When being good is missing the point: Closing the loop.

Sir,

We investigated the incidence of 48 h perioperative acute coronary events (PACEs) at our institution between January and December 2014. Based on our National surgical quality improvement Program (NSQIP) data, we performed a chart review of the affected patients to determine our postoperative visit compliance as well as our PACE documentation in these visits.

We determined that a postoperative visit by an anesthesia service team member had occurred in all patients with a PACE, mostly within the first postoperative day and to 100% within the recommended 48 h [Figure 1].

Figure 1

Postoperative myocardial infarction occurrence

Forty percent of PACE in our patients occurred on or after the second postoperative day and some studies suggest that the most perioperative cardiac events occur at an incidence of 5% within the first 48 h of the surgical procedure.[12] Therefore, we achieved excellent CMS compliance, but missed very important and potentially anesthesia related outcomes. We are not aware of any literature examining specifically postoperative event capture in anesthesia follow-up notes, but it is conceivable that our experience is not unique. Vacanti et al., showed that a team dedicated to completion of the postoperative anesthesia visit could increase the Centers for Medicare & Medicaid Services (CMS) compliance from 47% to 83% and they also documented an increased number of captured adverse events.[3] This seems in contrast to our experience with a 100% CMS compliance for the cases in question but still missing 40% of PACE, although Vacanti et al. did not comment on the overall capture of all postoperative event and their timeframe. Such differences may be explained by the differences of the authors' healthcare and IT systems, but also by the nature of postanesthesia adverse event evolution over several days.

We currently employ a hybrid system of paper and electronic systems, and the diversity of IT systems in place are not yet sufficiently integrated to seamlessly allow information exchange. The follow-up in our cases did not trigger electronic health record (EHR) access beyond the anesthesia information management system (AIMS), and the interpersonal communication between anesthesia clinicians, patients and their bedside care providers did not reveal the critical events either. Further follow-up information on patient outcomes is rarely reported back to the anesthesia team once the postoperative visit has concluded. The dynamic of future healthcare and the development of IT should allow for a closed loop where systems should be viewed based on a team approach and not in silos.

This observation raises several concerns that point to opportunities:

The need for real time integration of the EHR with the AIMS. The need to extend anesthesiology critical information capture for 48 h and possibly even longer postoperatively at least for in-patients, facilitated via health system integrated AIMS alerts.

Defining trigger criteria for automated anesthesia team notification about aberrant laboratory values, events or critical clinical results.

Current metrics in health care can promote the quality and safety of care and are multidisciplinary team oriented. It is, therefore, paramount to allow for multidirectional information flow within electronic information systems and to capture most if not all adverse events. We know that anesthetic management can effect the sub-acute outcomes beyond 48 h, and that there may be an extended role for anesthesia care, as demonstrated by the perioperative surgical home model. It behooves us to take the advantage of the increasing possibilities IT will offer now and in the future to more accurately assess our patients postoperatively, gather and document meaningful early outcomes and subsequently improve reporting, research and patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.