Documentation and Treatment of Intraoperative Hypotension: Electronic Anesthesia Records versus Paper Anesthesia Records

• Published in: Journal of medical systems 2017-05, Vol.41 (5), p.86-86, Article 86
• Main Authors: Shear, Torin D., Deshur, Mark, Lapin, Brittany, Greenberg, Steven B., Murphy, Glenn S., Szokol, Joseph, Ujiki, Michael, Newmark, Rebecca, Benson, Jessica, Koress, Cody, Dwyer, Connor, Vender, Jeffery
• Format: Article
• Language: English
• Subjects: Anesthesia; Blood Pressure; Documentation; Electronic health records; Health Informatics; Health Sciences; Humans; Hypotension; Intraoperative Care; Medicine; Medicine & Public Health; Monitoring, Intraoperative; Statistics for Life Sciences; Surgery; Systems-Level Quality Improvement
• ISSN: 0148-5598; 1573-689X
• DOI: 10.1007/s10916-017-0737-0

In this study, we examined anesthetic records before and after the implementation of an electronic anesthetic record documentation (AIMS) in a single surgical population. The purpose of this study was to identify any inconsistencies in anesthetic care based on handwritten documentation (paper) or AIMS. We hypothesized that the type of anesthetic record (paper or AIMS) would lead to differences in the documentation and management of hypotension. Consecutive patients who underwent esophageal surgery between 2009 and 2014 by a single surgeon were eligible for the study. Patients were grouped in to ‘paper’ or ‘AIMS’ based on the type of anesthetic record identified in the chart. Pertinent patient identifiers were removed and data collated after collection. Predetermined preoperative and intraoperative data variables were reviewed. Consecutive esophageal surgery patients ( N  = 189) between 2009 and 2014 were evaluated. 92 patients had an anesthetic record documented on paper and 97 using AIMS. The median number of unique blood pressure recordings was lower in the AIMS group (median (Q1,Q3) AIMS 30.0 (24.0, 39.0) vs. Paper 35.0 (28.5, 43.5), p