HANDWRITTEN VS. ELECTRONIC.

Handwritten anesthetic records are unlikely or unable to represent physiologic data with consistent accuracy and at high resolution. Many electronic anesthesia recording systems capture data and save averaged values over five minute periods.

Retrospective analysis of intraoperative events may thus be challenging with handwritten records or averaged electronic data, and may lead to inaccurate conclusions or failed learning opportunities from quality assurance or medicolegal investigations.

Recordation Workstation captures and saves up to one hundred numeric parameters at a typical frequency of once per second; this can prove critical in analyzing intraoperative events.

In the following example, Recordation Workstation show the same event in different ways with vital signs captured around an injection of local anesthetic with epinephrine.

↑ Local Anesthetic Injection
← Blood Pressure
↑ Local Anesthetic Injection
← Blood Pressure
↑ Local Anesthetic Injection
← Blood Pressure
↑ Local Anesthetic Injection
← Blood Pressure
↑ Local Anesthetic Injection
← Blood Pressure
Conduction Block ↓
Vital signs are displayed at 30 minute intervals, with blood pressure values averaged over five minute epochs.
Vital signs are displayed at 15 minute intervals, with blood pressure values averaged over five minute epochs. Note the highlighted Blood Pressure.
As the time interval is displayed as ten minutes with blood pressures averaged over two minutes, the heart rate and blood pressure changes become more obvious.
The horizontal time scale is displayed at five minute intervals, with verbatim blood pressures and heart rates as they are received in real time.
Second-per-second readings for heart rate (Yellow tracing: SpO2 derived; Red tracing: EKG derived), are shown.
The injection of local anesthetic with epinephrine [Arrow 1] with likely rapid absorption. The initial heart rate and pulse increase [Arrow 2], followed by an EKG heart rate increase with 1:2 conduction of SpO2 heart rate [Arrow 3], with increased blood pressure and the addition of isoflurane for arterial vasodilation [Arrow 4].

Recordation Workstation, by capturing and saving physiologic data at the highest resolution, typically captures up to one hundred numeric parameters per second, can be used to understand more reliably intraoperative events.

Nonetheless, graphing symbols for blood pressure, heart rate, oxygen saturation, temperature, ventilator settings and other parameters with pen on paper has disadvantages.

W

Disadvantages of the Handrwitten Record

  • Time consuming, tedious
  • Inaccurate
  • Unable to be verified or validated with respect to accuracy, time of entry
  • Relies on viewing and interpretation of patient monitor
  • May be illegible
  • Subject to medicolegal challenge
    Distracting
  • Lacks electronically extractable meaningful data

HAVE WE EVOLVED?

Despite the presence of low cost computer technology, the adoption of automated anesthetic recording systems has been slow.

Patient monitors have undergone significant evolution, although for many years even some older models have been able to output data electronically at high rates. Anesthesia information recording systems have been faced with interfacing with many different models, often in the same operating room suites, via communication protocols that may no longer be supported or are difficult maintain in modern computer operating systems and environments.

WHICH WOULD BE EASIER TO DEFEND?

Good medical care that is documented appropriately is the easiest to defend.

Arguments have been made that capturing vital signs electronically subjects the user to increased medicolegal liability. However just as a pilot’s flight recorder can be used retrospectively to understand the flight crew’s environment and how it might have been experienced, so too can a high resolution electronic anesthesia record such as those from Recordation Workstation be used for meaningful analyses and data aggregation.

In every case, and especially in an adverse outcome, or if liability claims are made to the anesthesia team with or without justification, the anesthesia record becomes the “flight recorder.” While Recordation Workstation presents most data averaged over 5 minute intervals, because the original raw data is saved with each anesthetic record, it may be reformatted at a later time to display at one minute or one second intervals for closer scrutiny.

Given that written records may pose legibility and validation challenges, the advantages of appropriate medical care that is documented accurately via automated high resolution physiologic data are clear.