Lorenzo Quinzio

Using an Anesthesia Information Management System to Prove a Deficit in Voluntary Reporting of Adverse Events in a Quality Assurance Program

Objective.A deficit is suspected in the manual documentation ofadverse events in quality assurance programs in anesthesiology. In order toverify and quantify this, we retrospectively compared the incidence ofmanually recorded perioperative adverse events with automatically detectedevents. Methods.In 1998, data of all anesthetic procedures, includingthe data set for quality assurance of the German Society of Anaesthesiologyand Intensive Care Medicine (DGAI), was recorded online with the AnesthesiaInformation Management System (AIMS) NarkoData4® (Imeso GmbH). SQL(Structured Query Language) queries based on medical data were defined for theautomatic detection of common adverse events. The definition of the SQLstatements had to be in accordance with the definition of the DGAI forperioperative adverse events: A potentially harmful change of parameters ledto therapeutic interventions by an anesthesiologist. Results.During16,019 surgical procedures, anesthesiologists recorded 911 (5.7%) adverseevents manually, whereas 2966 (18.7%) events from the same database weredetected automatically. With the exception of hypoxemia, the incidence ofautomatically detected events was considerably higher than that of manuallyrecorded events. Fourteen and a half percent (435) of all automaticallydetected events were recorded manually. Conclusion.Using automaticdetection, we were able to prove a considerable deficit in the documentationof adverse events according to the guidelines of the German quality assuranceprogram in anesthesiology. Based on the data from manual recording, theresults of the quality assurance of our department match those of othercomparable German departments. Thus, we are of the opinion that manualincident reporting seriously underestimates the true occurrence rate ofincidents. This brings into question the validity of quality assurancecomparisons based on manually recorded data.

Use Of an Anesthesia Information Management System (AIMS) To Evaluate The Physiologic Effects Of Hypnotic Agents Used To Induce Anesthesia

Objective.The aim of this study was to utilize an anesthesiainformation management system (AIMS) in investigating the effects of hypnoticagents used to induce anesthesia on blood pressure, heart rate and arterialoxygen saturation. The characteristics of these agents, known from previousstudies, were compared to the effects documented in this study during routineclinical use. Methods.During the years 1997 and 1998, all relevantdata from anesthetic procedures were recorded online using the automatedanesthesia information system NarkoData. The data from 8,078 generalanesthesia procedures using endotracheal intubation were exported via“structured query language” (SQL) from the AIMS database into astatistics program after excluding children (age < 14), patients whoreceived atropine during induction and procedures with use of extracorporealcirculation. The effects of drug administration on systolic, diastolic andmean arterial blood pressure (SBP, DBP, MBP), heart rate (HR) and arterialoxygen saturation (SpO2) were analyzed prior to induction and at5, 10 and 15 minutes following bolus administration of the hypnotic agent. Thedata were classified into three groups based on the induction agent used:thiopental, etomidate or propofol and further separated into two groups basedon ASA status (ASA ≤ II and ASA > II). The mean and standard deviationswere calculated for each parameter at each point in time. Statisticalcomparisons were performed to determine whether the results for each timepoint differed from the previous time point. Results.There was asignificant decrease in blood pressure (MAP, SBP, DBP) after bolusadministration of all three hypnotics in all of the 8,078 procedures analyzed.The decrease was greater in patients of ASA class > II than in those of ASAclass ≤ II. Propofol caused the greatest drop in blood pressure whereasetomidate caused the least. During the observation period the HR also fell ineach group, except for thiopental where an initial rise of the HR could beobserved. An initial rise of SpO2 was recorded in each group withno differences observed between the individual hypnotics. Conclusions.The effects of the induction hypnotic agents thiopental, etomidate andpropofol on blood pressure and heart rate as documented by an AIMScorresponded to those found in clinical studies. An AIMS with thecorresponding documentation, software and database structure is suitable forcollecting and evaluating data for clinical investigations.

Clinical and practical requirements of online software for anesthesia documentation : an experience report

The aim of this paper is the presentation of a new version of the anesthesia documentation software, NarkoData, that has been used in routine clinical work in our department as part of an anesthesia information management system (AIMS) since 1995. The performance of this software is presented along with requirements for future development of such a system. The originally used version, NarkoData 3.0, is an online anesthesia documentation software established by the software company ProLogic GmbH. It was primarily developed as a disk-based system for the MacOS operating system (Apple Computer Inc.). Based on our routine experience with the system, a catalogue of requirements was developed that concentrated on improvement in the sequence of work, administration and data management. In 1996, the concepts developed in our department, in close co-operation with medical personnel and the software company, led to a considerable enlargement of the program functions and the subsequent release of a new version of NarkoData. Since 1997, more than 20 000 anesthesia procedures have been recorded annually with this new version at 115 decentralized work stations at our university hospital.

Review of antibiotic drug use in a surgical ICU: Management with a patient data management system for additional outcome analysis in patients staying more than 24 hours

BACKGROUND A number of developments have been made in computerized patient data management systems (PDMSs), making them of interest to medical and nursing staff as a means of improving patient care. OBJECTIVES The aim of this study was to assess the capability of a PDMS to record and provide drug-administration data and to investigate whether the PDMS may be used as a means of support for clinical audits and quality control. Furthermore, we assessed whether antibiotic therapy as a surrogate for infections correlates with hospital mortality in patients staying >24 hours in a surgical intensive care unit (SICU). METHODS Because of its medical and economic importance in ICU treatment, we chose to use the field of antibiotic therapy as an example. A PDMS was used in a 14-bed SICU (Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Giessen, Giessen, Germany) to record relevant patient data, including therapeutic, diagnostic, and nursing actions. During a 15-month period (April 1, 2000 to June 30, 2001), antibiotic drug therapy was electronically analyzed and presented using the anatomic therapeutic chemical (ATC) category for antibacterials (ATC group, J01) with daily defined doses. Furthermore, the correlation of antibiotic therapy with patient outcome (hospital mortality) was tested using logistic regression analysis. RESULTS A total of 2053 patients were treated in the SICU. Of these, 58.0% (1190 patients) received antibiotics (4479 treatment days; 13,145 single doses). Cephalosporins (ATC category, J01DA) were used most frequently (1785 treatment days [39.9% of treatment days]), followed by combinations of penicillins with beta-lactam inhibitors (ATC category, J01CR; 1478 treatment days [33.0%]) and imidazole derivatives (ATC category, J01XD; 667 treatment days [14.9%]). The antibiotic therapy lasted <3 days in 65.6% of cases. In 13.8% of cases, the treatment lasted >1 week. A total of 36.7% of cases were treated with only 1 antibiotic agent, 14.1% were given a combination of 2, and 7.2% were given a combination of > or =3 antibiotic agents. Seven hundred twenty-six patients remained in the SICU for >24 hours; 143 (19.7%) died during their hospital stay; 110 (15.2%) in the SICU. The duration of antibiotic therapy (odds ratio [OR], 1.46) and number of different antibiotic drugs used (OR, 2.15) significantly correlated with hospital mortality. CONCLUSIONS Antibiotic therapy in a SICU can be assessed and analyzed in detail using a PDMS. Furthermore, in this study, the duration of antibiotic therapy and the number of antibiotic agents used correlated with hospital mortality. In further developing PDMSs, it is important for quality-assurance purposes to document the reasons for giving antibiotics and for changing prescriptions. It would also be helpful to integrate certain therapy standards and reminder functions for the duration of therapy in the PDMS.

Evaluation of the suitability of a patient data management system for ICUs on a general ward

The development of the ICUData patient data management system (PDMS) for intensive care units (ICU), by IMESO GmbH, Hüttenberg, Germany, was based on the assumption that processes and therapies at ICU are the most complex with the highest data density compared with those in other wards. Based on experience with the system and on a survey conducted among users at our pain clinic, we evaluated whether the concept of the present software architecture, which sufficiently reproduces processes and data at an ICU, is suitable as a PDMS for general wards. The highly modular and client-centric approach of the PDMS is founded on a message-based communications architecture (HL7). In the beginning of the year 2000, the system was implemented at the pain management clinic (12 beds) of our hospital. To assess its user friendliness, we conducted a survey of medical staff (n=14). From April 1st 2000 to August 31st 2000, all clinical and administrative data of 658 patients at the pain management clinic were recorded with the PDMS. From the start, all users had access to data and information of other connected data management systems of the hospital (e.g. patient administrative data, patient clinical data). Staff members found the system mostly useful, clearly presented, practical, and easy to learn and use. Users were relatively satisfied with stability and performance of the program but mentioned having only limited knowledge of the programs features. The need for external support during a computer crash was rated negatively. Despite the need for further usage training and improved program performance, the software architecture described seems to be a promising starting point for the construction of a PDMS for general wards.

Qualitätsdokumentation mit einem Anästhesie-Informations-Management-System (AIMS)

ZusammenfassungZiel der Arbeit: Die Abteilung Anaesthesiologie und Operative Intensivmedizin der Justus-Liebig-Universität Giessen hat sich 1994 für den Aufbau eines Anästhesie-Informations-Management-Systems (AIMS) entschieden, um die bisherige manuelle Papierdokumentation abzulösen. Einzelne Aspekte und Ergebnisse dieses Datenpools sollen mit der Fragestellung vorgestellt werden, wie das System in seiner jetzigen Form geeignet ist, die Qualitätsdokumentation nach den Vorgaben der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) zu gewährleisten. Methoden: Mit der Narkose-Dokumentations-Software NarkoData 4 (ProLogic GmbH, Erkrath) wurden seit 1997 die Daten von 41.393 Narkosen einschließlich des DGAI-Kerndatensatzes „online” dokumentiert, in einer relationalen Datenbank (Oracle Corporation) archiviert und mit Hilfe des SQL-basierten Programms Voyant (Brossco Systems, Espoo, Finnland) statistisch aufgearbeitet. Beispielhaft für zwei anästhesiologische Verlaufsbeobachtungen (AVB) verglichen wir die durch Mitarbeiter im AIMS dokumentierten AVB-Inzidenzen „Hypotension” und „Übelkeit/Erbrechen” mit dem Auftreten vergleichbarer Ereignisse, die mit Hilfe der erfaßten Onlinedaten wie „Blutdruck” und „Medikamentenapplikationen” während der Narkose erfaßt wurden. Ergebnisse: 1997 lag die Inzidenz der von Hand in das System eingegebenen anästhesiologischen Verlaufsbeobachtungen (AVB) bei 3,6% (mit Schweregrad >II bei 0,9%) und erhöhte sich im Verlauf des Jahres 1998 auf 22,2% (mit Schweregrad >II bei 1,9%). Der prozentuale Anteil der Narkosen mit manuell dokumentierten AVBs war deutlich niedriger als dies bei der Online-Erfassung von Narkosen mit AVB-entsprechenden Ereignissen der Fall war: Für die AVB „Hypotension” fanden wir ein Verhältnis von 1,8% vs. 8.5% und für „Übelkeit/Erbrechen” 4,9% vs. 8,3%. Schlußfolgerung: Die derzeit fast überall praktizierte manuelle AVB-Dokumentation ist nicht vollständig. Im Gegensatz zu manuellen Verfahren stehen innerhalb des AIMS alle erfaßten Daten für Auswertungen zur Verfügung und ermöglichen eine detailliertere und lückenlosere Qualitätsdokumentation. Ob mit diesen Daten tatsächlich Versorgungsqualität beschrieben und gemessen wird, muß durch weitere Untersuchungen evaluiert werden. Weiterhin ist zu überlegen, in Zukunft an die Qualitätsdokumentation bezüglich des Datenrasters und der AVB-Erkennung unterschiedliche Anforderungen in Abhängigkeit vom jeweiligen Dokumentationsverfahren zu stellen (z.B. automatische AVB-Erkennung bei einem AIMS).AbstractObjective: In 1994 the Department of Anaesthesiology and Intensive Care Medicine of the Justus Liebig University of Giessen decided to implement an Anaesthesia Information Management System (AIMS) to replace the previous hand-written documentation on paper. From 1997 until the end of 1998 the data sets of 41,393 anaesthesia procedures were recorded with the help of computers and imported into a data bank. Individual aspects and results of this data pool are presented under the aspect of how the system in its present form is able to guarantee documentation of quality according to the requirements of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). Methods: Since 1997 information on all anaesthesia procedures has been documented ”online” with the anaesthesia documentation software NarkoData 4 (ProLogic GmbH, Erkrath). The data sets have been stored in a relational data bank (Oracle Corporation) and statistically processed with the help of the SQL-based program Voyant (Brossco Systems, Espoo, Finland). As an example of two adverse perioperative events (AVB) we compared incidences of ”hypotension” and ”nausea/vomiting”, recorded by staff members into the AIMS, with the incidence of comparable events that were recorded with the help of online data during anaesthesia procedures, such as blood pressure and drug application. Since 1998 data recording has been revised constantly in department meetings; advanced training has been given. The results have been analysed critically. Results: In 1997 the incidence of adverse perioperative events entered manually into the system was 3.6% (grade III and higher 0.9%) and increased during 1998 to 22.2% (grade III and higher 1.9%). The frequency of anaesthesia procedures with manually documented AVBs was significantly below the incidence (determined with the help of online data) of comparable events: ”hypotension” (1.8% vs. 8.5%) and ”nausea/vomiting” (4.9% vs. 8.3%). Conclusion: The current documentation of AVBs in almost any hospital is incomplete. In contrast to the hand-written procedure, the AIMS provides recorded data for evaluation and guarantees more detailed and complete quality documentation. In addition, the effort needed for documentation is reduced. Whether these data sets really describe and measure quality or not has to be evaluated. In addition it has to be considered whether different requirements (such as automatic AVB recognition for an AIMS) are advantageous for quality documentation regarding the data raster and the AVB recognition, with respect to different documentation procedures.

Einsatz eines Anästhesie-Informations-Management-Systems (AIMS) in einer Operativen Tagesklinik

ZusammenfassungVon Januar 1997 bis Juni 1999 wurde der komplette Aufenthalt aller tageschirurgischen Patienten, von der Aufnahme bis zur Entlassung, mit einem computergestützten Dokumentationssystem erfasst. Einzelne Aspekte und Ergebnisse aus dem Routinebetrieb sollen mit der Fragestellung vorgestellt werden, ob ein Anästhesie-Informations-Management-System (AIMS) geeignet ist, auch im Bereich des “Ambulanten Operierens” eine umfassende und qualitativ hochwertige Dokumentation zu gewährleisten. Methodik. Die Installation des Systems erfolgte durch Einbindung von 8 Bettplatz-Computern und eines weiteren Clients über das Intranet in das bestehende AIMS. An den tagesstationären Bettplätzen wurden Patientendaten prä- und postoperativ bis zur Entlassung oder Verlegung der Patienten mit der Online-Dokumentationssoftware NarkoData® Version 4 (Imeso GmbH, Hüttenberg) dokumentiert und in einer Datenbank gespeichert. Dieses Programm erfasst sämtliche für den Narkoseverlauf und tagesstationären Aufenthalt relevanten Informationen, u. a. Medikamentenapplikationen, Vitaldaten, Überwachungszeiten, Befunde sowie den Kerndatensatz der DGAI, ICD 9 und ICPM. Zur Auswertung wurden die Daten mittels der “Structured Query Language” (SQL) aus der Datenbank in ein Statistikprogramm exportiert. Ergebnisse. Die Datensätze von 3.152 tagesstationären Patienten wurden mit der Online-Dokumentationssoftware erfasst. Die häufigsten tageschirurgischen Operationen führte mit 54,2% der Fälle die operierende Fachabteilung Unfallchirurgie durch, gefolgt von der Allgemeinchirurgie mit 16,0% und der Urologie mit 9,5%. Die häufigsten tageschirurgischen Eingriffe waren diagnostische Arthroskopie (923, 31,2%), Entfernung von Osteosynthesematerial (410, 13,8%) und die Zirkumzision (250, 8,4%). Von anästhesiologischer Seite kamen zumeist die Inhalationsnarkose (38,6%, n=1218) und die intravenöse Anästhesie (IVA; 29,9%, n=938) zum Einsatz. Eine Regionalanästhesie wurde in 22,6% der Fälle (n=713) durchgeführt. Die durchschnittliche postoperative Überwachungszeit betrug 289,2±140,1 min. 169 Patienten (5,4%) wurden ungeplant stationär aufgenommen. Die Entscheidung zu einer stationären Aufnahme wurde bei 50,9% der stationär aufgenommenen Patienten intraoperativ oder in den ersten drei postoperativen Stunden gefällt. Schlussfolgerung. Das beschriebene AIMS ist geeignet, den gesamten Behandlungsprozess eines Patienten in einer operativen Tagesklinik zu dokumentieren. Die Integration in das bestehende System stellte sich als wesentliche Voraussetzung für die Integrität der Dokumentationskette heraus und ermöglicht eine sinnvolle Kommunikation mit anderen klinischen Datenverarbeitungssystemen. Wie auch im Bereich der Anästhesie konnten die Dokumentationsqualität und der Informationsfluss am Narkosearbeitsplatz gesteigert werden. Neben medizinischen und administrativen Daten stehen Informationen für die Analyse klinischer Prozesse zur Verfügung.AbstractFrom January 1997 until June 1999, the complete durations of stay of 3152 outpatients were entered into a computerized documentation system. The scope of the data entry went from patient admission to patient release. The objective was to determine the usefulness of the anaesthesia information management system (AIMS) in producing complete and high-quality documentation in the field of outpatient operations. Some aspects and results from routine work are presented here. Method. The system was installed in eight bedside computers, in addition to a further client connected to the existing AIMS via Ethernet. Patient medical courses were documented both preoperatively and postoperatively in outpatient bedsides until their discharge or admission. The online documentation software NarkoData (Version 4, Imeso GmbH, Hüttenberg, Germany) was used to document and store patient data in a database. This program contains all relevant information concerning the course of anaesthesia and outpatient duration of stay, including application of drugs, vital signs, observation times, and medical findings as well as the data sets of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), ICD, and ICPM. Data was analyzed by exporting from the database into a statistical program using “structured query language.” Results. Data sets of 3152 outpatients were entered into the online documentation software. Most (54.2%) of the ambulatory surgical procedures were performed by the Department of Traumatology. General Surgery followed with 16.0%, and Urology managed 9.5% of the cases. The most frequent ambulatory surgical procedures were: diagnostic arthroscopy (923, 31.2%), removal of osteosynthetic material (410, 13.8%), and circumcision (250, 8.4%). Anesthesia procedures consisted of inhalative (38.6%, n=1218) and intravenous anesthesia (IVA) (29.9%, n=938). In 22.6% (713) of the cases, regional anaesthesia was performed. The average postoperative observation time was 289.2±140.1 minutes. One hundred sixty-nine patients (5.4%) were unexpectedly admitted to overnight care. The decision to admit patients to normal wards took place within the first 3 postoperative hours in 51.9% of the cases. Conclusion. The AIMS described above is sufficient in documenting the entire care process of patients in a day care unit. Integration into the existing AIMS was an important prerequisite for the integrity of the documentation chain. This allowed for a sensitive communication with other clinical data processing systems. The quality of documentation and flow of information at the workplaces in the day care unit were increased, similarly to other anaesthesiological workplaces in the hospital. Medical and administrative data and information for analyses of clinical processes are possible with such tools.