title: Automatic notifications mediated by anesthesia information management systems reduce the frequency of prolonged gaps in blood pressure documentation.
abstract: BACKGROUND
  Arterial blood pressure (BP) measurement at least every 5 minutes is part of the American Society of Anesthesiologists' 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 1 interval ≥10 minutes between successive BP measurements and then to ascertain whether 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 3 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 2 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 with baseline.
  
  
  RESULTS
  At Hospital A, the notification system reduced the incidence of cases with at least 1 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-minute 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 BP measurements 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 American Society of Anesthesiologists' standard for BP documentation every 5 minutes might 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.
authors.affiliation: Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. jehrenfe@post.harvard.edu
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Ehrenfeld
authors.forename: Richard H
authors.initials: RH
authors.lastname: Epstein
authors.forename: Stephen
authors.initials: S
authors.lastname: Bader
authors.forename: Sachin
authors.initials: S
authors.lastname: Kheterpal
authors.forename: Warren S
authors.initials: WS
authors.lastname: Sandberg
mesh_terms: D000046:Academic Medical Centers; D000293:Adolescent; D000328:Adult; D000368:Aged; D000758:Anesthesia; D001794:Blood Pressure; D016208:Databases, Factual; D004282:Documentation; D004868:Equipment Failure; D005260:Female; D005500:Follow-Up Studies; D006751:Hospital Information Systems; D006801:Humans; D019451:Information Management / Q000379:methods*; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods* / Q000706:statistics & numerical data; D012984:Software; D055815:Young Adult