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 BP, 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, BP, 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.

译文

目的 : 评估麻醉训练和经验是否影响图表的完成和准确性。
方法 : 一百二十四名受试者,包括医学生,麻醉居民以及社区和大学的临床麻醉师,在模拟器环境中接受了标准化患者的治疗,并要求其进行麻醉诱导和维持。引入了三个关键事件,导致BP,HR,PETCO2和spo2的变化。按照惯例,指示受试者管理患者和麻醉图表。通过训练水平与所有四个生理变量的双向重复测量方差分析 (ANOVA) 进行比较,差异计算为实际值和图表值之间的差异除以实际生理值。图表的完整性 (定义为针对三个关键事件的四个生理变量中的每一个记录的至少一个数据点) 在训练水平,参与者年龄和实践年限之间进行了比较。
结果 : 图表的总体完整性仍然很低 (< 37%),与麻醉师的年龄,培训水平或实践年限没有关系。所有生理变量 (HR,BP,PETCO2和SpO2,P <0.0001) 的图表均存在差异,在每个训练级别内差异程度均存在显着差异。培训导致图表差异没有差异。
结论 : 根据培训水平,年龄和实践年限,所有组的麻醉记录数据图表仍然不完整且不准确。

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