Automatic Notifications Mediated by Anesthesia Information Management Systems Reduce the Frequency of Prolonged Gaps in Blood Pressure Documentation

BACKGROUND: Arterial blood pressure (BP) measurement at least every five minutes is part of the American Society of Anesthesiologists' (ASA) monitoring standard, but prolonged BP gaps in electronic anesthesia records have been noted. We undertook multicenter studies to determine the frequency of cases with at least one interval ≥ 10 minutes between successive BP measurements and then to ascertain if educational feedback via an electronic, near real-time notification system alerting providers to the presence of such gaps would reduce their incidence. METHODS: We evaluated 212,706 electronic anesthesia records from three large academic centers. We determined the fraction of cases with ≥ 10 minute BP monitoring gaps at baseline and did a root cause analysis to determine common causes for these lapses. We then designed and implemented automated systems at two of the hospitals to notify point-of-care providers immediately after such 10-minute gaps occurred and determined the subsequent impact of this feedback on BP gap incidence, compared to baseline. RESULTS: At Hospital A, the notification system reduced the incidence of cases with at least one BP gap (1.48% ± 0.19% SD vs 0.79% ± 0.36% SD, p<0.0001). At Hospital B, the gap incidence was not significantly altered when notification was provided after a 10-min gap had already occurred (2.72% ± 0.60% SD vs. 2.45% ± 0.48% SD, P=0.27), but the incidence was reduced when such notification was provided after 6 minutes without a BP reading (2.72% ± 0.60% SD vs 1.54% ± 0.19% SD, P<0.0001). At Hospital C, where notification was not implemented, the baseline rate of BP gaps was consistent across the preintervention and follow-up periods (7.03% ± 1.27% SD vs. 7.13% ± 0.11% SD, p=0.74). Although monitors disconnected during position change was the most common identifiable cause of BP gaps, reasons for the missing BPs were often not documented. During a week when the electronic charting system was temporarily inoperable, no BP gaps were noted on a convenience sample of 500 paper records from Hospital A (99% upper confidence limit = 0.83%). CONCLUSIONS: BP gaps of ≥ 10 minutes were common in electronic anesthesia records, and their incidence was reduced but not eliminated by near real-time feedback to providers. The ASA standard for every 5 min BP documentation may not be achievable with current practices and technology. Anesthesia information management systems users need to be cognizant of the potential for gaps in BP measurement, take steps to minimize their occurrence, and document an explanation when such failures occur