Perioperative Electronic System A New Approach for Perioperative Nursing Performance Márcia Baptista1, Rita Silva2, Helena Gonçalves Jardim3 and António Quintal4 1Department of Information Technology Research, Santiago Compostela University, Spain 2OR, SESARAM Hospital, Funchal, Madeira, Portugal 3Health Higher School (ESS), Madeira University and The Health Sciences Research Unit: Nursing, Coimbra, Portugal 4Madeira 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 2 BACKGROUND AND SIGNIFICANCE According to World Health Organization (WHO), information and communication technologies (ICTs) The perioperative background is a unique have great potential to improve health in both environment that includes many challenging developed and developing countries by enhancing variables: complex clinical care performed by teams, access to health information and making health high cost, sophisticated technologies that often do services more efficient. They can also contribute to not interoperate and a large array of supplies, improving the quality of services and reducing their instruments, and implants that are difficult to cost. Patient information systems have the ability to manage. These variables create a setting of massive track individual health problems and treatment over complexity and are a source of a significant time, giving insight into optimal diagnosis and percentage of patient safety-related adverse events treatment of the individual as well as improving the (Jacques and Minear, 2008). delivery of services and care. An opportunity Surgical procedures are often the most intensive emerges to centre the patient in the care sphere, and efficacious therapeutic interventions available in ensuring security, efficiency, accessibility and medicine and these treatments are frequently quality, in health assistance. Soon, ICT will establish curative and are sometimes the only alternative for fast and effective communication among patients. Surgeons and other professionals are highly stakeholders, providing information and producing trained us the technology and resources that they knowledge and we all will benefit from its employ are typically advanced, expensive and scar- implementation. ce. So the optimization of these limited resources is paramount to the safe, effective, and efficient delivery of healthcare (Doebbeling et al, 2012). 505 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 Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved HEALTHINF 2018 - 11th International Conference on Health Informatics Perioperative information technology has the information gathered and included in potential to improve the quality of health care, documentation. These advantages aid in the reduce costs, decrease medication administration provision of safe handoffs, leading to safe patient errors, reduce time spent on paperwork, increase care and improved communication throughout the management efficacy and allow affordable access to health care system. These advantages also address health care. Researchers concluded that IT or the exposed gap involving the transfer of care that automation of aspects of the surgical patient takes place every day as patients move in and out of preparation process and the coordination and the operative areas (Yontz et al, 2015). management of surgical equipment has the potential This trend will continue as improvements are to increase the speed of information exchange, made in computer hardware, software, and reduce interruptions to clinicians and decrease the telecommunication infrastructure and as countries possibility of adverse events in the perioperative develop the skills necessary to implement electronic setting. With migration to the use of an electronic data storage and transmission systems (WHO, health record (EHR) in the operating room (OR), 2012). time that nurses previously spent on paperwork and administrative functions can be dedicated to providing better patient care and ensuring accuracy 3 STUDY PURPOSE in documentation (Sweeney, 2010). Contribute to the perioperative nursing care 2.1 Electronic Health Record improvement by recreating innovated nursing practices through the conception and implementation The electronic health record (EHR) is a particular of a perioperative electronic system. 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 4 STUDY OBJECTIVES and scientific, enabling communication between the members of the multidisciplinary team and Construct and implement a perioperative nursing continuity of care to the client. HER systems have electronic system at Doctor Nélio Mendonça Hospital; the potential to transform the health care system Evaluate health gains through the application of from a mostly paper-based industry to one that a dynamic and holistic model created for surgery utilizes clinical and other pieces of information to patient features and perioperative nursing practices; assist providers in delivering higher quality of care Calculate perioperative nursing production and to their patients (Menachemi and Collum, 2011). quality indicators. 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 5 METHODOLOGY patients, the perioperative setting is the initial entry point into the health care system, either through 5.1 Sample and Setting scheduled or unscheduled surgery. Correct and efficient use of the EHR can improve The setting for this project was the OR at Dr. Nélio communication throughout the system and help Mendonça Hospital. create a safer and more efficient patient-centered Perioperative nurses and surgery patients divided experience. Additional advantages of EHR use in the in two stages: before and after the implementation of perioperative setting include clear communication of the electronic system were the targeted populations information to other departments and effectively for this project. capturing workload, standardize perioperative This sample population was considered as causal nursing procedures, optimize the OR management or as a matter of convenience and it was process, adapt the nursing interventions to the characterized as non-probabilistic. The 113 nurses patient needs, improve the quality of customer were divided in two groups: the 1st group had 83 service in the OR. Patient care is enhanced and nurses and 2nd had 30 nurses. These nurses came improved when information can be easily accessed. from all areas of operative services. All the nurses In addition, there is less repetition of patient were invited to participate in the study. Inclusion 506 Perioperative Electronic System - A New Approach for Perioperative Nursing Performance criteria for the sample included the following: must A literature review on perioperative nursing was be a perioperative registered nurse. performed with special consideration for external / There was a second sample of 460 surgery internal norms, guidelines and mandatory protocols patients also divide in two groups with 230 patients inherent to the OR and perioperative nursing records in each one. Inclusion criteria for this sample from imperative organizations (DGS, ACSS, Dr. included patients with 65 years old and more for Nélio Mendonça Hospital) to assure its execution. elective surgery with no signs of cognitive deficit. The intervention strategies established periodic meetings with the different intervening areas; 5.2 Design training session’s development for surgical services nurses in the OR and in the "Perioperative Nursing" An observational, quantitative and descriptive situation; monitoring and evaluating perioperative survey design was used to determine perioperative electronic system procedures; continued adjustment nursing practices towards the use of the electronic