Anesth Analg 2004;99:1450-1452
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000132545.19806.3B
TECHNOLOGY, COMPUTING, AND SIMULATION
Access Denied; Care Impaired: The Benefits of Having Online Medical Information Available at the Point-of-Care
Barry A. Finegan, MB FFARCSI, FRCPC
Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
Address correspondence and reprint requests to Dr. B. A. Finegan, Department of Anesthesiology and Pain Medicine, 3B2.32 W. C. Mackenzie Health Sciences Center, Edmonton, Alberta, Canada, T6G 2B7. Address email to lm6{at}ualberta.ca
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Abstract
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The availability of Internet-enabled computers in the operating room (OR) facilitates unparalleled physician access to current peer reviewed research, either in abstract or full text format, a development that provides physicians with an exciting opportunity to incorporate such findings into clinical practice at the point-of-care. In this report I describe how the availability of online peer reviewed medical literature altered, in one case a planned surgical procedure and, in the other, the interpretation by the anesthesiologist of the clinical significance of an intraoperative echocardiographic finding. In case one, a free, rather than an intact, internal mammary (IM) artery graft was placed to the left anterior descending coronary artery of a patient with renal failure and an ipsilateral upper extremity arteriovenous fistula. The change occurred after the full text results of a study indicating that steal could well occur during the initiation of dialysis if an intact IM was used were made available to the surgeon. In case two, the occurrence of mild central mitral regurgitation in a Carpentier-Edwards Perimount prosthetic mitral valve was confirmed to be a benign finding after a study detailing the long term performance characteristics of this valve was accessed online in the OR. The benefits and potential pitfalls of searching and interpreting online medical information are discussed.
IMPLICATIONS: Two cases are described in which immediate access to a medical information database and other Internet available resources altered physician decision making intraoperatively. The potential benefits, limitations, and difficulties encountered using such resources in the operating room are discussed.
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Introduction
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It seems intuitive that clinical decision making should be improved if the provider has ready access to the most relevant and recent information on the health issue in question. The introduction of handheld wireless devices that facilitate the delivery of pertinent clinical information at the point-of-care (1,2) suggests that technology to enable this practice change is, or may soon be, available. Access to information to facilitate procedure scheduling, and to allow more effective human resource management, (3) is driving the purchase and installation of Internet-enabled computer hardware in operating room (OR) suites. Given the administrative imperative underlying the investment, the use by physicians of such computers in the OR is often discouraged rather than encouraged. The following case reports illustrate the importance of the availability of ready, unhindered access by anesthesiologists and surgeons to electronically stored medical literature in the OR.
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Case Reports
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Case 1
A 45-yr-old man with end-stage renal disease secondary to Type 1 diabetes mellitus undergoing routine hemodialysis via an arteriovenous fistula in his left arm presented for elective coronary artery bypass surgery. The planned surgery involved bypassing obstructions in the obtuse marginal and right coronary arteries with two saphenous vein grafts and a stenotic lesion in the left anterior descending artery with a left internal mammary (IM) graft. During the course of dissection of the IM, a discussion ensued regarding the possibility of coronary steal arising in the IM graft during subsequent hemodialysis runs. Experience with this particular scenario being limited, a search was performed using the National Library of Medicine (NLM) database PubMed. The search using the terms "CABG," "internal mammary," and "fistula" revealed a number of recent case reports including those by Kato et al. (4) and Crowley et al., (5) in which IM steal and consequent angina appeared to have occurred during hemodialysis using an ipsilateral arteriovenous fistula. The "Related Articles" link to Kato et al. (4) did not reveal any further citations of relevance. A similar search, using the GoogleTM search engine, resulted in the retrieval of a prepublication copy of a study by Gaudino et al., (6) who elegantly investigated flow patterns in the IM artery using color flow Doppler with concomitant assessment of ventricular function in five patients before and during hemodialysis. This study proved conclusively that IM steal and myocardial ischemia occur in patients with IM grafts undergoing hemodialysis via an ipsilateral arteriovenous fistula. These data resulted in a change in the planned surgery and the use of a free IM graft to bypass the obstruction in the left anterior descending artery.
Case 2
A 76-yr-old man underwent coronary artery bypass of the left anterior descending artery and replacement of an incompetent mitral valve with a 29-mm Carpentier-Edwards Perimount prosthetic mitral valve. Immediately after weaning from cardiopulmonary bypass, transesophageal echocardiographic examination revealed the presence of mild central mitral regurgitation and an anterolateral perivalvular leak. The patient was returned to cardiopulmonary bypass and the perivalvular leak was repaired. During the repair procedure PubMed was searched using the terms "mitral regurgitation" and "Perimount." Reassurance was obtained by review of the publication by Firstenberg et al., (7) which stated that mild central regurgitation in this valve immediately postoperatively was a benign finding.
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Discussion
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The last two decades have seen the role of the medical library change from being a depository of bound journals and aging textbooks—where one had to be physically present and frequently seek the assistance of a librarian to find relevant information—to an online repository of easily searchable databases and electronic journals available at any location with an Internet connection. It is imperative that the value inherent in this transformation, easy and immediate availability of the medical literature, be applied to patient care. Although there are few, if any, studies assessing the impact, positive or negative, on individual patients of immediate access by physicians to the general medical literature as described in this case report, it is clear that computer-based decision support systems can improve the performance of physicians (8).
The quality of medically-related information available on the Internet is highly variable, (9) and although criteria have been developed by several medical organizations, including the American Medical Association, (10) to appropriately structure medically-related information on web sites, the application of these principals has been limited. Health-related sites may have a commercial or advocacy agenda and thus may be unsuitable sources of robust information (11). Fortunately, for the medical professional, the NLM has developed a comprehensive abstract database of medical/biological peer-reviewed literature that provides a trusted source for physicians seeking the most recent information on any topic of medical interest. The journal database linked to this site is expanding rapidly, increasing the availability of free full text access to many of the abstracts contained in the PubMed database. Our institution has incorporated into the PubMed retrieval page an advisory icon indicating whether an institutional full-text link is available online or if a print copy is in the library. These features simplify access to the complete text of the abstracts if they are not available as free links via the NLM.
In Case 1, the compelling piece of evidence in favor of altering the surgical procedure, the article by Gaudino et al. (6) had not yet appeared in print or been archived in PubMed at the time of the procedure, highlighting the value of the timely availability online of medical research findings ahead of the print copy. The default option used in Case 1 was to search the topic in the popular GoogleTM search engine. In the search for peer-reviewed scientific information, this is definitely a less robust method than using the service of the NLM; however, as this report demonstrates, one may, albeit serendipitously, access full-text peer reviewed data before print publication and listing of the abstract in PubMed. In general, a search for medical information using general search engines, such as GoogleTM, retrieves many sites that do not have content relevant to the query. A listing and assessment of some of the more popular sites offering medical information are contained in the comprehensive study of the subject by Berland et al. (12).
Searching databases, including PubMed, is easy and satisfying if the structure and query tools of the database are familiar to the user. In the cases cited, less than 5 minutes was required on each occasion to retrieve the relevant information. It is advisable to practice using PubMed outside the OR environment and to become comfortable with it before using it in an urgent or emergency situation.
A major barrier to the widespread use of information technology in medicine is the cost inherent in providing the computer hardware at the point-of-care (1). It is crucial, if the benefits of our past and current investment in medical research are to be realized, that hardware be installed in appropriate locations and that physicians be encouraged to access relevant peer-reviewed literature of relevance to the well-being of their patients. It is equally essential that professionals behave responsibly and use point-of-care access to the Internet only for clinically relevant tasks; otherwise our credibility will rightly be called into question.
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References
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- Kato H, Ikawa S, Hayashi A, Yokoyama K. Internal mammary artery steal in a dialysis patient. Ann Thorac Surg 2003; 75: 270–1.[Abstract/Free Full Text]
- Crowley SD, Butterly DW, Peter RH, Schwab SJ. Coronary steal from a left internal mammary artery coronary bypass graft by a left upper extremity arteriovenous hemodialysis fistula. Am J Kidney Dis 2002; 40: 852–5.[ISI][Medline]
- Gaudino M, Serricchio M, Luciani N, et al. Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula. Circulation 2003; 107: 2653–5.[Abstract/Free Full Text]
- Firstenberg MS, Morehead AJ, Thomas JD, et al. Short-term hemodynamic performance of the mitral Carpentier-Edwards PERIMOUNT pericardial valve. Ann Thorac Surg 2001; 71: S285–8.[Abstract/Free Full Text]
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Accepted for publication April 27, 2004.
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Abstract
Introduction
