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Electronic Documentation

Perioperative information systems streamline flow and increase quality.

Successful perioperative information systems can help hospitals increase efficiency, measure quality outcomes data, establish evidence-based practice and ensure patient safety.

At Anna Jaques Hospital, a 123-bed community facility in Newburyport, MA, computerized documentation helps the operating room track quality and safety initiatives, noted chief nursing officer Richard Maki, MHSA, BA, RN.

For example, the hospital found it needed to improve documentation for monitoring patient temperature. To measure compliance under a paper-based system, staff had to hand-pull records and painstakingly review data. Instead, fields were added to the program where OR nurses could fill in the required information, such as prewarming patients and monitoring core temperatures during surgery. Should a patient's temperature drop, the anesthesiologist notes that in the record, and the patient immediately receives a warming blanket or other intervention.

"It's so much easier to look at the data in real time," said Jeanine Cunningham, RN, director of surgical services. "We now have no issues with core temperatures."

Similarly, electronic documentation also helps the hospital track when preop antibiotics were administered.

"The nurse asks the question then documents the information," Cunningham said. "Data is easily passed to the quality person and helps us establish evidence-based practice and adherence to core measures."

The hospital also is conducting a trial to electronically log and track implants in the OR record. For example, if a vendor issues a recall on a pacemaker, staff can use the electronic system to instantaneously find out which patients received the device. Without the information system, a staff member needs to spend "a few hours" reviewing paperwork to identify patients affected by the recall, Cunningham said.

Efficiency & Safety

At the University of Connecticut (UConn) Health Center in Farmington, online documentation has helped both anesthesiology and nursing ensure efficient data flow and protect patients from harm. The 204-bed hospital performs about 10,000 inpatient and outpatient procedures each year.

Nurses use five clinical modules with most patients, including a preadmission record before the patient arrives; separate clinical records on the day of the procedure in preop, OR and PACU; and a post discharge follow-up record for patient groups who receive a call after discharge.

Anesthesia is online at the main facility and documents both surgical and nonsurgical cases electronically; soon, the hospital hopes to introduce an electronic anesthesiology record at its ambulatory surgical facility.

"We can set up defaults with certain parameters from past care events within a specific time frame and within clinical modules as the patient moves through the perioperative phases," noted Carol Schramm, MSN, RN, CNOR, perioperative clinical nurse specialist. An example might include pain management for patients who are on multiple medications or require a series of treatments within a short period of time.

"The nurse would review the med list but would be spared the tedious job of re-entering a dozen or more medications into the patient's record," she said.

Online systems also allow for quick modifications. For example, staff can easily add updated regulatory or performance improvement information to documentation programs.

Recently, the hospital modified the application to capture complete information about timing of a preoperative prophylactic antibiotic administration - a measure of the Joint Commission's Surgical Care Improvement Project. To measure trends and outcomes, the UConn Health Center also can audit fields within records and across modules and practice areas.

In the PACU, patient monitors automatically feed vital sign data into the computer, eliminating that potential source of erroneous documentation and leaving more time for patient care, Schramm said. The system prompts desired documentation, as well. For instance, a prompt for pain rating occurs 5-10 minutes after documentation of pain control medications, Schramm added.

Electronic Documentation

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