12. Data Collection and Audit

• The NHS is undergoing a widespread modernisation plan that includes improved use of information technology.


• Hospital Episode Statistics (HES), a division of the Department of Health, collects data on patient episodes, including operations. These data are quite crude and currently give little information about the anaesthetic.


• From April 2004, HES will record considerably more data on operations, including the type of anaesthetic, identity of the anaesthetist, ASA grade and NCEPOD code. Some trusts may have difficulty providing this information, and it is important that local managers understand its importance.


• At the time of writing, an AAGBI working party that includes members of HES, the NHS Information Authority (NHSIA), the Society for Computing and Technology in Anaesthesia (SCATA) and the RCA is working collaboratively to produce a suitable and useful dataset for anaesthesia.


• There will be local issues about collecting appropriate information and anaesthetists should be involved in specifying these systems. This will normally be done through the procurement process for Electronic Patient Records (EPR).


• Data should only be collected once, and in real time rather than by retrospective entry. Data collected as part of the clinical process will improve reliability. Anaesthetists must be aware of the security and patient confidentiality issues relating to systems they use.


• Good data collection systems in operating theatres are crucial to the increased efficiency of theatre utilisation. Records should be kept of operation, anaesthetic, recovery and transfer times (key stages in the patient's journey), any equipment shortages, reasons for cancellation and critical incidents. This will enable effective audit of the problems and stimulate change required to improve efficiency. This activity will require time and staffing (see sections 7,8 and 11).


• Electronic booking of patients for most operations is planned by 2004. This will result in change to the organisation of patient care. Anaesthetists must be involved in developing these changes, such as organised pre-operative assessment. During the lifetime of this document, it is anticipated that better data will become available enabling investigative audit leading to improved theatre efficiency.