The effect of Anesthesia Information Management Systems (AIMS) on perioperative epidural documentation: A retrospective cohort study
Dulmi Nawarathna, John Shaker, Thomas P. WallObjectives
Perioperative epidural documentation is an essential record of a procedure which has significant clinical and medico-legal implications. Little is known about the impact of the introduction of electronic Anesthesia Information Management Systems (AIMS) on the quality of epidural documentation compared to handwritten records. This study identifies elements of epidural documentation and, using a novel scoring system (Documentation Completion Score, DCS) quantifies the difference in documentation completeness between handwritten and AIMS records.
Methods
In a single-centre retrospective cohort study, 100 handwritten anesthesia records involving epidural placement were randomly selected from historic paper charts and a further 100 electronic records were randomly chosen from the AIMS database. All records retrieved were assessed for 15 pre-identified documentation components. DCS was calculated for each record and the groups were compared using inferential statistical tests.
Results
Of 15 documentation components, 11 were more consistently entered in AIMS compared to handwritten records. DCS was significantly higher in the AIMS group (13.48 ± 1.01, mean ± standard deviation) versus the handwritten group (9.91 ± 2.93),
Conclusion
In our institution, completion of epidural documentation components is more consistent in AIMS compared to handwritten records, although local factors (e.g. user training) may limit the generalisability of this finding. Not including all desired elements on a single page can lead to user failure to document them in other areas of the AIMS chart. Such user behaviour should be considered when configuring AIMS interfaces.