Data and its Influence on Perioperative Care
Healthcare systems have long collected data on patients undergoing surgery. However, pre-digitization, there was no method for compiling or storing a set of universal data. The internet, electronic medical records (EMRs) and quantitative clinical research have each played an important role in improving the delivery of healthcare. In the modern age of surgery and anesthesia care, data is a powerful tool to increase the efficacy of procedures and improve outcomes for all patients.
Collecting Data and Determining Which Data Should Be Collected
The data captured by your organization should be in line with your facility’s specific priorities. Since most EMR systems today can be tailored to align with your unique data capture goals, this customization option should be fully leveraged. At a minimum, the following data should be collected:
- Patient identifiers
- Patient demographics
- Diagnoses
- Medications
- Procedure records
- Lab data
- Vital signs
- Surveys
The Preanesthesia evaluation captures the following data points:
- Patient and procedure identification
- Anticipated disposition
- Medical history (includes patient’s ability to give informed consent)
- Surgical history (PSHx)
- Anesthetic history
- Current medication list (pre admission and post admission)
- Allergies/adverse drug reactions
- NPO status
- Documenting the presence of and the proper perioperative plan for existing advance directives
- Vital signs
- Height and weight
- Documentation of airway assessment and cardiopulmonary exam
- Review of objective diagnostic data and medical records
- Medical consultations when applicable
- Assignment of ASA physical status, including emergent status when applicable
- The anesthetic plan – including plans for post-anesthesia care and pain management
- Documentation of informed consent (to include risks, benefits and alternatives) of the anesthetic plan and postoperative pain management plan
- Appropriate premedication and prophylactic antibiotic administrations (if indicated).
Next, intraoperative/procedural anesthesia data is collected that includes physiologic monitoring data, medications administered, intravenous fluids given, techniques used, patient positioning, additional procedure performed, unusual or noteworthy events and patient status at transfer of care to staff in a Postanesthesia Care Unit.
Although a large quantity of data capture is required for anesthesia care, accurate and detailed documentation is an essential element of high quality and safe anesthesia care. In addition to supporting patient safety, these informatics help drive efficiencies that can ultimately enhance your bottom line.
How to Analyze Anesthesia Data
Once a substantive amount of data has been collected systematically, the next step is to apply this data to address existing and future patient practices. Analyzing the data and applying changes can help not only OR and administrative performance, but patient outcomes as well. An eye-opening way to analyze anesthesia data is to compare it to current national patient safety goals, facility accreditation standards and compliance initiatives. Examining this information at least quarterly is best so that any oversights can be corrected in a timely fashion.
Putting Data to Work for Your Facility
At CCI Anesthesia, data is among our most valuable assets. We challenge our team of billing and compliance experts to regularly examine documentation samples at each of our client facilities to ensure thoroughness and accuracy in charting. Our practice management teams monitor operational efficiency in real-time through our tablet-based EMR system while our clinical informatics team maintains a constant watch on quality metrics. The end result for our clients is reduced costs, increased efficiency, improved quality and better clinical outcomes across your health system, hospital or surgery center.
Is your facility struggling to use data to its fullest potential? If you have questions about how data can positively influence your care continuum, contact us today at 800.494.3948. We can apply our approach to using anesthesia information management in ways that will reverse inefficiencies and reduce costs for your hospital or surgery center.