INFORMATICS IN ANESTHESIA - Development of an anesthesia informatization project to introduce the computer in the daily practice

V. LANZA ,MD
Chief of Anesthesia, Department of Anesthesia - Ospedale Buccheri La Ferla, Fatebenefratelli -Via Messina Marine 197, 90123 Palermo, Italy

The recording of anesthesiological data on a computer has been the subject of studies for quite a few years. Anesthesiological records, in fact, present certain peculiarities which do not adapt themselves too well to an informatic transition, such as that of the archivation of a large amount of data in the moment they are produced.

It is not, in fact, feasible to register on a computer the parameters and therapies practised by the anesthesist subsequently, without having the use of a manually written record compiled during anesthesia in the exact moment they are obtained. This choise would necessitate the filling-in manually of clinical records; a procedure which would go against the normal hospital structures.

On the other hand it would be easy to imagine the advantages of anesthesiological computerised records when there is the need to obtain a speedy and faithful documentation of such a delicate event as that of the anesthesiological procedure of the doctor and the responses of the patient during surgery.

Taking all this into consideration in the 1985 at Buccheri La Ferla Hospital (B.L.F.H.) anaesthesia department an informatization project started. The guidelines of this project were:

1) a compilation as near as possible true to the manually written records

2) a possibility to fill in data in real time during the anesthesiological visit and during anesthesia itself

3) the use of low cost personal computers

The software design and the codes was written by an anaesthesiologist (the author of this article) according to these main features:

Overlay tecnique

FIG.1 WORKSTATION SOFTWARE STRUCTURE. The software was a collection of modules. Only the needed modules are loaded in the RAM according to enviroment activity.(i.e. preoperative visit,anesthesia,etc.).This permits to use a small PC (subnotebook) to perfom the preoperative visit at patient's bed.

Codes (FIG.2)

FIGURE 2 Codes tables

The program uses codes extensively. Codes tables are customised by the user. This task permits an English (or other country) workstation to read an italian record sheet. In fact an italian anesthetist uses "76" to write "cuore". The computer records "76", an English customised table workstation can read heart.

This task allows the exportability of the anesthetic procedures saving disk space.

Secrecy of data

The access to the programm is only obtained if a special file is found in diskette sited in drive A.

Safety to record anesthesiological data

It is possible to set the interval to automatic disk storage. This feature is very important to prevent an electrical failure to lose data.

Structure of the Clinical Record Sheet

This record sheet is made up of two fundamental parts:

1) Pre-operative visit

2) Anesthesiological procedure

FIG.3 Flowchart of user interface.

PREOPERATIVE VISIT

Loading a new patient:

A new progressive number will be assigned and the data loading of the pre-operative visit will begin:

Page 1, history of diseases

The combination of codes (35 max) allows a fast compilation of the anesthesiological anamnesis; while 70 characters can be typed on another field for the insertion of other annotations.

Page 2, drug allergies

Eventual complications in previous anesthetical sessions or allergies of which the patient could be a carrier: first field in codes (20 max) , other three fields of 70 characters, one can also typed the drugs which have provoked the complication or the allergy and the applied therapy.

Page 3, physical examination

The data referring to the visit of the various apparatuses are reported (the body surface area is calculated by the computer). The fields will accept codes or alpha numerical characters for the description of reports of eventual instrumental examinations. 140 characters are available for annotations.

Page 4, laboratory tests

The hematochemical data, the surgical diagnosis, eventual pre-operative prescriptions, the A.S.A. classification of the operational risk, the date (entered by the computer) and the name of the anesthesist can be entered.

Page 5, surgical diagnosis

The surgical diagnosis is reported. The fields will accept codes and alpha numerical characters. It is therefore possible to go back to the various pages already entered or to display the entire visit, decoded and compacted .

From this video it is possible to go back to the previous pages of the visit and modify them or to input the patient into a file or go to the research section. The latter allows for the access to the general index of the files and therefore to the preoperative visit or to the anesthesiological procedures.

ANESTHESIOLOGICAL PROCEDURES

This part includes 8 sections.

Page 1 PATIENT'S DATA: the date of operation, the name of surgeons and anesthesists, type of operation are entered

Page 2 PREMEDICATION: time, drugs and doses of premedication are entered.

Arterial pressure: time, the arterial pressure max values, min and heart rate are transcribed, and at last 50 characters can be typed for other annotations.

Page 3 LUMBAR ANESTHESIA: the loading of data is similar to the premedication section. Time, type and intervertebral space of the lumbar anesthesia (spinal, epidural, sacral) performed and drugs utilised are entered. Moreover the arterial pressures and a description of the characteristics of the analgesia obtained (onset) can be entered. The highest metameric level (for ex.: umbelical line =T10) the lowest level (for ex. scrotum = S5), the onset of the analgesia and the motor block , the type of needle and the catheter diameter can be entered. Finally 40 characters are available for eventual notes.

Page 4 PERIPHERIC ANESTHESIA (other types besides the lumbar): input of data is the same as page 3 except for the description of the type of anesthesia applied without the use of codes but with alphanumerical characters and the onset field in which it is expected the insertion of the analgesia and motor block latency.

Page 5 ANESTHESIA INDUCTION: the input of data follows the same modalities the previous pages of peripheric anesthesia. Nevertheless on this page the onset field is substituted by the ventilation field where the diameter of the endotracheal tube used, the liter per min. of oxygen and of the nitrous oxide (N2O) distributed, the high and low pressures of the upon airways registered during ventilation and respiratory frequency are entered.Eventual variations of the ventilation parameters which can occur successively can be inputed on two other fields. Finally 40 characters can be typed for eventual annotations.

Page 6 SURGERY: in the preceding pages the section that was recalled was preceded on the video by the decodificated and compacted description of the procedures already executed. In the section dedicated to the surgery,in order to offer more space on the input of drugs and phisiological parameters, only the data to identify the patient is left on the video. (The preceding part of the anesthesia is anyway visible with the procedure of the general impagination of the menu). The initial time is recorded and also the temporal value to attribute to each character of the line in respect to the initial time. Once entered these parameters we can have access to the surgery page. The surgery section allows the recording in function of drug time, infusion etc. administered from the moment of the incision and also the recording of the monitorized vital parameters. 18 lines are available, the first 3 (maximum and minimum arterial pressure and heart rate) are already there, the remainig can be inserted typing the code or the name of the drug. After entering the name of the drug on the same line is inserted the modality of the administration in relation to the time. A second "operation" page with the same characteristics can be created by the user.

Page 7 EVALUATION: the first field is dedicated to the description in code of eventual problems during the awakening. A field of 50 characters can be inputed for other annotations. Another field in code for the description of eventual problems that can arise during the post operative period followed by another field of 50 characters.

Page 8 POST OPERATIVE TREATMENT: the characteristics of this page are similar to the surgery page. Once entered the starting time one can choose some standard therapies to which one can add other drugs with the same procedure described in the "surgery" section.

HELP: On line are also available help functions to farmacological calculations and anesthesia administration, by using <F8> key (fig.4).

An analitical search (i.e. drug name) is also possible .

From the menu it is possible to follow other procedures:

1) All data loaded in the various sections can be entered in files and the program will return to the section search by the number keeping in memory the number of the patient entered.

2) All the loaded data can be entered in files but the program continued the search per keys previously started searching for another patient.

3) The operation is decoded and displayed in compacted form

4) The preoperative visit of the patient is displayed

5) Printing of the anesthesia section is produced.

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	Fig.5 The recordsheet given to the discharging patient. Visit
	Anesthesia procedures and postoperative teraphy

RESEARCH SECTION:

The patient search could be performed by either the number of the patient or by keys.

Search by keys: this section allows the search of patients according to eight keys. The video presents the following search keys:

1) "DATE OF VISIT":

- **-MM-YY (only the last two digits of the year) all the patients visited in the month requested.

- DD-MM-YY all the patients in the requested day.

- It is possible to search from one date to the other.

2) "DATA OF THE OPERATION": same procedures of the field "DATE OF VISIT".

3) "LAST NAME", "NAME": complete or partial data.

4) "BIRTH": search for birthdate (DD-MM-YY) or for the age.

5) "SURGERY" search for complete or partial data (with or without codes ). For example a subject having gone through a colecystectomy can be searched by typing: I02A14(complete) A14(partial).

It is possible to limit the search to a length of defined characters limiting the field with "/". For example to search for all the patients named LANZA without searching all others whose last name begins with LANZA (such as LANZAFAME, LANZARONE, etc.) search for LANZA/. This will avoid the search of patients not asked for. The same procedure is applicable on all specific searches.

6) MINIDISK: search for the desidered years changing the year number included within the slash those of the desidered year or else for all the registered years starting from a determined year. We will have therefore outputed the index data regarding the patient. It is therefore possible the output of the anesthesiological data that can be visualized with the same procedure as in the "Search by the number".

PRINTING OPTION:

The program has available the printing of data either in series or on single basis. The single printing is available through the visit, search, anesthesia sections while the series procedure is activated with the search section. The types of printouts available are:

1) VISIT: printing of the visit

2) ANESTHESIA: printing of anesthesiological procedures

3) VISIT + ANESTHESIA

4) POST OPERATIVE THERAPY

5) INDEX:printing of the index of the patients, in other words, the fields outputed in the search section (date of visit, date of operation, etc).In figure 5 is showed the complete recordsheet given to the discharging patient .

Development of the anesthesia informatization project

The project was completed in december 1986. In 1988 a new module that perfoms an automatic serial connection (analog-digital optional) to patient monitor system was added. This last feature completed the anaesthesia workstation. Like an office workstation the anaesthesia workstation is a collection of anaestesiological tools shared between the components of the anaesthesia department. The B.L.F.H. anaesthesia workstation provides:

1) A ten years patients data-base with a preoperative and anaesthesia data form.

2) Vital signals automatic collection and trend storage from patient monitoring by an analog-digital conversion or serial communications.

3) On line available help to farmacological calculations and anaesthesia administration

4) Network mail and data sharing with other anaesthesia workstations.

1. Automatic transfer to network of preoperative visit collected at patient's bed with the portable computers.
   

FIGURE 6 FLOWCHART OF THE B.L.F.H. ANAESTHESIOLOGICAL ACTIVITY

The preoperative visits are collected in real time by a portable PC at patient's bed or during the out-patients visit. Then the anaesthesist transfers the collected forms to the anaesthesia workstation network by serial port communications or by a floppy diskette. A printed surgery list with the anaesthesiological advise for the scheduled patients is given to the ward the day before surgery. On surgery day the anaesthesia nurse retrieves the scheduled patients from the network, prints the surgery list with the preoperative patient's form and disposes for the patients arrival. The anaesthesist introduces the anaesthesiological procedure data, (premedication, induction etc.) in real time by a PC workstation sited in the Operating rooms while having corrently available the pre-operative visit's data, on line anaesthesiological help and communications facilities with the other anaestesists. Also the PC perfoms an automatic data monitoring collection building a trend with a minute resolution. In the recovery room the nurse writes on the computer the procedures and the post-operative therapies wich are printed depending on the actual procedures done by various anaesthesists. Such therapies are then given to the particular wards to which the patients belong.

Finally in 1993 the anaesthesia network has been improved with a remote control supervisor feature (fig.7). All the staff activity is monitored on line. At any workstation (e.g. chairman's office) it is possible to display any anaesthetic procedures in progress.

The patient is represented with a smiling or a sad coloured small face according to his status: scheduled , premedicated , during surgery , during recovery , discharged

A small sign signals the patients undergoing emergency procedures . Furthermore, patient's trend can be displayed and analyzed (fig.7,down).

TECHNICAL REFERENCES

10 anaesthesia workstations and 2 portable PC are using in the B.L.F.H. anaesthesia department. The 10 workstations are networked by a Ethernet LAN (10 Mbits). The workstation computers are Olivetti 486 DX2 66Mhz 8Mb RAM . An Olivetti 486 DX 100Mhz 16Mb ram 1200Mb hard disk computer is utilized as dedicated server. The portable computers are two Olivetti 386sx 25. Seven workstations are placed in the operating rooms. The others are situated in the recovery room and at the chairman's office.

Any PC workstation is able to display a complete anaesthesiological record and to analyze the ECG, NIBP CO2 SO2 invasive PA trend . A patient record needs 7942 Kb for the text data and needs 9607 Kb for the vital signals trend. The remote control supervisor program (RCSP) is able to perform automatic data collection from monitoring devices, building an on line trend with a minute to minute resolution, for any patient. It is possible to display on line trends progress of 6 patients simultaneously. The update interval range is user programmable from 1 to 60 minutes. It is also possible to retrieve and to analyse previous activity (trends, surgery list ,etc.), stored in a server's database. A modem connection is provided at the chairman office workstation. The modem provides displays of above mentioned frames at remote locations by phone line, providing support for on line control or consultations with remotely logged-in anaesthesiologist by interactive computer dialogue.

The software written with Microsoft Visual Basic 3.0 language uses a SQL database that runs on a Microsoft Open Database Connectivity (ODBC) server.

2 databases are created :

-The first one, updated every minute by the LAN workstations , contains the table of the current anaesthesia activity in progress.

-The second one stores the table of previous anaesthetic activities.

The modem remote control runs under Carbon Copy for Windows V.2.0 and it is called from RCSP by dynamic data exchange (DDE).

RESULTS

19189 patient records are on line available. 3500 records are processed for year.The workstation are used by all anaesthesiologists and nurses.

FIGURE 8 The figure shows the trend of the processed records for year and the number of the users.The priming course to utilize the software is long a month.

The use of the workstation improved the number of the out-patients visits up 40-50 every week . In particular, the use of workstation allows us to spreed the peridural analgesia during the labour. In fact the pregnant performs an anaesthesiological visit a month before delivery. This visit is transferred to the network.When the pregnant enters to the Hospital for the labour this visit is retrieved. The anaesthesist is able to consult the preoperative visit by the network and so he can draw as more informations as possible to perform epidural anaesthesia.

At present in the B.L.F.H. ,every year, 1000 delivery are treated with epidural anaesthesia.

Furthermore the RCSP allows for an automatic continuous update of the hospital anaesthetic activities. Like an airport control panel that displays flies and passenger status, an anesthesia workstation running the RCSP displays current patient status and anaesthesiologist activities. Furthermore the RCPS displaying the surgery progress contributes to the improvement of the OR working processes allowing for optimisation of the patient's turnover. The supervisor anaesthesiologist can prevent mistakes during anaesthetic procedures and help an inexperienced anaesthesiologist controlling patient trends and using the pop-up mail. In conclusion the introduction of the computer in the anaesthetic activity improves the patient care because it is possible a total control of the patients management steps.

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