Abstract
Purpose
To evaluate if anesthesia training and experience influenced chart completion and accuracy.
Methods
One hundred and twenty-four subjects, including medical students, anesthesia residents and community and university based clinical anesthesiologists, were given a standardized patient in a simulator environment and asked to conduct induction and maintenance of anaesthesia. Three critical events were introduced resulting in changes in BR HR, PETCO2 and SpO2. Subjects were instructed to manage the patient and the anesthetic chart, as was their customary practice. Discrepancy, calculated as the difference between the actual and charted values divided by the actual physiological value was compared by level of training with a two-way repeated measures analysis of variance (ANOVA) for all four physiological variables. The completeness of charting, defined as at least one data point recorded for each of the four physiological variables of the three critical events, was compared across level of training, age of participants and number of years in practice.
Results
The overall completeness of charting remained low (< 37%) with no relationship based on the anesthesiologist’s age, level of training or number of years in practice. There was discrepancy in charting for all physiological variables (HR, BR PETCO2 and SpO2, P < 0.0001), with a marked difference in the degree of discrepancy within each level of training. Training resulted in no differences in charting discrepancy.
Conclusion
Charting of data to the anesthetic record remained incomplete and inaccurate in all groups based on level of training, age and number of years in practice.
Résumé
Objectif
Évaluer si la formation en anesthésie et l’expérience influencent la tenue de dossier et son exactitude.
Méthode
Cent vingt-quatre sujets, y compris des étudiants en médecine, des résidents en anesthésie et des anesthésiologistes de pratique privée ou universitaire ont reçu le modèle d’un patient dans un environnement simulé et on leur a demandé de procéder à l’induction et à l’entretien de l’anesthésie. On a introduit trois incidents critiques impliquant des changements de TA, FC, PETCO2 et SpO2. On a demandé aux sujets de procéder à l’anesthésie et de remplir le dossier comme ils avaient l’habitude de le faire. La discordance, calculée à partir de la différence entre les valeurs réelles et celles du dossier divisée par la valeur physiologique véritable, était comparée sur la base du niveau de formation selon une analyse de variance (ANOVA pour valeurs répétées) pour les quatre variables physiologiques. Le dossier complet, défini par l’enregistrement d’au moins une donnée pour chacune des variables physiologiques des trois incidents critiques, était comparé selon le niveau de formation, l’âge des participants et le nombre d’années d’expérience.
Résultats
Lachèvement global du dossier a été faible (< 37 %) et ne présentait pas de différences basées sur l’âge, la formation ou le nombre d’années de pratique. Il y avait des divergences d’inscription au dossier pour toutes les variables physiologiques (HR, BR PETCO2 et SpO2, P < 0,0001), avec une nette différence dans le degré de divergence pour chaque niveau de formation. La formation n’a pas eu d’influence sur la discordance dans le dossier.
Conclusion
Lentrée des données au dossier anesthésique était incomplète et inexacte dans tous les groupes basés sur le niveau de formation, l’âge et le nombre d’années d’expérience.
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Devitt, J.H., Rapanos, T., Kurrek, M. et al. The anesthetic record: accuracy and completeness. Can J Anesth 46, 122–128 (1999). https://doi.org/10.1007/BF03012545
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DOI: https://doi.org/10.1007/BF03012545