Perceived Barriers to Computerised Quality Documentation During Anaesthesia

A Survey of Anaesthesia Staff

Johannes Wacker; Johann Steurer; Tanja Manser; Elke Leisinger; Reto Stocker; Georg Mols

BMC Anesthesiol. 2015;15(13)

Abstract and Introduction

Abstract

Background Underreporting of intraoperative events in anaesthesia is well-known and compromises quality documentation. The reasons for such omissions remain unclear. We conducted a questionnaire-based survey of anaesthesia staff to explore perceived barriers to reliable documentation during anaesthesia.

Methods Participants anonymously completed a paper-based questionnaire. Predefined answers referred to potential barriers. Additional written comments were encouraged. Differences between physician and nurse anaesthetists were tested with t-tests and chi-square tests.

Results Twenty-five physician and 30 nurse anaesthetists (81% of total staff) completed the survey. The reported problems referred to three main categories: (I) potential influences related to working conditions and practices of data collection, such as premature entry of the data (indicated by 85% of the respondents), competing duties (87%), and interfering interruptions or noise (67%); (II) problems referring to institutional management of the data, for example lacking feedback on the results (95%) and lacking knowledge about what the data are used for (75%); (III) problems related to specific attitudes, e.g., considering these data not useful for quality improvement (47%). Physicians were more sceptical than nurses regarding the relevance of these data for quality and patient safety.

Conclusions The common perceived difficulties reported by physician and nurse anaesthetists resemble established barriers to incident reporting and may similarly act as barriers to quality documentation during anaesthesia. Further studies should investigate if these perceived obstacles have a causal impact on quality reporting in anaesthesia.

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Abstract and Introduction
Background
Methods
Results
Discussion
Conclusions
References

Table 1. Reported working conditions and practices of data collection
Topic, Survey Questions (Italics)	Answer choices	Physicians (N = 24)	Nurses (N = 28)	Total (N = 55)	Significance χ2-test
User friendliness: "Please assess the user friendliness of the electronic anaesthesia record/data entry system (AIMS)"	"good" or "sufficient"	22 (92%)	26 (96%)	51 (94%)	n/a
	"unsatisfactory"	2 (08%)	1 (04%)	3 (06%)
	Total respondents	24	27	54
Clarity of definitions: "Are the definitions of events (definition text) in the window "SGAR problems and complications/intraoperatively" unambiguous?"	"good" or "sufficient"	19 (79%)	18 (67%)	39 (72%)	n/a
	"unsatisfactory"	5 (21%)	9 (33%)	15 (28%)
	Total respondents	24	27	54
Adequacy of time available for data entry: "Do you have enough time to enter these data?"	"always" or "usually"	22 (92%)	24 (86%)	49 (89%)	n/a
	"rarely" or "never"	2 (08%)	4 (14%)	6 (11%)
	Total respondents	24	28	55
Timing of data entry: "When do you usually enter the data?" (before or after end of anaesthetic)	"after end"	3 (13%)	2 (07%)	5 (09%)	n/a
	"before end"	19 (79%)	25 (89%)	47 (85%)
	"both"	2 (08%)	1 (04%)	3 (05%)
	Total respondents	24	28	55
Concomitant important duties during data entry: "Do you have to carry out other important duties at the time of quality data entry?"	"always" or "usually"	22 (92%)	24 (86%)	48 (87%)	n/a
	"rarely" or "never"	2 (08%)	4 (14%)	7 (13%)
	Total respondents	24	28	55
Which duties: "If yes: which duties?" (multiple answers possible; see text for items)	Specific answers	23 (96%)	24 (86%)	49 (89%)	**
	No answers	1 (04%)	4 (14%)	6 (11%)
	Total respondents	24	28	55
Frequency of noise or interruptions during data entry: "Please estimate how often noise or interruptions interfere with data entry"	"always" or "usually"	15 (63%)	20 (74%)	36 (67%)	n/a
	"rarely" or "never"	9 (38%)	7 (26%)	18 (33%)
	Total respondents	24	27	54
Record check before data entry: "Do you regularly perform a check of the anaesthesia record before data entry?"	"always" or "usually"	6 (26%)	18 (67%)	25 (47%)	0.017*
	"rarely" or "never"	17 (74%)	9 (33%)	28 (53%)
	Total respondents	23	27	53

(%) indicate column percentages related to total respondents of the respective group to this question. Note: Results of three respondents who did not indicate their profession were not included in the comparison of professional groups. n/a, chi-square (χ2) test "not applicable" because the requirements for sufficient accuracy were not met, see methods section. *, accuracy of chi-square statistic was borderline. **, open question and therefore not included in group comparison. AIMS, Anaesthesia Information Management System; SGAR, Swiss Society of Anaesthesiology and Reanimation. Combined answers (e.g., "always" or "usually") have been bundled into an essentially positive and an essentially negative answer category after data collection to facilitate interpretation (see methods section).

Table 2. Knowledge of in-house management of data on anaesthesia quality
Topics, Survey Questions (Italics)	Answer choices	Physicians (N = 24)	Nurses (N = 28)	Total (N = 55)	Significance χ2-test
Reliability of data: "How reliable are the collected data, in your opinion?"	"reliable"	1 (04%)*	5 (19%)	7 (13%)	n/a
	"moderate"	8 (33%)	17 (63%)	27 (50%)
	"unreliable"	15 (63%)	5 (19%)	20 (37%)
	Total respondents:	24	27	54
Feedback about quality data: "Do you get feedback about the collected data on quality?"	"no"	22 (92%)	27 (96%)	52 (95%)	n/a
	"yes"	2 (08%)	1 (04%)	3 (05%)
	Total respondents	24	28	55
Use of the data: "What are the collected data used for?"	"I don't know"	19 (79%)	21 (75%)	41 (75%)	n/a
	"I know"	4 (17%)	5 (18%)	10 (18%)
	no answer	1 (04%)	2 (07%)	4 (07%)
	Total respondents	24	28	55
Handling of identified problems by leading board and management: "How do the institute"s leading board and the hospital management handle problems and flaws identified with the systematic registration of intraoperative events?"	answers	23 (96%)	23 (82%)	49 (89%)	**
	no answer	1 (04%)	5 (18%)	6 (11%)
	Total respondents	24	28	55
Who should enter the quality data: "In your opinion, who should ideally enter these data: anaesthesia physicians or anaesthesia nurses?"	"Physician"	20 (83%)	17 (61%)	40 (73%)	0.155
	"Nurse"	1 (04%)	1 (04%)	2 (04%)
	"both"	3 (13%)	10 (36%)	13 (24%)
	Total respondents	24	28	55
Need to improve data collection: "In your opinion, is there a need to improve data collection?"	"yes"	8 (33%)	17 (61%)	27 (49%)	0.108*
	"I don't know"	11 (46%)	9 (32%)	21 (38%)
	"no"	5 (21%)	2 (07%)	7 (13%)
	Total respondents	24	28	55
Estimate of correct documentation: "Please estimate the percentage of "events" as captured in the record (categories hypotension, hypertension, bradycardia, tachycardia, hypoxia) correctly documented using the window "intra-operative events"	mean	23.3%	38.5%	31.7%	0.012 t-test¹⁾
	SD	18.2%	23.3%	22.0%
	lowest	1	7.5	1
	highest	50	90	90

(%) indicate column percentages related to total respondents of the respective group to this question. Note: Results of three respondents who did not indicate their profession were not included in the comparison of professional groups. n/a, chi-square (χ2) test "not applicable" because the requirements for sufficient accuracy were not met, see methods section. *, accuracy of chi-square statistic was borderline. **, open question and therefore not included in group comparison. ¹⁾means of estimates were compared using t-test; CI of the difference 3.4, 27.0.

Table 3. Knowledge and attitudes regarding data collection
Topics, Survey Questions (Italics)	Answer choices	Physicians (N = 24)	Nurses (N = 28)	Total (N = 55)	Significance χ2-test
Relevance of data for patient safety: "In your opinion, how relevant is the collection of these data for patient safety?"	"relevant"	8 (33%)*	19 (68%)	28 (51%)	0.032
	"I don't know"	6 (25%)	5 (18%)	12 (22%)
	"irrelevant"	10 (42%)	4 (14%)	15 (27%)
	Total respondents:	24	28	55
Potential of data to improve anaesthesia quality: "In your opinion, do these data generally allow for an improvement of anaesthesia quality?"	"yes"	4 (17%)	13 (46%)	18 (33%)	0.002
	"I don't know"	2 (08%)	8 (29%)	11 (20%)
	"no"	18 (75%)	7 (25%)	26 (47%)
	Total respondents	24	28	55
Concern of easier prosecution because of the reported event data: "Do you have concerns of being prosecuted more easily based on the reported intraoperative event data in case of liability?"	"yes"	2 (08%)	7 (25%)	9 (16%)	n/a
	"I don't know"	4 (17%)	6 (21%)	11 (20%)
	"no"	18 (75%)	15 (54%)	35 (64%)
	Total respondents	24	28	55
Trust in data anonymisation: "Do you trust anonymisation of the quality data?"	"yes"	9 (38%)	18 (64%)	29 (53%)	0.156*
	"I don't know"	12 (50%)	8 (29%)	21 (38%)
	"no"	3 (13%)	2 (07%)	5 (09%)
	Total respondents	24	28	55

Authors and Disclosures

Johannes Wacker¹*, Johann Steurer², Tanja Manser³, Elke Leisinger¹, Reto Stocker¹ and Georg Mols⁴

¹Institute of Anaesthesia and Intensive Care, Hirslanden Clinic, Witellikerstrasse 40, CH-8032 Zürich, Switzerland. ²Horten Center for Patient-Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, CH-8091 Zürich, Switzerland. ³Institute for Patient Safety, Faculty of Medicine, University of Bonn, Stiftsplatz 12, D-53111 Bonn, Germany. ⁴Department of Anaesthesia & Surgical Intensive Care Medicine, Hospital Lahr-Ettenheim, Klostenstr. 19, D-77933 Lahr, Germany

*Correspondence
johannes.wacker@hirslanden.ch

Competing interests
JW is member of the Scientific Subcommittee 'Patient Safety' of the European Society of Anaesthesiology (ESA), Brussels, Belgium. TM is member of the Scientific Subcommittee 'Patient Safety' of the ESA. They have no conflict concerning this publication. GM is member of the scientific subcommittee on intensive care of the German Congress of Anaesthesia and Intensive Care Medicine. He is also a member of the editorial board of Critical Care Medicine. RS has received travel funding from Fresenius-Kabi and unrestricted research grants from Baxter, Fresenius-Kabi, CSLBehring, and Astra Zeneca. He is also a member of the Cantonal Ethics Committee, Canton of Zurich, Switzerland, and leads a subcommittee of the Swiss Academy of Medical Sciences dealing with ethics in intensive care medicine.

Authors' contributions
JW developed the research idea, conducted the literature search, drafted and revised the article, and takes responsibility of the overall content as guarantor. JW, JS, and TM contributed to the conception of the study and of the article. JW, JS, TM, EL, RS, and GM contributed to study design and/or to the survey questions. JW, EL, and GM participated in data acquisition. JW and TM performed the data analysis. All authors contributed to the interpretation of results. All authors also contributed to the critical revision of the article, and approved the final version to be published.

Authors' information
JW, EL: Consultant Anaesthesiologists, Institute of Anaesthesia and Intensive Care, Hirslanden Clinic, Zurich, Switzerland. JS: Director, Horten Center for Patient-Oriented Research and Knowledge Transfer, and Professor of Internal Medicine, University of Zurich, Switzerland. TM: Professor for Industrial Psychology and Human Factors, Department of Psychology, University of Fribourg, Switzerland; TM is now Director, Institute of Patient Safety, Faculty of Medicine, University of Bonn, Germany. RS: Head, Institute of Anaesthesia and Intensive Care, Hirslanden Clinic, Zurich, and Professor of Surgical Intensive Care Medicine, University of Zurich, Switzerland. GM: Head, Department of Anaesthesia & Surgical Intensive Care Medicine, Hospital Lahr-Ettenheim, Lahr, and Professor of Anaesthesia and Critical Care Medicine, University of Freiburg im Breisgau, Germany.