(OPPE) Using Automatically Captured Electronic Anesthesia Data

The Joint Commission Journal on Quality and Patient Safety
were consistent with national practice and centered on patient
care. Thus, the committee looked closely at the American Society
of Anesthesiologists (ASA) standards for monitoring and patient
care as put forth by the ASA Standards and Practice
Parameters Committee. 10
To minimize any administrative burden and reduce the effect
of observation and bias in our measurements, the committee ultimately
decided to focus on extraction of readily available electronic
AIMS data, thereby enabling the creation of an automatic,
reliable, cost-effective process applied on a continuous, ongoing
basis. We could easily modify the process over time to replace
metrics or add additional metrics as needed.
SELECTING THE INITIAL METRICS
By October 2008 the committee selected the initial metrics:
blood pressure (BP) monitoring, end tidal CO 2monitoring, and
timely documentation of compliance statements.
Blood Pressure Monitoring: Requires that a physician document
BP prior to induction of general anesthesia. Documentation
of BP in the AIMS occurs automatically if the BP is
measured. The induction of anesthesia was inferred from manually
entered comments or was inferred from the automatic detection
of inhalation anesthetics in the exhaled gases.
End Tidal CO 2 Monitoring: Requires that a physician monitor
the end tidal CO 2 level at least once during the provision of
general anesthesia. Documentation of end tidal CO 2 monitoring
is automatic if the monitor is functional and connected.
Timely Documentation of Compliance Statements. Requires
that a physician document all the necessary case compliance/
attestation statements that make a record billable no more than
120 minutes after the end of anesthesia care. This documentation
is part of the normal clinical documentation work flow.
BASELINE DATA COLLECTION
After designing the three metrics, in an eight-month period
(January 1, 2008–August 31, 2008), we performed a baseline
set of measurements to validate the metrics. Our goal was to be
able to set a performance threshold for passing each metric that
would distinguish acceptable from unacceptable performance
while taking into consideration any limitations or artifacts contained
within the electronic AIMS database. The committee ultimately
decided to set the threshold for passing each metric at
a level that encompassed 95% of all physicians in the baseline
dataset—that is, 95% of physicians met the metric.
Of the 149 anesthesiologists in the department, 128 (86%)
were subject to the metrics. The remaining 18 anesthesiologists
(9 pain physicians, 4 critical care physicians, and 5 physicians
February 2012 Volume 38 Number 2
Copyright 2012 © The Joint Commission
who work exclusively in our preoperative evaluation clinic) were
not subject to the metrics.
Electronic Database Queries. Using SQL Query Analyzer
(Microsoft, Redmond, Washington), we developed a set of electronic
database queries to extract electronic data from our AIMS.
For each case during the baseline data collection period, the
query returned the unique case identifier, date of service, physician
identification, operating room (OR), type of anesthesia
(general, monitored anesthesia care, or regional), and the specific
variables relevant to each of the three metrics—as now described.
■ BP Monitoring. To perform the BP monitoring query, the
following metric specific variables were obtained:
–Start of Anesthesia Care Time (manually documented)
–Anesthesia Induction Time (manually documented)
–First Inhalational Agent Name (automatically recorded from
gas analyzer)
–First Inhalational Agent Value (automatically recorded from
gas analyzer)
–First BP Measurement Time (automatically recorded from
physiologic monitor)
–First Systolic BP Value (automatically recorded from physiologic
monitor)
–First Diastolic BP Value (automatically recorded from physiologic
monitor)
The query compared the time stamp of the first BP recorded
in the chart to the time stamp associated with the anesthesia induction
time (the earlier of either the manually documented
anesthesia induction time or the time of first inhalational
agent).* The logic also excluded nonphysiologic BP values (from
zeroed but disconnected arterial lines) from consideration. We
chose BP measurement prior to induction as a quality measure
because it is frequently not adhered to. Beyond our own collective
clinical experience, the authors’ research into the documentation
of BP during anesthesia has shown significant evidence
that BP monitoring does not always meet our expectations and
that progress is needed to enhance patient care. 11 We therefore
believe that standard practices can, in many cases, make for ideal
metrics of patient care—that is, how often do we adhere to the
standard. Although we hope that standard practice is reflected in
routine care, we know that it sometimes does not. For example,
administering on-time antibiotics prior to surgical incision is a
standard operating procedure that is not always adhered to. 12,13
Thus, insofar as this task—or BP monitoring, for that
* For the purposes of our query we used the following thresholds: Isoflurane > 0.1
minimum alveolar concentration (MAC); sevoflurane > 0.2 MAC; desflurane > 0.5
MAC.
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