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Improving Documentation of a Beta-Blocker Quality Measure Through an Anesthesia Information Management System and Real-Time Notification of Documentation Errors

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Abstract:

Background: Continuation of perioperative beta-blockers for surgical patients who are receiving beta-blockers prior to arrival for surgery is an important quality measure (SCIPCard-2). For this measure to be considered successful, name, date, and time of the perioperative beta-blocker must be documented. Alternately, if the beta-blocker is not given, the medical reason for not administering must be documented.

Methods: Before the study was conducted, the institution lacked a highly reliable process to document the date and time of self-administration of beta-blockers prior to hospital admission. Because of this, compliance with the beta-blocker quality measure was poor (~65%). To improve this measure, the anesthesia care team was made responsible for documenting perioperative beta-blockade. Clear documentation guidelines were outlined, and an electronic Anesthesia Information Management System (AIMS) was configured to facilitate complete documentation of the beta-blocker quality measure. In addition, real-time electronic alerts were generated using Smart Anesthesia Messenger (SAM), an internally developed decision-support system, to notify users concerning incomplete beta-blocker documentation.

Results: Weekly compliance for perioperative beta-blocker documentation before the study was 65.8±16.6%, which served as the baseline value. When the anesthesia care team started documenting perioperative beta-blocker in AIMS, compliance was 60.5±8.6% (p = .677 as compared with baseline). Electronic alerts with SAM improved documentation compliance to 94.6±3.5% (p < .001 as compared with baseline).

Conclusions: To achieve high compliance for the beta-blocker measure, it is essential to (1) clearly assign a medical team to perform beta-blocker documentation and (2) enhance features in the electronic medical systems to alert the user concerning incomplete documentation.

Document Type: Research Article

Publication date: 2012-06-01

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  • The Joint Commission Journal on Quality and Patient Safety will be published by Elsevier beginning in 2017! For readers who receive access to the journal through their institutions, the journal can now be found on ScienceDirect (http://www.sciencedirect.com/science/journal/15537250). For librarians looking to subscribe to the journal for their institutions please contact your Elsevier Account Manager or visit www.myelsevier.com for more information. All other readers, please visit http://www.jointcommissionjournal.com/ to subscribe to the journal or to claim your access for an existing subscription.
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