Anesthesia recordkeeping: accuracy of recall with computerized and manual entry recordkeeping

Abstract

Anesthesia information management systems (AIMS) are rapidly gaining widespread acceptance. Aggressively promoted as an improvement to manual-entry recordkeeping systems (MERS) in the areas of accuracy, quality improvement, billing and vigilance, these systems record all patient vital signs and parameters, providing a legible hard copy and permanent electronic record. Concern exists that the practitioner may be less vigilant unless this data is recorded manually. This study's purpose was to determine if vigilance, as measured by the ability to recall important data, is influenced by the method of recordkeeping. This study analyzed differences in the accuracy of Certified Registered Nurse Anesthetists' (CRNAs) recall of specific patient variables during the course of an actual anesthetic case. CRNAs using AIMS were compared to CRNAs using MERS. Accuracy of recalled values of 10 patient variables was measured: highest and lowest values for heart rate, systolic blood pressure, inspiratory pressure, and end-tidal carbon dioxide levels, lowest oxygen saturation and total fluid volume. Four tertiary care facilities participated in this research; two of which used MERS, two utilized AIMS. A total of 214 subjects participated in this study; 106 in the computerized recordkeeping group, and 108 in the manual entry recordkeeping group. Demographic covariates were analyzed to ensure homogeneity between groups and facilities. No significant statistical differences were identified between the accuracy of recall among the groups. There was no difference in the accuracy of practitioners' recall of patient variables when using computerized or manual entry recordkeeping systems, suggesting little impact on vigilance.