|Year : 2018 | Volume
| Issue : 4 | Page : 819-824
Clinical audit on the practice of documentation at preanesthetic evaluation in a specialized university hospital
Yophtahe B Woldegerima, Semira D Kemal
Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
|Date of Web Publication||18-Dec-2018|
Yophtahe B Woldegerima
Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Performing preanesthetic evaluation, documenting, and keeping readily accessible record are responsibilities of anesthetists. Documentation can improve overall patient outcome. It also has an irreplaceable role in medico-legal aspects. Documentation is one of the challenges of providing quality care. Aim: The aim of this study was to evaluate the quality of documentation practice during preanesthetic visits. Materials and Methods: This clinical audit was conducted in the University of Gondar Hospital. Predefined 22 practice quality indicators were prepared according to modified global quality index. Statistical Analysis: Descriptive statistics was performed using SPSS version 20. Results: A total of 122 preanesthetic evaluation tools (PAETs) were reviewed. None of PAETs found fully completed according to the indicators. Trends differ between elective and emergency conditions. Indicators with high completion rate (>90%) were signed a consent, medical history, history of medication, allergy, anesthesia and surgery, cardiopulmonary examination, airway examination, preoperative diagnosis, and planned procedure. Anesthetic plan, vital signs, a name, per-oral status, premedication, and age were found with below average (<50%) completion rate. Conclusions: Documentation practice during the preanesthetic visit was below the standard. Unclear instructions should be replaced with standardized contents. Providing regular trainings on clinical documentation for students and staffs, and introducing modern electronic-based documentation system and preanesthetic clinics may improve the practice.
Keywords: Clinical record keeping, documentation, medical documentation, preanesthetic evaluation
|How to cite this article:|
Woldegerima YB, Kemal SD. Clinical audit on the practice of documentation at preanesthetic evaluation in a specialized university hospital. Anesth Essays Res 2018;12:819-24
|How to cite this URL:|
Woldegerima YB, Kemal SD. Clinical audit on the practice of documentation at preanesthetic evaluation in a specialized university hospital. Anesth Essays Res [serial online] 2018 [cited 2019 Jan 21];12:819-24. Available from: http://www.aeronline.org/text.asp?2018/12/4/819/247638
| Introduction|| |
Preanesthetic evaluation is a clinical base and framework for perioperative patient management. It potentially minimizes perioperative morbidity and mortality. The main goals of preanesthetic evaluation are to obtain vital information about the current and past medical history (PMH), settle assessments, stratify risks, essential clinical optimization, and prepare a plan of management before anesthesia and surgery. Preanesthetic evaluations enhance patient safety, resource utilization and reduce cost, delay, and cancellation.,, Inadequate preoperative evaluation and poor patient preparation are two of the most common causes of anesthetic complications. The Australian Incident Monitoring Study reported that inadequate preoperative assessment and management were directly related to increased mortality. A study on anesthesia-related perioperative deaths showed that 53 of the 135 deaths (39.25%) involved inadequate preoperative assessment and management. Hence, well-elaborated preanesthetic evaluation before the administration of anesthesia by anesthesia professional is very mandatory. Preanesthetic evaluation has several components that can be broadly classified into five major components: that are identification, history, physical examination, laboratory studies, and informed consent. Documentation is an important part of medical practice. Good documentation may improve patient outcome and easy the transfer of information from one care provider to another. Documentation of preanesthetic evaluation and informed consent should present in the patient's chart. It is very important for both quality assurance and medico-legal purposes. Inadequate documentation and poor record-keeping are challenges for quality care and better patient outcome. The American Society of Anesthesiologists (ASA) ethical guidelines for the practice of anesthesiology stated that “anesthesiologists have ethical responsibilities to their patients and should provide a preoperative evaluation.” It also should include keeping readily accessible medical record. Completed and a well-written document is very important during perioperative management and safeguards in medico-legal courts. Inappropriate documentation has potential risk for medical malpractice liability. Real-time documentation at the end of service is recommended. However, this may not always be possible due to workload., Other factors that can affect documentation practice are a use of tools, practitioner interest, and availability of information. “I did it; I just forgot to write it down… would someone be able to give a legal account of one's care if it is not documented?” Different institutions use different formats of preanesthetic evaluation. Using standardized preanesthetic evaluation tool (PAET) can help to elaborate and keep quality information. Naik et al. investigated the use of standardized form and found it can improve quality of preanesthetic evaluation and overall patient outcome. Another study has shown that using a standardized tool improved global quality index (GQI) by 26%. The design of PAET has a significant effect on the completion rate of components of preanesthetic evaluation. The general objective of the current study was to assess the practice of documentation at preanesthetic evaluation and completeness of PAETs. We aimed to improve the quality of documentation practice and preanesthetic service at large in the specialized teaching hospital.
| Materials and Methods|| |
This clinical audit aimed to evaluate the quality of practice in preanesthetic documentation. To achieve this, a descriptive study was conducted in the University of Gondar Hospital (UoGH). The hospital is a specialized referral and teaching institution found in Gondar town, Amhara regional state, Ethiopia. There were three main operation theaters, two obstetric, two gynecologic, and one ophthalmologic operation theaters in the hospital. Operation records of the hospital showed that approximately 4000 surgical operations were performed annually in the previous years. As a teaching hospital, many stakeholders are involved in preanesthetic evaluations. At the time of data collection, 87 undergraduate students, 21 postgraduate students, 18 senior and junior anesthetic staffs, overall, 126 anesthetic personnel were actively engaged in preanesthetic evaluations. Approval was obtained from the departmental council. The identities of the anesthetic personnel were kept confidential.
Preanesthetic evaluation was usually performed in wards and in the waiting area during emergency conditions. To conduct the audit project, documents of all 122 consecutive patients come for both elective and emergency operations were reviewed. A checklist was developed by the investigators based on the indicators in the modified GQI. Twenty-two quality practice indicators were selected from the GQI and labeled as “Yes” for complete documentation or checked negative, “Illegible” for partial documentation and “No” if left blank. For each item, completeness was predefined by components of the item [Table 1]. PAETs used by the anesthetists at the university hospital were reviewed after corresponding anesthetists completed each preoperative assessment. Expected completion rate was 100% for all indicators. Indicators with >90% completion rate were marked as acceptable. Completion rate of <50% was considered as areas of critically need improvement. The data were checked, coded, entered, and cleaned using SPSS version 20 (IBM Corporation, New York, United States). Descriptive analysis was performed. Cross-tabulations were done when appropriate. Results were expressed in frequencies and percentage.
|Table 1: Indicators drawn from modified GQI criteria and PAET used in UoGH|
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| Results|| |
A total of 122 PAETs used to assess patients to be undergone both elective and emergency surgical operations were reviewed during the study. Of which, 53 (43.4%) were for elective and 69 (56.6%) were for emergency operations. Sixty-seven (54.9%) were of male patients and 55 (45.1%) were of female patients.
We found none of PAETs fully completed according to indicators. Indicators with high completion rate (>90%) were signed a consent, PMH, medication history, allergy, anesthetic and surgical history, respiratory examination, cardiovascular examination, airway examination, preoperative diagnosis, and planned procedure. Anesthetic plan, vital signs, patient's name, nil per os status, premedication, age were found with below average (<50%) completion rate. The trends differ between elective and emergency operations [Table 2] and [Table 3].
|Table 3: Completion rate of indicators of physical examination and miscellaneous|
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Large numbers of PAETs 115 (94.3%) had illegible names of patients. They only had a first name or first name with a middle name. Only on 5 (4.1%) PAETs, the last name was mentioned. The remaining 2 (1.6%) had no name record.
Legible per-oral status of patients was documented only on 11 (9%) PAETs. On 57 (46.7%) PAETs, the field that describes per-oral status left blank and the remaining 54 (44.3%), either duration or type of meal mentioned. Out of these, on the majority 51 (94.4%) duration was recorded and type of meal documented only on 3 (5.6%) PAETs.
Regarding vital signs, only 1 (0.8) PAET has included all the predefined vital signs (heart rate, respiratory rate, and blood pressure) whereas on 74 (60.7%) PAETs either one or two of them were recorded. Overall, heart rate was recorded on 72 (59%), blood pressure on 45 (36.9), and respiratory rate only 1 (0.8) PAETs. From combinations, 43 (59.7%) PAET had both heart rate and blood pressure. Forty-seven (38.5%) had no any vital sign records.
| Discussion|| |
Preanesthetic evaluation helps to understand the patient's condition and facilitates perioperative care., It also can influence the satisfaction of surgical patients toward perioperative care. An Australian study showed that inadequate preoperative evaluation was associated with anesthesia-related mortality and major morbidities that needed unplanned high dependency unit admissions. It also identified poor communication as a contributing factor. Hence, it recommended fully documented assessment and accurate information exchange during assessment and care. Furthermore, failure to document relevant data itself is considered as a major breach and deviation from the standard of care then make liable.
Marco et al. compared using nonstructured and structured forms for preanesthetic evaluation and found completion rate was higher in the group used structured form. Based on the indicators used, none of the PAETs were complete. This finding was in accordance with a study done in South Africa. In the current study, PAETs used to assess patients scheduled for elective operations had higher completion rate with most of the indicators than those used in emergency conditions. Medical documentation was found to be a major obstacle for efficient treatment in emergency conditions. This finding can be explained by time constraint in emergency operations.
Patient identity is a basic component of medical records. A name is one of the identifiers used in clinical practice. In the current study, most of the names recorded (94.5%) were illegible as they did not include full name (First, middle, and last). The large difference compared to other studies might be due to legibility criteria., In the taxonomy of medical errors, record problems were classified as process errors. Inadequate identification contributes to these errors. In addition to other benefits in management, preoperative diagnosis, and surgical procedure have identification role in the operation theater., Both had documentation rate of 92.6%.
Medication history is an integral part of any medical assessment. Details of drug type, dose, route, and previous adverse events must be recorded. Help to recognize possible interactions and need for perioperative administration. Medication errors are associated with potentially dangerous harms to patients. Medication documentation errors were estimated in the range between 3.5% and 13.3%., Recently, an American study found that perioperative medication errors were recorded in 5.3% of cases. Out of this, 64.7% were serious, 33.3% were significant and 2.0% were life-threatening. Studies identified less clear preoperative instructions as contributing factors for perioperative medication errors., In our study, medication history records were complete in 113 (92.6%) PAETs. Whereas premedication orders were completely documented only in 12 (9.8%) PAETs. Trends in documentation of allergic history was 97.5%. Compared to other studies, it was higher completion rate., The incidence of allergic reactions during anesthesia is estimated 1: 10,000–20,000. The leading causative agents are neuromuscular blockers, antibiotics, and latex., Careful evaluation and documentation can help to identify and avoid triggers.
One of the determinants of pulmonary aspiration during anesthesia is oral intake. Documenting per-oral status helps to identify risk and modifying plan. Previous studies showed poor documentation of per-oral status., In this study, only on 9% of PAETs legible per-oral status documented. The time duration from the last meal was recorded more frequently than the type of meal.
Documentation of vital signs is a component of preanesthetic evaluation as a minimal requirement. Alarmingly, in the current study, only 1 PAET was found with a complete record of vital signs (at least heart rate, respiratory rate, and blood pressure). It was the only document on which respiratory rate recorded. Even though there are gaps in recording all vital signs, multiple studies have shown that respiratory rate became a neglected vital sign. However, the altered respiratory rate is a crucial predictor of serious conditions.,,
Weight has a central role to calculate the dosage of drugs, ventilation parameters, airway equipment size, fluid requirement. In this study, only 53.3% of the documents had a weight recorded. Mokgwathi et al. found a comparable result in Dr. George Mukhari Hospital, South Africa.
It is not surprising that we found airway tests documented on the majority (93.4%) of PAETs because the airway is a primary concern of anesthetists. Airway assessment is still challenging and no single or comprehensive test can accurately predict difficult airway., In UoGH, anesthetists commonly use the combination of Mallampati class, thyromental distance, jaw slide and range of neck motion to assess the airway. Along with airway, dental assessment should be done and clearly documented. A dental injury is one of the most common events that can occur in the perioperative period and anesthetists may become liable., Dental records were found in 84.4% PAETs.
Cardiopulmonary complications are potentially the most serious events that can occur during anesthesia. Through decades, cardiopulmonary events are still leading cause of morbidity and mortality for patients during the perioperative period.,, Anesthetists at UoGH tend to provide emphasis on the assessment of cardiopulmonary status. More than 95% of PAETs had cardiopulmonary assessment notes. This is in-line with previous studies., In relation to this, ASA physical status is commonly used for stratification of perioperative outcomes. We found 71.3% PAETs had appropriate ASA physical status record.
An anesthetic plan should be included in PAETs as GQI recommendations. None of PAETs had notes regarding the anesthetic plan. In contrary to this, there was a study in which anesthetic plan was checked in 96% forms. We thought this discrepancy occurred because of less clear instruction on the field dedicated to an anesthetic plan on a PAET used in UoGH. On the other side, signed consent was found in all PAETs. Even though sign for consent was present in all PAETs, compared to standards for clinical audit developed by the Royal College of Anaesthetists in 2012, we found instructions did not meet those standards.
As reasons for areas of poor documentation practice; most of the preanesthetic evaluations were done by students and junior staffs. Hence, active involvement and supervision by senior anesthetic staffs may be helpful. In emergency conditions, time has a central role. Since single anesthetist is responsible for a theater in the hospital, it may increase the workload while limited time is available. Hence increasing numbers of anesthetists per theater may be necessary. In addition, timely communication between surgical and anesthetic staffs can help to solve this problem. Inappropriate attitude toward documentation should be corrected by providing training. Utilization of traditional paper-based manual documentation can be a reason for poor documentation practice. Preanesthetic evaluations for elective cases were performed in wards; and in waiting area for emergency condition. These areas might not be ideals places for preanesthetic evaluation. Preanesthetic clinics may have the potential to solve this problem. Introducing electronic-based documentation system in the hospital can maximize the quality of information obtained and documentation practice.,
| Conclusions|| |
PAETs used to assess patients were found incomplete below the standard. Less clear instructions regarding the anesthetic plan and informed consent should be replaced with standardized contents. Providing regular training on clinical documentation and for students and staffs may improve the practice. Maintain availability of devices useful during preanesthetic evaluation. Introduce preanesthetic clinics and modern electronic-based documentation system to the hospital may help to solve problems in documentation practice.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]