Using an anesthesia information management system (AIMS) for documentationin a day care unit for ambulatory surgery

From January 1997 until June 1999, the complete durations of stay of 3152 o utpatients were entered into a computerized documentation system. The scope of the data entry went from patient admission to patient release. The obje ctive was to determine the usefulness of the anaesthesia information manage ment system (AIMS) in producing complete and high-quality documentation in the field of outpatient operations. Some aspects and results from routine w ork 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 medi cal courses were documented both preoperatively and postoperatively in outp atient bedsides until their discharge or admission. The online documentatio n software NarkoData (Version 4, Imeso GmbH, Huttenberg, Germany) was used to document and store patient data in a database. This program contains ail relevant information concerning the course of anaesthesis and outpatient d uration of stay, including application of drugs, vita I 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 w as 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 documen tation software. Most (54.2%) of the ambulatory surgical procedures were pe rformed by the Department of Traumatology. General Surgery followed with 16 .0%, and Urology managed 9.5% of the cases. The most frequent ambulatory su rgical procedures were: diagnostic arthroscopy (923, 31.2%), removal of ost eosynthetic material (410, 13.8%), and circumcision (250, 8.4%). Anesthesia procedures consisted of inhalative (38.6%, n=1218) and intravenous anesthe sia (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 admitte d to overnight care. The decision to admit patients to normal wards took pl ace within the first 3 postoperative hours in 51.9% of the cases. Conclusion. The AIMS described above is sufficient in documenting the entir e care process of patients in a day care unit. Integration into the existin g 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 a t the workplaces in the day care unit were increased, similarly to other an aesthesiological workplaces in the hospital. Medical and administrative dat a and information for analyses of clinical processes are possible with such tools.