Thrush D N
Department of Anesthesiology, University of South Florida College of Medicine, Tampa 33612-4799.
J Clin Anesth. 1992 Sep-Oct;4(5):386-9. doi: 10.1016/0952-8180(92)90161-s.
To determine whether data recorded by an information management system is significantly different from that recorded manually.
A comparison was made between 13 handwritten and 13 computer-generated anesthesia records by calculating the frequency with which recorded variables were outside predetermined acceptable ranges. Five physiologic variables [systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), end-tidal partial pressure of carbon dioxide (PETCO2), and oxygen saturation by pulse oximeter (SpO2)] were compared during the initial 1 1/2 hours of operation.
Surgical suite at a university-affiliated hospital.
Thirteen adult patients scheduled for operations that required general anesthesia for longer than 1 1/2 hours.
In addition to the traditional handwritten anesthesia records, an information management system (ARKIVE Patient Management System, DIATEK, San Diego, CA) was used to collect data from each case.
No significant differences were found between the methods in the frequency of elevated SBP, elevated DBP, and tachycardia. However, the manual records showed low SBP, DBP, and HR with a significantly lower frequency (2%, 11%, 1%, respectively) than the automated records (6%, 26%, 5%, respectively; p < 0.01). The automated PETCO2 readings were higher than the upper limit (40 mmHg) with a higher frequency (18%) than the manual records (3%; p < 0.01). On the automated records, SpO2 was noted to be 90% or less on two occasions, but significant desaturation was noted only once on the manual charts.
Observer bias, missed readings, and errors of memory, which affect manual anesthetic records, may cause significant inaccuracy and may be avoided by using automated records generated by information management systems.
确定信息管理系统记录的数据与手工记录的数据是否存在显著差异。
通过计算记录变量超出预定可接受范围的频率，对13份手写麻醉记录和13份计算机生成的麻醉记录进行比较。在手术开始的1.5小时内，对五个生理变量[收缩压（SBP）、舒张压（DBP）、心率（HR）、呼气末二氧化碳分压（PETCO2）和脉搏血氧饱和度（SpO2）]进行比较。
大学附属医院的手术室。
13例计划接受全身麻醉超过1.5小时手术的成年患者。
除了传统的手写麻醉记录外，还使用了一个信息管理系统（ARKIVE患者管理系统，DIATEK，加利福尼亚州圣地亚哥）从每个病例中收集数据。
两种方法在SBP升高、DBP升高和心动过速的频率上没有显著差异。然而，手工记录显示SBP、DBP和HR较低的频率（分别为2%、11%、1%）明显低于自动记录（分别为6%、26%、5%；p<0.01）。自动PETCO2读数高于上限（40mmHg）的频率（18%）高于手工记录（3%；p<0.01）。在自动记录中，有两次SpO2被记录为90%或更低，但在手工图表上仅一次记录到明显的血氧饱和度下降。
影响手工麻醉记录的观察者偏差、漏读和记忆错误可能导致显著的不准确，使用信息管理系统生成的自动记录可以避免这些问题。
