The practice of documentation at a pre-admission anesthesia clinic among anesthesia professionals for outpatient surgical patients: a quality improvement study
Keywords:
Clinical audit, Documentation, Pre-Admission, Pre-Anesthesia Clinic, Preoperative, EvaluationAbstract
Background: At pre-admission anesthesia clinics, the practice of evaluation, documenting, and having an accessible record are everyday tasks of anesthetists. Documentation can also improve patient outcome. This study aimed to evaluate the practice of documentation among anesthesia professionals for outpatient surgical patients at the pre-admission anesthesia clinic at Hawassa University Comprehensive Specialized Hospital in 2023. Method: A clinical audit was conducted at the Hawassa University Comprehensive Specialized Hospital pre-admission anesthesia clinic in 2023. Thirty-three predefined indicators were prepared according to the Association of Anaesthetists of Great Britain and Ireland, the Australian and New Zealand College of Anesthetists, and the Global Quality Index. SPSS version 20 was used for all analyses. Results: A total of 20 outpatient surgical patient charts in phase one and 18 charts in phase three were reviewed. In phase one, indicators with a high completion rate (>90%) of documentation were patient name, age, sex, medical history, preoperative diagnosis, vital signs, airway examination, cardiovascular examination, respiratory examination, American Society of Anesthesiologists (ASA) physical status, and final assessment. Documentation of patient identification number, date of visit, allergy, weight, dental examination, risks explained, recommendations, and signature had a <50% completion rate. However, in phase three there was a significant improvement in almost all indicators, with documentation of the patient identification number, date of visit, allergy, weight, dental examination, risks explained, recommendations, and signature improved from <50% to >90%, with a maximum of 100% and weight of 83% from 0%. Discussion: The indicator with the greatest improvement was dentition, which improved from 0% to 94%. This improvement was due to implementation of an evidence-based pre-admission pre-anesthetic evaluation form with proper training and guidance for anesthesia providers. Conclusion: We developed a pre-admission anesthesia evaluation form for documentation at an anesthesia clinic and followed its use. This audit demonstrated and confirmed that the implementation of these guidelines has a significant effect on the promotion of documentation practices toward the standard level.
References
Emanuel-macpherson. The-anaesthetic-pre-admission-clinic-is-effective-in-minimising-surgical-cancellation-rates; 2013.
Kasaye MD, Beshir MA, Endehabtu BF, Tilahun B, Guadie HA, Awol SM, et al. Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021. BMC Health Serv Res. 2022;22(1):465.
Nilakantam S, Gurudatt C, Dayananda M. Setting up preanesthesia evaluation clinic; An experience of planning and establishment at a private medical college and hospital. International Journal of Health & Allied Sciences. 2020;9(3):246-50.
Gupta A, Gupta N. Setting up and functioning of a preanaesthetic clinic. Indian J Anaesth. 2010;54(6):504-7.
Zambouri A. Preoperative evaluation and preparation for anesthesia and surgery. Hippokratia. 2007;11(1):13-21.
Kamau A, Mung'ayi V, Yonga G. The effect of a preanaesthesia clinic consultation on adult patient anxiety at a tertiary hospital in Kenya: a cohort study. Afr Health Sci. 2017;17(1):138-46.
Blitz JD, Kendale SM, Jain SK, Cuff GE, Kim JT, Rosenberg AD. Preoperative Evaluation Clinic Visit Is Associated with Decreased Risk of In-hospital Postoperative Mortality. Anesthesiology. 2016;125(2):280-94.
Distinguishing Between a Pre-Anesthesia Evaluation and a Separately Reportable Evaluation and Management Service.
Woldegerima YB, Kemal SD. Clinical Audit on the Practice of Documentation at Preanesthetic Evaluation in a Specialized University Hospital. Anesthesia Essays and Researches. 2018;12(4):819-24.
Bierle DM, Raslau D, Regan DW, Sundsted KK, Mauck KF. Preoperative Evaluation Before Noncardiac Surgery. Mayo Clin Proc. 2020;95(4):807-22.
Mokgwathi G BB, Ogunbanjo G. An audit of preoperative evaluation of general surgery patients at Dr George Mukhari Hospital. . South African J Anaesth Analg 2011;17(2):177–80.
Schwartz AJ. Anesthetic Records: Lessons about Ethics and Education. Anesthesiology. 2016;124(6):1208-9.
Saxena N. Airway management plan in patients with difficult airways having regional anesthesia. J Anaesthesiol Clin Pharmacol. 2013;29(4):558-60.
Kasaye MD, Beshir MA, Endehabtu BF, Tilahun B, Guadie HA, Awol SM, et al. Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021. BMC Health Services Research. 2022;22(1):465.
Woldegerima YB, Kemal SD. Clinical Audit on the Practice of Documentation at Preanesthetic Evaluation in a Specialized University Hospital. Anesth Essays Res. 2018;12(4):819-24.
Gutheil TG. Fundamentals of medical record documentation. Psychiatry (Edgmont). 2004;1(3):26-8.
Woldegerima Y KS. Clinical audit on the practice of documentation at preanesthetic evaluation in a specialized university hospital. . Int J Surg Open [Internet] 2019 16:1–5.
Naik SV, Mohammad B, Dhulkhed VK. An Audit of Comparison of Perioperative Outcomes with the Introduction of Standardized Preoperative Evaluation form at a Tertiary Care Hospital in Rural India. Anesth Essays Res. 2017;11(2):426-30.
PG. S. Preoperative, intraoperative, and postoperative anesthesia assessment and monitoring in oral surgery Oral Maxillofac Surg Clin North Am [Internet]. 2013;25(3):367–71.
Worku M, Loha E. Assessment of client satisfaction on emergency department services in Hawassa University Referral Hospital, Hawassa, Southern Ethiopia. BMC Emerg Med. 2017;17(1):21.
Zuck D. The Association of Anaesthetists of Great Britain and Ireland 1932-1992 and the Development of the Specialty of Anaesthesia. Anaesthesia. 2000;55(11):1144-5.
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