Perioperative Electronic System

A New Approach for Perioperative Nursing Performance

Márcia Baptista

, Rita Silva

, Helena Gonçalves Jardim

and António Quintal

Department of Information Technology Research, Santiago Compostela University, Spain

OR, SESARAM Hospital, Funchal, Madeira, Portugal

Health Higher School (ESS), Madeira University and The Health Sciences Research Unit: Nursing, Coimbra, Portugal

Madeira University, Funchal, Madeira, Portugal

Keywords: Electronic Health Records, Perioperative System, Performance.

Abstract: Nowadays, IT and informatics are permanently and highly integrated into the delivery of quality health care

and in the perioperative care is no exception. At Dr. Nélio Mendonça Hospital the implementation of a

perioperative electronic system was a major step. The purpose of this study was to contribute to the

perioperative nursing care improvement by recreating innovated nursing practices through the conception

and implementation of a perioperative electronic system. Before the perioperative electronic system

implementation in the OR only 1,2 % of the nurses registered the preoperative visit and after its

implementation 87,6 % of the nurses registered it. The patient features assessed exhibited inferior anxiety

levels (1st group: 13,72/ 2nd group: 10,97) and lower pain levels in the preoperative stage (1st group: 2,66/

2nd group: 1,19), intraoperative stage (1st group: 2,05/ 2nd group: 0,72) and postoperative stage (1st group:

4,5/ 2nd group: 0,45) after the implementation of the perioperative electronic system (p-value <0,05). The

results indicate that this system was beneficial to the nurses and to the surgery patients.

1 INTRODUCTION

According to World Health Organization (WHO),

information and communication technologies (ICTs)

have great potential to improve health in both

developed and developing countries by enhancing

access to health information and making health

services more efficient. They can also contribute to

improving the quality of services and reducing their

cost. Patient information systems have the ability to

track individual health problems and treatment over

time, giving insight into optimal diagnosis and

treatment of the individual as well as improving the

delivery of services and care. An opportunity

emerges to centre the patient in the care sphere,

ensuring security, efficiency, accessibility and

quality, in health assistance. Soon, ICT will establish

fast and effective communication among

stakeholders, providing information and producing

knowledge and we all will benefit from its

implementation.

2 BACKGROUND AND

SIGNIFICANCE

The perioperative background is a unique

environment that includes many challenging

variables: complex clinical care performed by teams,

high cost, sophisticated technologies that often do

not interoperate and a large array of supplies,

instruments, and implants that are difficult to

manage. These variables create a setting of massive

complexity and are a source of a significant

percentage of patient safety-related adverse events

(Jacques and Minear, 2008).

Surgical procedures are often the most intensive

and efficacious therapeutic interventions available in

medicine and these treatments are frequently

curative and are sometimes the only alternative for

patients. Surgeons and other professionals are highly

trained us the technology and resources that they

employ are typically advanced, expensive and scar-

ce. So the optimization of these limited resources is

paramount to the safe, effective, and efficient

delivery of healthcare (Doebbeling et al, 2012).

Baptista, M., Silva, R., Jardim, H. and Quintal, A.

Perioperative Electronic System - A New Approach for Perioperative Nursing Performance.

DOI: 10.5220/0006647205050509

In Proceedings of the 11th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2018) - Volume 5: HEALTHINF, pages 505-509

ISBN: 978-989-758-281-3

505

Perioperative information technology has the

potential to improve the quality of health care,

reduce costs, decrease medication administration

errors, reduce time spent on paperwork, increase

management efficacy and allow affordable access to

health care. Researchers concluded that IT or

automation of aspects of the surgical patient

preparation process and the coordination and

management of surgical equipment has the potential

to increase the speed of information exchange,

reduce interruptions to clinicians and decrease the

possibility of adverse events in the perioperative

setting. With migration to the use of an electronic

health record (EHR) in the operating room (OR),

time that nurses previously spent on paperwork and

administrative functions can be dedicated to

providing better patient care and ensuring accuracy

in documentation (Sweeney, 2010).

2.1 Electronic Health Record

The electronic health record (EHR) is a particular

document consisting on a set of information, signs

and images recorded, generated from facts, such as,

events and health situations; the assistance he

provided and can be of legal character, confidential

and scientific, enabling communication between the

members of the multidisciplinary team and

continuity of care to the client. HER systems have

the potential to transform the health care system

from a mostly paper-based industry to one that

utilizes clinical and other pieces of information to

assist providers in delivering higher quality of care

to their patients (Menachemi and Collum, 2011).

The use of the EHR in the perioperative set

offers great advantages to the perioperative team

through the creation of accessibility of all patients’

information in one location. Additionally, for many

patients, the perioperative setting is the initial entry

point into the health care system, either through

scheduled or unscheduled surgery. Correct and

efficient use of the EHR can improve

communication throughout the system and help

create a safer and more efficient patient-centered

experience. Additional advantages of EHR use in the

perioperative setting include clear communication of

information to other departments and effectively

capturing workload, standardize perioperative

nursing procedures, optimize the OR management

process, adapt the nursing interventions to the

patient needs, improve the quality of customer

service in the OR. Patient care is enhanced and

improved when information can be easily accessed.

In addition, there is less repetition of patient

information gathered and included in

documentation. These advantages aid in the

provision of safe handoffs, leading to safe patient

care and improved communication throughout the

health care system. These advantages also address

the exposed gap involving the transfer of care that

takes place every day as patients move in and out of

the operative areas (Yontz et al, 2015).

This trend will continue as improvements are

made in computer hardware, software, and

telecommunication infrastructure and as countries

develop the skills necessary to implement electronic

data storage and transmission systems (WHO,

2012).

3 STUDY PURPOSE

Contribute to the perioperative nursing care

improvement by recreating innovated nursing

practices through the conception and implementation

of a perioperative electronic system.

4 STUDY OBJECTIVES

Construct and implement a perioperative nursing

electronic system at Doctor Nélio Mendonça

Hospital;

Evaluate health gains through the application of

a dynamic and holistic model created for surgery

patient features and perioperative nursing practices;

Calculate perioperative nursing production and

quality indicators.

5 METHODOLOGY

5.1 Sample and Setting

The setting for this project was the OR at Dr. Nélio

Mendonça Hospital.

Perioperative nurses and surgery patients divided

in two stages: before and after the implementation of

the electronic system were the targeted populations

for this project.

This sample population was considered as causal

or as a matter of convenience and it was

characterized as non-probabilistic. The 113 nurses

were divided in two groups: the 1st group had 83

nurses and 2nd had 30 nurses. These nurses came

from all areas of operative services. All the nurses

were invited to participate in the study. Inclusion

HEALTHINF 2018 - 11th International Conference on Health Informatics

506

criteria for the sample included the following: must

be a perioperative registered nurse.

There was a second sample of 460 surgery

patients also divide in two groups with 230 patients

in each one. Inclusion criteria for this sample

included patients with 65 years old and more for

elective surgery with no signs of cognitive deficit.

5.2 Design

An observational, quantitative and descriptive

survey design was used to determine perioperative

nursing practices towards the use of the electronic

system in providing.

Regarding the surgery patients, a correlational

and longitudinal study design was performed to

evaluate health gains.

5.3 Data Collection

An observation grid was prepared for the periopera-

tive nurses in the intraoperative, postoperative and

preoperative stages. For the surgery patients, a

questionnaire was used to gather demographic data,

clinical data, the Amsterdam Preoperative Anxiety

and Information Scale (APAIS), Spielberger State-

Trait Anxiety Inventory (STAI), postoperative pain,

pressure ulcers, the Barthel scale and the risk of

falling.

5.4 Preparedness Planning

5.4.1 Electronic Perioperative System

Creation and Implementation

First of all, for the Electronic Perioperative System

conception and implementation a task force was

gathered, including surgeons, anesthesiologists,

nurses and computer engineers.

The main stages included:

- Presentation of the Perioperative Electronic

System to surgeons, anaesthetists,

perioperative nurses and others involved in

the surgical process;

- Clarification of its implementation;

- Elucidation of the advantages of improving

assistance care, with greater security to the

surgical process, not only for the patient, but

also for health professionals and units;

- Alert to the importance of this system as a

knowledge management tool, innovating and

developing the perioperative process by

gathering production, structure, process and

outcome indicators.

A literature review on perioperative nursing was

performed with special consideration for external /

internal norms, guidelines and mandatory protocols

inherent to the OR and perioperative nursing records

from imperative organizations (DGS, ACSS, Dr.

Nélio Mendonça Hospital) to assure its execution.

The intervention strategies established periodic

meetings with the different intervening areas;

training session’s development for surgical services

nurses in the OR and in the "Perioperative Nursing"

situation; monitoring and evaluating perioperative

electronic system procedures; continued adjustment

and development and confidentiality concerning the

use of clinical data.

This system was designed with a specific layout,

for the surgical procedure which gathers the main

stages: intraoperative, postoperative and preoperati-

ve processes. This system implementation led all

professionals like surgeons, anaesthesiologists,

nurses and other technicians to work in an organized

manner in one platform, with more detailed,

standard, completed and updated procedures

following Direção Geral da Saúde guidelines and

policies. New data was registered like patients

surgical times, which were not yet accounted for,

surgical safety checklist was also filled, with direct

connection to the national database, surgical

infection HELICS epidemiological surveillance,

updated waiting lists and others, and therefore

suitable for perioperative reality.

5.4.2 Perioperative Nurses Observation

In the preoperative stage a preoperative visit was

conducted and applied a preoperative checklist

(service and block) observing the patient reception at

the OR and recorded registration.

In the intraoperative stage the action plan

continuity, nursing diagnoses and record registration

were observed.

In the postoperative stage the post anaesthetic

care, postoperative visit and record registration were

observed.

5.5 Statistical Methods

The statistical methods used descriptive measures,

T-Student teste for independent samples and One-

way Anova. The statistical package was IBM SPSS

22.0 and the significance level α=0,05.

5.6 Ethical Procedures

The perioperative nurses were informed before the

observation was conducted and given their written

Perioperative Electronic System - A New Approach for Perioperative Nursing Performance

507

and informed consent. To the surgery patients was

assured anonymous participation and given their

written and informed consent. They were also

informed about the importance of the study.

6 FINDINGS

The study principal results showed that before the

perioperative electronic system implementation in

the OR only 1,2 % of the nurses registered the

preoperative visit and after its implementation 87,6

% of the nurses registered it.

In the intraoperative stage, before the

perioperative electronic system implementation in

the OR the nursing plan was registered by 62,7%

nurses; there was no register about the security

checklist and time indicators like the operative

times. After the electronic system implementation

the nursing plan was registered by 96,7% of the

nurses, security checklist and operative times was

recorded by 100%.

In the postoperative stage, before the

perioperative electronic system implementation in

the OR the acute pain monitoring was not registered

and the register of the postoperative visit was

recorded by only 4,8% of the nurses. After the

electronic system implementation the acute pain

monitoring and the postoperative visit was registered

by 86,7% of the nurses.

Note that the register made before the electronic

system was on paper.

The surgery patients were mostly women (1st

group: 57,8%/ 2nd group: 63%) between 65 and 69

years old (1st group: 36,5%/ 2nd group: 30%). The

surgery performed was manly major (1st group:

70%/ 2nd group: 78,7%) with general anaesthetic

(1st group: 58,7%/ 2nd group: 59,1%). The medium

time of surgery was 2 hours and 58 minutes in the

first group. In the second group was 3h and 2

minutes.

The different patient features assessed exhibited

that after the implementation of the perioperative

electronic system the anxiety levels (1st group:

13,72/ 2nd group: 10,97) monitored and the falling

risk (1st group: 57,0%/ 2nd group: 48,3%) were

lower than before (p-value <0,05). The pain level

observed in the preoperative stage (1st group: 2,66/

2nd group: 1,19), intraoperative stage (1st group:

2,05/ 2nd group: 0,72) and postoperative stage (1st

group: 4,5/ 2nd group: 0,45) were inferior too (p-

value <0,05).

7 DISCUSSION

The purpose of this study was to develop and

implement a perioperative electronic system at Dr.

Nélio Mendonça Hospital OR. The records in paper

form were now computerized. By assessing health

gains through the application of a dynamic and

holistic model created for surgery patient features

and perioperative nursing practices the results

indicate that the perioperative electronic system was

beneficial to the nurses and to the surgery patients.

The new registry units interdisciplinary in the

perioperative period was achieved like recorded

operative times, which were not counted in the

patients, surgical safety checklist application, direct

link to the national database, epidemiological

surveillance of surgical site infection HELICS-

Surgical Site Infection, updated waiting lists and

others.

Perioperative nursing practices included

preoperative visit, hospitalization, intraoperative

interventions, postoperative visit, monitoring of

postoperative acute pain and anxiety levels which

were lower than before implementing the

perioperative electronic system.

With the reorganization and compilation of

various components and instruments, professionals

cooperated by resolving many problems, never

discussed before, and that, in a way, converged for

the quality assurance and safety of perioperative care

conditions, for all the intervenient.

8 CONCLUSION

Perioperative care is complex and involves multiple

interconnected subsystems which are a microcosm

of the hospital. Delayed starts, prolonged cases and

overtime are common. Surgical procedures are

major drivers of patient morbidity, mortality,

satisfaction, and overall hospital costs and

profitability. These challenges in perioperative and

surgical care are overwhelming. To fulfill the

promise of new informatics and technology

approaches, a dramatic change is needed in how

technology is designed, deployed, and supported

within the perioperative environment. Technology

that is designed expressly for and adequately tailored

to the demands of the perioperative care process and

requirements will result in optimal clinical adoption

and outcomes. New digital equipment can decrease

surgery time and created a safer environment for

both patients and staff members. Through the design

HEALTHINF 2018 - 11th International Conference on Health Informatics

508

and implementation of such systems, the perioperati-

ve process can help maximize improvements to

safety, patient and clinician satisfaction, and

ultimately the success of this highly complex and

financially important area of clinical care.

9 FINAL RECOMMENDATIONS

As technology changes the OR environment,

perioperative nurses and surgery patients are faced

with new challenges and opportunities. The best

possible outcome for patients and institutions

requires the electronic system continuous

improvement, construction of management and

quality indicators in the OR, cost control assessment

and adverse event monitoring.

At Dr. Nélio Mendonça Hospital the

implementation of this perioperative electronic

system was a major step and faced some challenges.

In order to evolve to the next stage of its

development it is vital to assess the acceptance and

satisfaction among the end users and assess the

maturity’s system.

REFERENCES

Doebbeling, B. N., Burton, M. M., Wiebke, E. A., Miller,

S., Baxter, L., Miller, D., Pekny, J., 2012. Optimizing

Perioperative Decision Making: Improved Information

for Clinical Workflow Planning. AMIA Annual

Symposium Proceedings, 154–163.

World Health Organization (WHO), 2012. Management of

patient information: trends and challenges in Member

States: based on the findings of the second global

survey on eHealth. Global Observatory for eHealth

series -Volume 6.

Menachemi, N., Collum, T. H., 2011. Benefits and

drawbacks of electronic health record systems. Risk

Management and Healthcare Policy, 4, 47–55.

St. Jacques, J., Minear, N., 2008. Improving Perioperative

Patient Safety Through the Use of Information

Technology. In: Henriksen K, Battles JB, Keyes MA,

et al., editors. Advances in Patient Safety: New

Directions and Alternative Approaches (Vol. 4:

Technology and Medication Safety). Rockville (MD):

Agency for Healthcare Research and Quality (US).

Sweeney, P., 2010. The Effects of Information

Technology on Perioperative Nursing. 92(5).

Yontz, L. S., Zinn, J. L., Schumacher, E. J., 2015.

Perioperative Nurses’ Attitudes Toward the Electronic

Health Record. Journal of PeriAnesthesia Nursing,

30(1), 23-32.

Perioperative Electronic System - A New Approach for Perioperative Nursing Performance

509