The Design, development, implementation, and evaluation of a computerized anesthesia charting system.

A Computerized Anesthesia Charting System (CACS) was developed and implemented as an addition to the HELP hospital information system at LDS Hospital in Salt Lake City, Utah. Instead of using the traditional manually recorded anesthesia record, the anesthesiologists charted using a computer terminal mounted on the anesthesia delivery machine. CACS automatically captured patient physiological variables as well as demography, laboratory, Admit-Discharge-Transfer (ADT), and operation timing data during the surgical anesthesia. Computer programs were developed for anesthesia data entry, display, storage, and report generation. Results of evaluation showed that anesthesiologist's average charting time was reduced by 34.3% (from 20.4% to 13.4%, P = 0.0001 by two tailed t-test). The average time spent on scanning the area was reduced by 46.7% (from 10.5% to 5.6%, P = 0.0011 by two tailed t-test). The average time spent on patient preparation was increased by 29.7% (from 10.1% to 13.1%, P = 0.0204 by two tailed t-test). The average time spent on arranging equipment was increased by 26.6% (from 6.4% to 8.1%, P = 0.0303 by two tailed t-test). The average time spent on non-anesthesia activities was increased by 81.0% (from 6.3% to 11.4%, P = 0.0137 by two tailed t-test). Results of the evaluation did not show significant differences in the anesthesiologist's average time spent on mixing and administrate drugs (from 13.2% to 14.3, P = 0.3217 by two tailed t-test), observing the patient (from 10.9% to 10.5%, P = 0.0691 by two tailed t-test), observing monitors and instruments (from 8.8% to 10.5%, P = 0.0852 by two tailed t-test), and transfer data (from 8.4% to 8.2%, P = 0.8931 by two tailed t-test). The computerized anesthesia record was more legible, complete, and accurate. The overall assessment of the CACS by anesthesiologists was positive. The computerized anesthesia charting was preferred by the anesthesiologists who after one or two training sessions used the system on their own.