将计算机化麻醉记录整合到医院信息系统中。

Wang X, Gardner R M, Seager P R

LDS Hospital, Salt Lake City, Utah, USA.

Int J Clin Monit Comput. 1995 May;12(2):61-70. doi: 10.1007/BF01142485.

BACKGROUND

Systems for computerization of anesthesia records have typically been 'stand-alone' computers many times connected to monitoring devices in the operating theater. A system was developed and tested at LDS Hospital in Salt Lake City, Utah, USA that was an integral part of the Health Evaluation through Logical Processing (HELP) hospital information system.

METHODS

The system was evaluated using time and motion studies to assess impact of the system on the anesthesiologists use of time, an assessment for completeness of the anesthesia record was conducted, and a questionnaire was used to assess anesthesiologists attitudes. Timing studies were performed on 44 surgical cases before computerization and 41 surgical cases after computerization. For both before and after computerization, about 80% of procedures were D&C, vaginal hysterectomy, laparoscopy, tubal ligation, or A&P repair.

RESULTS

The study showed a major reduction in time required for charting from 20.4% to 13.4% which was statistically significant (p = 0.0001). Other significant factors were a reduction in the time spent scanning the entire area which dropped from 10.5% to 5.6% (p = 0.001), patient preparation time increased from 10.1% to 13.1% (p = 0.02), the time spent arranging equipment increased from 6.4% to 8.1%, and the average time spent on non-anesthesia activities increased from 6.3% to 11.3%. The computerized anesthesia record was more legible, and complete than the manual record. The overall assessment of computer charting by anesthesiologists questionnaire was positive. The computerized anesthesia charting was preferred by the anesthesiologists, who, after one or two training sessions, used the system on their own.

CONCLUSIONS

It appears that having a computerized anesthesia charting system that is an integral part of a hospital information system not only saves anesthesiologists charting time, but also improves the quality of the record and was well accepted by busy private practice anesthesiologists.

背景

麻醉记录计算机化系统通常是“独立”计算机，多次连接到手术室中的监测设备。美国犹他州盐湖城的LDS医院开发并测试了一个系统，该系统是通过逻辑处理进行健康评估（HELP）医院信息系统的一个组成部分。

方法

使用时间和动作研究对该系统进行评估，以评估该系统对麻醉医生时间利用的影响，对麻醉记录的完整性进行评估，并使用问卷调查来评估麻醉医生的态度。在计算机化之前对44例手术病例进行了计时研究，在计算机化之后对41例手术病例进行了计时研究。在计算机化前后，约80%的手术为刮宫术、阴道子宫切除术、腹腔镜检查、输卵管结扎术或肛门直肠修补术。

结果

研究表明，记录所需时间大幅减少，从20.4%降至13.4%，具有统计学意义（p = 0.0001）。其他显著因素包括扫描整个区域的时间减少，从10.5%降至5.6%（p = 0.001），患者准备时间从10.1%增加到13.1%（p = 0.02），安排设备的时间从6.4%增加到8.1%，非麻醉活动的平均时间从6.3%增加到11.3%。计算机化的麻醉记录比手工记录更清晰、完整。通过麻醉医生问卷调查对计算机记录的总体评价是积极的。麻醉医生更喜欢计算机化的麻醉记录，经过一两次培训后，他们就自行使用该系统。