Quality documentation with an Anaesthesia Information Management System (AIMS)

Objective: In 1994 the Department of Anaesthesiology and Intensive Care Med icine of the Justus Liebig University of Giessen decided to implement an An aesthesia Information Management System (AIMS) to replace the previous hand -written documentation on paper. From 1997 until the end of 1998 the data s ets of 41,393 anaesthesia procedures were recorded with the help of compute rs and imparted into a data bank. Individual aspects and results of this da ta pool are presented under the aspect of how the system in its present for m is able to guarantee documentation of quality according to the requiremen ts of the German Society of Anaesthesiology and Intensive Care Medicine (DG AI). Methods: Since 1997 information on all anaesthesia procedures has been docu mented "online" with the anaesthesia documentation software NarkoData 4 (Pr oLogic 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 "hypotens ion" and "nausea/vomiting", recorded by staff members into the AIMS, with t he incidence of comparable events that were recorded with the help of onlin e data during anaesthesia procedures, such as blood pressure and drug appli cation. 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 manu ally into the system was 3.6% (grade ill and higher 0.9%) and increased dur ing 1998 to 22.2% (grade III and higher 1.9%). The frequency of anaesthesia procedures with manually documented AVBs was significantly below the incid ence (determined with the help of online data) of comparable events:"hypote nsion" (1.8% vs. 8.5%) and "nausea/vomiting" (4.9% vs. 8.3%). Conclusion: The current documentation of AVBs in almost any hospital is inc omplete. In contrast to the hand-written procedure, the AIMS provides recor ded data for evaluation and guarantees more detailed and complete quality d ocumentation. In addition,the effort needed for documentation is reduced. W hether these data sets really describe and measure quality or not has to be evaluated. In addition it has to be considered whether different requireme nts (such as automatic AVB recognition for an AIMS) are advantageous for qu ality documentation regarding the data raster and the AVB recognition, with respect to different documentation procedures.