Sebastian Böttger

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.

Discriminative power on mortality of a modified Sequential Organ Failure Assessment score for complete automatic computation in an operative intensive care unit.

Objective To evaluate the discriminative power on mortality of a modified Sequential Organ Failure Assessment (SOFA) score and derived measures (maximum SOFA, total maximum SOFA, and delta SOFA) for complete automatic computation in an operative intensive care unit (ICU). Design Retrospective study. Setting Operative ICU of the Department of Anesthesiology and Intensive Care Medicine. Patients Patients admitted to the ICU from April 1, 1999, to March 31, 2000 (n = 524). Data from patients under the age of 18 yrs and patients who stayed <24 hrs were excluded. In the case of patient readmittance, only data from the patient’s last stay was included in the study. Interventions None. Measurements and Main Results The main outcome measure was survival status at ICU discharge. Based on Structured Query Language (SQL) scripts, a modified SOFA score for all patients who stayed in the ICU in 1 yr was calculated for each day in the ICU. Only routine data were used, which were supplied by the patient data management system. Score evaluation was modified in registering unavailable data as being not pathologic and in using a surrogate of the Glasgow Coma Scale. During the first 24 hrs, 459 survivors had an average SOFA score of 4.5 ± 2.1, whereas the 65 deceased patients averaged 7.6 ± 2.9 points. The area under the receiver operating characteristic (ROC) curve was 0.799 and significantly >0.5 (p < .01). A confidence interval (CI) of 95% covers the area (0.739–0.858). The maximum SOFA presented an area under the ROC of 0.922 (CI: 0.879–0.966), the total maximum SOFA of 0.921 (CI: 0.882–0.960), and the delta SOFA of 0.828 (CI: 0.763–0.893). Conclusion Despite a number of differences between completely automated data sampling of SOFA score values and manual evaluation, the technique used in this study seems to be suitable for prognosis of the mortality rate during a patient’s stay at an operative ICU.

A prospective randomized trial on preventative methods for positional head deformity: physiotherapy versus a positioning pillow.

OBJECTIVE To evaluate the impact of stretching exercises versus available bedding pillows on positional head deformities. STUDY DESIGN Fifty children aged 5 months or younger with positional head deformity were included in this prospective clinical trial (n=20 plagiocephaly, n=10 brachycephaly, n=20 combination). A random distribution was performed for treatment with the bedding pillow alone (n=25) or with stretching exercises (n=25) for 6 weeks. Anthropometric caliper measurements were done before and after that interval. Cranial vault asymmetry index (CVAI) and cranial index (CI) were calculated and analyzed using a descriptive statistical general linear model. RESULTS ΔCVAI in the stretching group was 2.09% for plagiocephaly and 2.34% for combined head deformities. Using the bedding pillow, ΔCVAI was 3.01% in plagiocephal children and 2.86% for combined head deformity. The ΔCI in the stretching group was 0.94% for isolated brachycephal children and 2.24% for combined head deformity. ΔCI in the pillow group was 3.63% for brachycephaly and 3.23% in children with combined head deformities, respectively. CONCLUSIONS Bedding pillows and stretching exercises both resulted in improvements in positional cranial deformation. For children with combined plagiocephaly and brachycephaly, improvement in cranial asymmetry was slightly greater when using bedding pillows versus stretching.

Retrospective analysis of autologous blood use in bimaxillary repositioning osteotomy surgery: a quality improvement study

BACKGROUND: Multiple studies have considered the necessity of preoperative autologous blood donation before bimaxillary orthognathic osteotomies. In the context of a quality improvement project, this topic was also investigated in our institution. Furthermore, the transfusion practice was analyzed and the correlations between patient, operative variables, and blood loss were studied.

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.