Serum creatinine and perioperative outcome--a matched-pairs approach using computerised anaesthesia records.

BACKGROUND AND OBJECTIVE: A study was designed to utilise the resources of our computerised anaesthesia record keeping system to assess the attributable effects of increased preoperative creatinine (> 1.3 mg dL(-1)) on outcome in patients undergoing non-cardiac surgery. METHODS: This retrospective study was based on data sets of 58 458 patients recorded with a computerised anaesthesia record keeping system over a period of 4 yr at a tertiary care university hospital. Cases were defined as patients with a preoperative creatinine > 1.3 mg dL(-1); controls (creatinine < or = 1.3 mg dL(-1)) were selected and automatically matched according to several parameters (ASA physical status, high risk and urgency of surgery, age and gender) in a stepwise fashion. Main outcome measures were hospital mortality and the incidence of intraoperative cardiovascular events. RESULTS: Three-thousand-and-twenty-eight patients (5.2%) had preoperative creatinine values > 1.3 mg dL(-1). Matching was successful for 54.5% of the cases, leading to 1649 cases (mean creatinine 3.3 +/- 2.2 mg dL(-1)) and 1649 controls (1.0 +/- 0.2 mg dL(-1)). The crude mortality rates for the cases and matched controls were 2.2% (n = 36) and 0.9% (n = 15), respectively (P = 0.003). Intraoperative cardiovascular events were found in 30.1% of the patients (n = 496) and in 28.3% of the matched controls (n = 466; P = 0.25, power = 0.46). Using logistic regression analyses a significant association between preoperative increased creatinine and hospital mortality was found (odds ratio 2.62; 95% confidence interval [1.39; 4.931). CONCLUSIONS: An increased preoperative serum creatinine in patients undergoing non-cardiac surgery is associated with an increased perioperative risk, but not with a higher incidence of intraoperative cardiovascular events.

Impact on postoperative pain of long-lasting pre-emptive epidural analgesia before total hip replacement: a prospective, randomised, double-blind study.

Clinical studies on pre-emptive analgesia have produced inconsistent results. We conducted a clinical study investigating the effect of long-lasting pre-emptive epidural analgesia on consumption of analgesics and acute pain. Forty-two patients scheduled for elective hip replacement for osteo-arthritis were randomly assigned to receive, on the day before operation, either 5 ml.h(-1) ropivacaine 0.2% (study group, n = 21) or 5 ml.h(-1) saline (control group, n = 21). Postoperative analgesia was achieved in both groups by patient-controlled epidural analgesia (PCEA) with ropivacaine 0.2%. The main outcome measure was consumption of local anaesthetics. Additional parameters included visual analogue pain scale (VAS) scores, consumption of rescue analgesics, requests for PCEA boluses, and side-effects. The pre-operative parameters and pain scores were similar in the two groups. Epidural blocks provided sufficient operative analgesia in all patients. Pre-emptive analgesia was continued for 11-20 h and led to significantly decreased pain scores before surgery. The consumption of local anaesthetics was decreased postoperatively in the study group (194 mg vs. 284 mg in the postoperative period). Furthermore, bolus requests occurred more frequently in the control group. VAS scores did not differ significantly between groups. Long-lasting "pre-emptive" epidural analgesia decreases postoperative pain with improved pain control.

User acceptance of an anaesthesia information management system.

BACKGROUND AND OBJECTIVE: This paper describes the user acceptance of an anaesthesia information management system at the University Hospital in Giessen, Germany, after 5 yr of routine use. METHODS: A questionnaire with 75 items was distributed to all anaesthesiologists and anaesthetic nurses of the Department of Anaesthesiology. The questions were answered anonymously on a five-point Likert scale. RESULTS: The return rate was 60% (44 physicians and 24 nurses). The results indicated that the system generally met user expectations. The respondents thought that electronic record keeping improved the quality of their work, and they did not want to switch back to paper records. Problems arose with hardware placement and software features, e.g. coding tools for diagnoses and type of surgery. The perceived quality of training strongly influenced user acceptance. CONCLUSIONS: Despite the deficits revealed by the survey, the respondents did not want to switch back to manual record keeping. A structured user survey is a useful tool for the development, adaptation and implementation of an anaesthesia information management system. A training strategy that takes the needs of the users into account is recommended.

Potential benefits of Anaesthesia Information Management Systems for multicentre data evaluation: risk calculation of inotropic support in patients undergoing cardiac surgery.

OBJECTIVE: The aim of this study was to test the hypothesis whether it is easily possible to transfer and apply the methods of data extraction and analysis of a performed study to a data pool of a different medical centre using the same type of Anaesthesia Information Management System (AIMS). For this purpose the objective of a study in cardiac anaesthesia, investigated at the University Hospital Giessen, was applied to the data pool of the Heart Centre Siegburg. RESEARCH DESIGN AND METHODS: The Giessen study evaluated factors related to the use of positive inotropic drugs (PIDs) in adults undergoing elective cardiac surgery with cardiopulmonary bypass (CPB). The same objective and methods were applied to data of 1672 patients of the Heart Centre Siegburg. In both centres anaesthetic procedures were recorded with the AIMS NarkoData. Existing database queries were adapted according to the Siegburg database configuration for detection of patients having received PIDs during or after weaning from CPB. RESULTS: It was revealed that data from the Siegburg database using the same data model and configuration, were identical to the Giessen database except for a few items only. Thus database queries of the Giessen study could be applied to the new data pool requiring no considerable additional input. CONCLUSIONS: We could demonstrate that multicentre data analysis in anaesthesia using AIM systems can be carried out successfully. Once the methods of data extraction and analysis are established they can be transferred to data pools of different centres without requiring additional time, personnel and material resources.

[Risk predictors, scoring systems and prognostic models in anesthesia and intensive care. Part I: anesthesia]. / Risikoindizes, Scoring-Systeme und prognostische Modelle in der Anästhesie und Intensivmedizin. Teil I: Anästhesie.

Risk predictors and scoring systems are commonly used in medicine to provide a reliable and objective estimation of disease prognoses, probability of adverse events and outcome. Furthermore, they were designed to classify severity of illness or the course of diagnostic and therapeutic interventions and to perform a risk stratification for scientific studies in a standardized way. In quality management and cost control, scoring systems and predictors are used for risk adjustment and evaluation of care performance. The aim of this review article was to describe common risk indices and scoring systems in anesthesia (part I) and intensive care (part II), and to point out their possible benefits and limitations. Different scoring systems and classifications are available to stratify perioperative risk and adverse events in anesthesia. Especially in cardiac surgery, an increasing interest in risk-adjusted outcome studies led to the modeling and validation of different prognostic systems for postoperative morbidity, mortality and length of stay. Furthermore, there are scoring-systems for special events, such as difficult laryngoscopy or postoperative nausea and vomiting (PONV). Risk check lists and risk indices are superior to the ASA classification of physical status in providing more exact results and the possibility of statistic risk calculation. Nevertheless, they are not frequently used in clinical routine. Because of its simplicity and easy handling the ASA classification has worldwide popularity and recent studies demonstrated at least equal prognostic performance.

[Requirements for the successful installation of an data management system]. / Voraussetzungen für das Gelingen einer Installation von Daten-Management-Systemen.

Due to increasing requirements on medical documentation, especially with reference to the German Social Law binding towards quality management and introducing a new billing system (DRGs), an increasing number of departments consider to implement a patient data management system (PDMS). The installation should be professionally planned as a project in order to insure and complete a successful installation. The following aspects are essential: composition of the project group, definition of goals, finance, networking, space considerations, hardware, software, configuration, education and support. Project and finance planning must be prepared before beginning the project and the project process must be constantly evaluated. In selecting the software, certain characteristics should be considered: use of standards, configurability, intercommunicability and modularity. Our experience has taught us that vaguely defined goals, insufficient project planning and the existing management culture are responsible for the failure of PDMS installations. The software used tends to play a less important role.

An Anesthesia Information Management System (AIMS) as a tool for controlling resource management of operating rooms.

OBJECTIVES: In our department, we have been using an Anesthesia Information Management System (AIMS) for five years. In this study, we tested to what extent data extracted from the AIMS could be suitable for the supervision and time-management of operating rooms. METHODS: From 1995 to 1999, all relevant data from 103,264 anesthetic procedures were routinely recorded online with the automatic anesthesia record keeping system NarkoData. The program is designed to record patient related time data, such as the beginning of anesthesia or surgical procedure, on a graphical anesthesia record sheet. The total number of minutes of surgery and anesthesia for each surgical subspecialty per hour/day and day of the year was calculated for each of the more than 40 ORs, amounting to a total of 112 workstations. RESULTS: It was possible to analyze the usage and the utilization of ORs at the hospital for each day of the year since 1997. In addition, annual and monthly evaluations are made available. It is possible to scrutinize data of OR usage from different points of view: queries on the usage of an individual OR, the usage of ORs on certain days or the usage of ORs by a certain surgical subspecialty may be formulated. These data has been used repeatedly in our hospital for decision making in OR management and planning. CONCLUSIONS: In assessing the results of our study, it should be considered that the system used is not a specialized OR management tool. Despite these restrictions, the system contains data which can be used for an exact and relevant presentation of OR utilization.

[Registration of material consumption in anesthesia using a data management system]. / Erfassung des Materialverbrauchs in der Anästhesie mit einem Datenmanagementsystem.

BACKGROUND: The aim of this study was to investigate whether an Anesthesia Information Management System (AIMS) can provide reliable data on the consumption of single-use anesthetic material without necessitating an expensive and time-consuming inventory. To this end, the number of selected anesthesia-related materials and the total costs in orthopedic theatres for which the department of anesthesia had been charged in the year 2000 were compared to the data calculated by the AIMS. METHODS: Anesthesia-related material is provided by a computer-based system of storage facilities (KLIMA II) in the Department of Anesthesiology and Intensive Care Medicine at the University Hospital Giessen. All costs arising in orthopedic theatres are exclusively charged to one single account. At the same time, the online-documentation software, NarkoData (IMESO GmbH, Hüttenberg, Germany), collects all data on consumption of anesthetic single-use material. The total amount of peripheral (PVC) and central-venous catheters (CVC), urinary catheters (UC) and endotracheal tubes (ET) used in the year 2000 was ascertained by the AIMS and compared to the respective data accounted by the administration. RESULTS: In the year 2000, the number of patients treated in orthopedic theatres totaled 1,865. By means of the AIMS, a consumption of 783 CVCs, 644 UCs and 949 ETs could be documented. In contrast, hospital administration had billed 880 CVCs, 700 UCs, and 1,050 ETs: discrepancies of 11.0 % for CVCs, 8.0 % for UCs and 9.6 % for ETs. Concerning the two most frequently used CVCs, the AIMS failed to document costs of 3,238 DM. For PVCs (16 gauge and 14 gauge), the official cost was 10.8 % and 46.7 % higher compared to the number documented by the AIMS. Since the number of PVCs totaled 3,400, the AIMS failed to document costs of 1,900 DM. CONCLUSION: Comparison of both methods revealed substantial deficits in documenting cost-relevant materials. There were no detailed data available on the whereabouts of the materials used, i.e. whether tubes and catheters were undocumented, used or discarded. However, the AIMS may provide additional valuable information about possible sources of material wastefulness. This is especially true for infrequently used anesthesia-related materials.

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 program's 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.

Influence of the method of data collection on the documentation of blood-pressure readings with an Anesthesia Information Management System (AIMS).

The influence of methods for record keeping on the documentation of vital signs was assessed for the Anesthesia Information Management System (AIMS) NarkoData. We compared manually entered blood-pressure readings with automatically collected data. These data were stored in a data-base and subsequently evaluated and analyzed. The data sets were split into two groups, "manual" and "automatic". We evaluated the effect of automatic data collection on the incidence of corrected data, data validity and data variation. Blood-pressure readings of 37,726 data sets were analyzed. We could assess that the method of documentation did influence the data quality. It could not be assessed whether the incorrectness of data during automatic data gathering was caused by artefacts or by the anesthesiologist.

[Using an anesthesia information management system (AIMS) for documentation in a day care unit for ambulatory surgery]. / Einsatz eines Anästhesie-Informations-Management-Systems (AIMS) in einer Operativen Tagesklinik.

UNLABELLED: From 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.

[From data entry to data presentation at a clinical workstation--experiences with Anesthesia Information Management Systems (AIMS)]. / Von der Datenerfassung zur Ergebnispräsentation am klinischen Arbeitsplatz--Erfahrungen mit einem Anästhesie-Informations-Management-System (AIMS).

Anesthesia Information Management Systems (AIMS) are required to supply large amounts of data for various purposes such as performance recording, quality assurance, training, operating room management and research. It was our objective to establish an AIMS that enables every member of the department to independently access queries at his/her work station and at the same time allows the presentation of data in a suitable manner in order to increase the transfer of different information to the clinical workstation. Apple Macintosh Clients (Apple Computer, Inc. Cupertino, California) and the file- and database servers were installed into the already partially existing hospital network. The most important components installed on each computer are the anesthesia documenting software NarkoData (ProLogic GmbH, Erkrath), HIS client software and a HTML browser. More than 250 queries for easy evaluation were formulated with the software Voyant (Brossco Systems, Espoo, Finland). Together with the documentation they are the evaluation module of the AIMS. Today, more than 20,000 anesthesia procedures are recorded each year at 112 decentralised workstations with the AIMS. In 1998, 90.8% of the 20,383 performed anesthetic procedures were recorded online and 9.2% entered postopeatively into the system. With a corresponding user access it is possible to receive all available patient data at each single anesthesiological workstation via HIS (diagnoses, laboratory results) anytime. The available information includes previous anesthesia records, statistics and all data available from the hospitals intranet. This additional information is of great advantage in comparison to previous working conditions. The implementation of an AIMS allowed to greatly enhance the quota but also the quality of documentation and an increased flow of information at the anesthesia workstation. The circuit between data entry and the presentation and evaluation of data, statistics and results directly available at the clinical workstation was put into practice.

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.

Data processing at the anesthesia workstation: from data entry to data presentation.

Main requirements for an Anesthesia Information Management System (AIMS) are the supply of additional information for the anesthesiologist at his workstation and complete documentation of the anesthetic procedure. With the implementation of an AIMS (NarkoData) and effective user support, the quality of documentation and the information flow at the anesthesia workstation could be increased. Today, more than 20,000 anesthesia procedures are annually recorded with the AIMS at 112 decentralized workstations. The network for data entry and the presentation and evaluation of data, statistics and results directly available at the clinical workstation was made operational.

Comparison of manual and automated documentation of adverse events with an Anesthesia Information Management System (AIMS).

In this study, an Anesthesia Information Management System (AIMS) is used for the comparison of manually recorded adverse events with automatically detected events from anesthesiological procedures. In 1998, data from all anesthesia procedures, including the data set for quality assurance defined by the German Society of Anesthesiology and Intensive Care Medicine (DGAI), were recorded online with the documentation software NarkoData 4 (IMESO GmbH, Hüttenberg, Germany) followed by storage into a relational database (Oracle Corporation). The occurrence of manually recorded adverse events, as defined by the DGAI, is compared with automatically detected events. Automated detection was done with SQL-statements. The following adverse events were selected: hypotension, hypertension, bradycardia, tachycardia and hypovolemia. Data obtained from 16,019 electronic anesthesia records show that in 911 patients (5.7%), one of the selected adverse events was documented manually whereas in 2,996 patients (18.7%) a adverse event was detected automatically. The incidence of automatically detected events is obviously higher compared to manually recorded events. With the help of an AIMS, automatic detection proved significant deficiencies in the manual documentation of adverse events.

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 anesthesia information management system (AIMS) in investigating the effects of hypnotic agents used to induce anesthesia on blood pressure, heart rate and arterial oxygen saturation. The characteristics of these agents, known from previous studies, were compared to the effects documented in this study during routine clinical use. METHODS: During the years 1997 and 1998, all relevant data from anesthetic procedures were recorded online using the automated anesthesia information system NarkoData. The data from 8,078 general anesthesia procedures using endotracheal intubation were exported via "structured query language" (SQL) from the AIMS database into a statistics program after excluding children (age < 14), patients who received atropine during induction and procedures with use of extracorporeal circulation. The effects of drug administration on systolic, diastolic and mean arterial blood pressure (SBP, DBP, MBP), heart rate (HR) and arterial oxygen saturation (SpO2) were analyzed prior to induction and at 5, 10 and 15 minutes following bolus administration of the hypnotic agent. The data were classified into three groups based on the induction agent used: thiopental, etomidate or propofol and further separated into two groups based on ASA status (ASA < or = II and ASA > II). The mean and standard deviations were calculated for each parameter at each point in time. Statistical comparisons were performed to determine whether the results for each time point differed from the previous time point. RESULTS: There was a significant decrease in blood pressure (MAP, SBP, DBP) after bolus administration 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 ASA class < or = II. Propofol caused the greatest drop in blood pressure whereas etomidate caused the least. During the observation period the HR also fell in each group, except for thiopental where an initial rise of the HR could be observed. An initial rise of SpO2 was recorded in each group with no differences observed between the individual hypnotics. CONCLUSIONS: The effects of the induction hypnotic agents thiopental, etomidate and propofol on blood pressure and heart rate as documented by an AIMS corresponded to those found in clinical studies. An AIMS with the corresponding documentation, software and database structure is suitable for collecting and evaluating data for dinical investigations.

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 of adverse events in quality assurance programs in anesthesiology. In order to verify and quantify this, we retrospectively compared the incidence of manually recorded perioperative adverse events with automatically detected events. METHODS: In 1998, data of all anesthetic procedures, including the data set for quality assurance of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), was recorded online with the Anesthesia Information Management System (AIMS) NarkoData4 (Imeso GmbH). SQL (Structured Query Language) queries based on medical data were defined for the automatic detection of common adverse events. The definition of the SQL statements had to be in accordance with the definition of the DGAI for perioperative adverse events: A potentially harmful change of parameters led to therapeutic interventions by an anesthesiologist. RESULTS: During 16,019 surgical procedures, anesthesiologists recorded 911 (5.7%) adverse events manually, whereas 2966 (18.7%) events from the same database were detected automatically. With the exception of hypoxemia, the incidence of automatically detected events was considerably higher than that of manually recorded events. Fourteen and a half percent (435) of all automatically detected events were recorded manually. CONCLUSION: Using automatic detection, we were able to prove a considerable deficit in the documentation of adverse events according to the guidelines of the German quality assurance program in anesthesiology. Based on the data from manual recording, the results of the quality assurance of our department match those of other comparable German departments. Thus, we are of the opinion that manual incident reporting seriously underestimates the true occurrence rate of incidents. This brings into question the validity of quality assurance comparisons based on manually recorded data.