Manual Anesthesia Record Keeping at a Tertiary Care Center: A Descriptive Cross-sectional Study

Introduction: Intraoperative record form is one of the cardinal parts of anesthesia practices. Ideally, it should contain complete information about patients under anesthesia and intraoperative events. It serves as valuable information for subsequent patient management, research, or during medicolegal conditions. The objective of this study was to assess the practice and completeness of manual intraoperative anesthesia record keeping. Methods: A descriptive cross-sectional study was conducted from May 1 to July 31, 2021, in the postoperative ward of Kathmandu Medical College, which is a multispecialty tertiary care center. Approval from the ethical committee of Kathmandu Medical College Teaching Hospital was obtained (Reference: 2603202105) before conducting the study. Convenience sampling was used. The data were entered in Microsoft Excel and statistical analysis was done using Statistical Package for the Social Sciences version 20. Point estimate was done at 95% Confidence Interval and data present in numbers and percentages. We devised forty-two variables, which included demographics, personal identifiers, intraoperative events, anesthesia and airway management, intraoperative parameters, monitoring and medication. Results: The overall completion rate was 202 (52.59%) (47.6-57.57 at 95% Confidence Interval). Out of 42 variables, the completion rate of 14 variables was less than 50%. Among those were important parameters such as known allergies 94 (24.4%), Body mass index 50 (13%), intraoperative saturation of oxygen 104 (27%), intraoperative electrocardiogram recording 107 (27.8%), total fluid volume administered 45 (11.7%), patient status on transfer 84 (21.8%) had poor completion rate. Conclusions: Our intraoperative record form shows poor completion rate, which was similar to other studies. many important variables were missing and had incomplete data.

INTEGRATION OF THE TRANS-OPERATIVE INFORMATION WITH THE PATIENT'S ELECTRONIC RECORD

This article presents an integration project between the anesthetic station used in the step of trans-operative (life signals multiparameter monitor, anesthesia device and controlled target infusion pump) and the system of hospital information. The main goal of this project is to capture in an automatic way the vital signals from the medical equipment and the records trans-operatives and provide an anesthesia record to be storage in the patient’s electronic medical record (PEMR). The integration mode is through a gateway that execute the conversion of the machine - specific language into data/information of the HL7 standard. This interaction will allow to integrate data and information from multiparametric monitors, anesthesia devices, Controlled target Infusion pumps and the intra-operative anesthesiologist inputs.

Anesthesia Information Management Systems (AIMS) for the OOOR Setting

Anesthesia information management systems (AIMS) offer significant benefits to an anesthesiologist who practices beyond the operating room. AIMS systems have the potential to improve patient care because they deliver a customized, legible anesthesia record while storing the patient’s physiologic data in an easily searchable database. An electronic workflow allows the anesthesiologist to focus on patient care while facilitating tasks such as quality assurance, compliance, research, and billing.