes.⁴

A modern computerised anaesthetic record system should also have comprehensive links to other clinical information systems to ensure that up-to-date information is available, and to avoid duplicate entry of pre-existing information (e.g. demographic details, proposed surgery, key personnel, etc.).

The National Health Service in England is currently making a major investment in information technology for integrated medical records through NHS Connecting for Health.⁵ Initially anaesthetic and critical care systems were to be a key component, but delays in introducing the core systems have made it unlikely that anaesthetic systems will remain part of the programme. Now it is anticipated that the ‘Clinical Five’⁶ (see Box 22.1) will be delivered for most hospitals through off-the-shelf solutions, which will be linked to each other and to existing systems (including anaesthesia and critical care) by some form of integration system.

Box 22.1

The ‘Clinical Five’

Patient Administration System (PAS)

Order communications and reports

Scheduling

Clinical correspondence with coding

Electronic prescribing

Another of the key features of the NHS programme is the summary care record, which will carry summary information from the patient’s medical record to be accessible at any site. This has now been developed and is being rolled out throughout England so the anaesthetist will have online access to key features of the patient’s medical history, including medications and allergies. This should be available at any point of care including the anaesthetic work station.

The features required of a computerized anaesthetic system are listed in Box 22.2.

Box 22.2

Criteria for anaesthetic record systems

• Should link to:

– Pre-assessment information

– Electronic clinical record

– Electronic prescribing system

– Pathology

– Radiology and PACS (public access computer system)

– Theatre system for operating list information, personnel

• Perioperative record should have:

– Appropriate user interface

– Anaesthetic preoperative assessment record

– Validation of staff

– Capture of all patient monitor data

– Capture of all machine monitor data

– Configurable display of all trend data

– Comprehensive data dictionary

– Rapid entry of narrative from menus

– Automatic coding

– Free text entry

– Drugs/fluids/infusions (including calculations)

– Critical incidents

– Postoperative instructions

– Recovery progress

– Key outcomes (death, pain, PONV, etc.)

– Audit trail

• Reporting should include:

– Staff logbooks

– Activity analysis

– Performance indicators

– Data for audit

– Financial analysis.

Automatic data capture

All displayed data from patient and machine monitoring systems (including infusion pumps, ventilators, etc.) should be captured by the system (Fig. 22.1). (Where target controlled infusion pumps are in use, data capture should include details of the pharmacokinetic model used together with the patient variables and the calculated drug concentrations.)

Figure 22.1 An established networked anaesthetic record keeping system in place on the workstation.

Automatic data logging is perhaps one of the principal benefits of computerised systems for anaesthetists, who may otherwise spend 10–15% of their time during a case on record keeping.⁷ Some of this time may be saved and, more importantly, transcription errors are avoided. It may be argued that the act of keeping a manual record focuses the attention, but this is unsupported and is outweighed by the provision of a clear detailed graphical record (Fig. 22.2). Any anaesthetist keeping a manual record will be aware of the tendency during long cases for the interval between recordings to increase as the case progresses. An automatic record will maintain recordings with the same granularity throughout – including times when the anaesthetist is occupied directly with the patient.

Figure 22.2 Screen shots from the type of record keeping system seen in Fig. 24.1: A. the splash screen; B. the trend page in use; C. a dialogue box for drug entry.

The software for a computerized record system may be either a local application on the anaesthetic machine or a web-based application on a remote server. The latter is now the most common scenario for electronic patient record systems, generally as it is far easier to maintain. However, this does make data capture more complex as it must be relayed via the network. Specialist products are available to handle this.

The most robust configuration for a real-time continuous record system, such as that for anaesthesia, is a locally based application where the record is constantly mirrored to a central server. This ensures that it can continue in the event of a network failure, and in the event of a local terminal failure the record can be restored as soon as the terminal is replaced. However, the improved reliability of most networks and the ease of maintenance of client/server applications will make web-based solutions more common in the future.

Data entry

There should be an appropriate method of entering information to the system. This will normally be a keyboard or touch screen, together with some pointing device. These must all be suitable for use in the theatre, and should be easy to clean to avoid cross infection. Washable, sealed, plastic-coated keyboards, which may even be cycled through a dishwasher, are now available (Fig. 22.3).

Figure 22.3 Washable keyboard incorporating a ‘trackpad’, suitable for clinical use. Man & Machine Computer Accessories Ltd, UK.

Data entered should conform to the standards recommended by the Royal College of Anaesthetists (see Box 22.3),⁸ and the system should be capable of attributing all procedures to the individual member of staff. Data should also adhere to a standard schema and terminology to ensure information is comparable wherever it is collected.⁹

Box 22.3

Suggested anaesthetic record set