Wax David B, Beilin Yaakov, Hossain Sabera, Lin Hung-Mo, Reich David L
Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
Anesthesiology. 2008 Nov;109(5):811-5. doi: 10.1097/ALN.0b013e3181895f70.
Anesthesia information management systems allow automatic recording of physiologic and anesthetic data. The authors investigated the prevalence of such data modification in an academic medical center.
The authors queried their anesthesia information management system database of anesthetics performed in 2006 and tabulated the counts of data points for automatically recorded physiologic and anesthetic parameters as well as the subset of those data that were manually invalidated by clinicians (both with and without alternate values manually appended). Patient, practitioner, data source, and timing characteristics of recorded values were also extracted to determine their associations with editing of various parameters in the anesthesia information management system record.
A total of 29,491 cases were analyzed, 19% of which had one or more data points manually invalidated. Among 58 attending anesthesiologists, each invalidated data in a median of 7% of their cases when working as a sole practitioner. A minority of invalidated values were manually appended with alternate values. Pulse rate, blood pressure, and pulse oximetry were the most commonly invalidated parameters. Data invalidation usually resulted in a decrease in parameter variance. Factors independently associated with invalidation included extreme physiologic values, American Society of Anesthesiologists physical status classification, emergency status, timing (phase of the procedure/anesthetic), presence of an intraarterial catheter, resident or certified registered nurse anesthetist involvement, and procedure duration.
Editing of physiologic data automatically recorded in an anesthesia information management system is a common practice and results in decreased variability of intraoperative data. Further investigation may clarify the reasons for and consequences of this behavior.
麻醉信息管理系统可自动记录生理和麻醉数据。作者调查了某学术医学中心此类数据修改的发生率。
作者查询了其2006年实施麻醉的麻醉信息管理系统数据库，并将自动记录的生理和麻醉参数的数据点计数以及被临床医生手动作废的数据子集（包括有和没有手动附加替代值的情况）制成表格。还提取了记录值的患者、从业者、数据源和时间特征，以确定它们与麻醉信息管理系统记录中各种参数编辑的关联。
共分析了29491例病例，其中19%有一个或多个数据点被手动作废。在58名主治麻醉医生中，每位医生作为唯一从业者时，其病例中有7%的数据被作废。少数作废值被手动附加了替代值。心率、血压和脉搏血氧饱和度是最常被作废的参数。数据作废通常导致参数变异性降低。与作废独立相关的因素包括极端生理值、美国麻醉医师协会身体状况分类、紧急状态、时间（手术/麻醉阶段）、动脉内导管的存在、住院医生或注册护士麻醉师的参与以及手术持续时间。
在麻醉信息管理系统中自动记录的生理数据编辑是一种常见做法，会导致术中数据变异性降低。进一步调查可能会阐明这种行为的原因和后果。
