The performance documentation system of the Department was developed at the ‘Research Institution for Intensive Therapy’ in order to document patient statistics, medical performances and for data analysis. Using this system, all patients operated in cardiothoracic and vascular surgical operating rooms since January 1st, 1997 are registered in an uninterrupted fashion.

This documentation system is a client/server application whose hardware is made up from an import PC, several work stations and a data base server, which are located in the recovery room 1 (operation wing II), the intensive care unit 13 B2, in the office of the head of the department, in the department secretariat and in the Technician’s room of the Research Institution for Intensive Therapy. This simultaneous availability of the documentation system in central areas of the department enables physicians to enter data at any time, to gain information about the current situation in the operating rooms, the recovery room and the intensive care unit, and to institute appropriate measures as required.

The software of the documentation system consists of three modules:
1. Import module: When a patient is included in the patient data management system of the operation wing II , this module at the import PC automatically generates master data of the patient and some operation data (operating time etc.).
2. Entry and Viewing module: After a patient has been registered in the documentation system, detailed data concerning the anaesthesia protocol can be added by clicking the patient’s name:
*Premedication data (preoperative laboratory data, risk factors and allergies, ASA, NYHA and CSS scores, etc.)
*Operation data (indication for operation, performed operation, anaesthesia efforts, intraoperative incidents, names of physician and nursing staff, remarks, etc.)
After the data is entered, the patient can be admitted to the recovery room, the intensive care unit 13B2 or to other intensive care units. When admitted to 13B2, the patient is auto-matically entered into the ICDOC (Intensive Care Documentation) System.
3. Evaluation module: As the registered data are stored in a standard SQL data base, data can be recalled and statistical analyses performed for the purpose of research, quality assurance and administration. Some routine inquiries are already implemented in the system and can be performed in a few seconds at any time and for any time period. For instance, the Patient-Flow Diagram (next page) and the Operation-Overview (page after next) as well as an automatic print-out of the Medical Performance report, a quick patient search and automatic calculation of Parsonnet scores for cardiac surgical coronary and valve patients, can be obtained. Further configurations for evaluation are in the process of being developed.