Quality Anesthesia Documentation – Barriers and a Possible Solution

Anesthesia DocumentationDocumenting vitals and patient history during pre-op anesthesia is time consuming while recording vitals in the post-anesthesia care unit (PACU) will take away a significant portion of time dedicated for patient care. Electronic anesthesia documentation is considered a fast and efficient method that ensures clear communication among providers and diligent patient care. However, underreporting of intraoperative events in anesthesia is common and affects the quality of documentation. A new study that used a questionnaire-based survey of anesthesia staff explored such mistakes and found significant barriers to computerized quality documentation during anesthesia.

Around 81% of the total staff in a hospital including 25 physicians and 30 nurse anesthetists completed the survey. As per the study, the difficulties identified were related to three major areas such as:

  • Working Conditions and Practices of Data Collection – Majority of respondents considered the electronic data entry system sufficiently user friendly and said they had enough time to enter the data. They indicated that they do this usually before the end of the anesthetic. Also, data is entered without checking the anesthesia record and while carrying out other important duties such as anaesthesia work and administrative tasks.
  • Institutional Management of the Data – Around 75% of the respondents indicated that they did not know for what the collected data was used while only 18% knew what happened to the data. Other respondents said they were not even aware of the efforts taken by the department’s management to handle problems identified with the collected data. Around 95% are not getting feedbacks of the collected data. While 75% said only physicians should be responsible for data entry, 5% said this task should be carried out exclusively by nurses and 20% supported the current institutional standard of data entry by both groups. Suggestions for data collection improvement included the possibility of later data entry (22%), improvement of the content (30%) and layout of the quality data window (11%).
  • Specific Attitudes – This indicates the negative attitudes of staff members towards the relevance of different data for patient safety and anesthesia quality. Physicians were more negative than nurses. Physician and nurse anesthetists share their work environment and practical tasks to a large extent compared to the physicians and nurses in other clinical settings. So the difference in their attitudes can be a significant barrier to quality reporting.

In this survey, 53% of respondents reported not to check the anesthesia record before data entry, 85% reported to complete entry before the end of the anesthetic and 87% reported to have other important duties during data entry. These findings are at variance with the answer of 89% to have usually or always sufficient time to enter the data. If the anesthesia record is not checked before entering data, events that need to be entered are likely to be overlooked. A complete evaluation of intraoperative anesthesia quality should include the entire period of emergence because quality defining events may occur during that period as well and if the data entry is completed before the end of the anesthetic, these may not be reported. Other duties that anesthesia providers have to engage in may interfere with data entry. Considering these issues, the statement that they have enough time for data entry does not appear very credible. It may be assumed that the survey participants may have had time for “incomplete” quality data collection rather than “appropriate” data collection. The answers hint at “workarounds” to cope up with the time constraints, or the existence of knowledge gaps.

This research highlights the barriers that exist when it comes to appropriate reporting of anesthesia. Further research is required to find the actual causes for deficient quality reporting and how the data quality can be improved.

Electronic anesthesia documentation can be really effective only if the data collected is of excellent quality. EMR transcription with quality assurance may be able to ensure superior quality of the data collected. This involves obtaining transcription services from a reliable provider. In this method, both physicians’ and nurses’ dictations are transcribed with the help of experienced transcriptionists and the transcribed data is checked thoroughly for mistakes, omissions and incompleteness by proofreaders and editors. The accurate data thus obtained is populated into corresponding EMR fields. In this way, you can achieve maximum accuracy, completeness and quality for anesthesia documentation. Healthcare providers can save time and focus more on providing appropriate care without being weighed down by documentation tasks.