Improvement of information gained from the pre-anaesthetic visit through a quality-assurance programme{dagger}

S. Ausset1, H. Bouaziz1, M. Brosseau2, B. Kinirons3 and D. Benhamou*,1

1Département d’Anesthésie Réanimation, 2Direction de la Prospective et de la Clientèle, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, BP 405, F-92141 Clamart, France and 3Hôpital de Bicêtre, 78 rue du Général Leclerc, F-94270 Le Kremlin, Bicêtre, France*Corresponding author

{dagger}Presented in part at the annual meeting of the French Society of Anaesthesia and Intensive Care in September 2000.

Accepted for publication: October 16, 2001


    Abstract
 Top
 Abstract
 Introduction
 Methods and results
 Results
 Comment
 References
 
Background. Pre-anaesthetic evaluation is a fundamental component of anaesthetic practice. The aims of the present study were to assess the quality of the preoperative anaesthetic information gathered and to observe the quality profile after the introduction of a standardized form. This occurred through a four-step quality assurance programme over a 4-yr period.

Methods. The proportion of cases in which a complete recording of data was collected at the preoperative assessment was evaluated by searching in each patient’s medical record for what was considered to be the minimum information required to provide satisfactory perioperative care. Fifteen criteria were selected. The recovery profile for each indicator and a global quality index (GQI expressed in %) for each patient’s record were collected. In phase 1, the existing situation was assessed. Next, a standardized pre-anaesthetic form (PAF 1) was designed and its implementation evaluated (Phase 2). Phase 3 was performed 16 months after implementation of PAF 1 to assess the long-term value. The form was revised (PAF 2) and its use evaluated again 6 months later (Phase 4). For each evaluation, the records of a 1-month period were examined. Overall 1129 medical records were audited.

Results. The GQI increased significantly from 62 to 88% with similar changes for both elective and emergency cases. The recovery profile was improved for most indicators.

Conclusions. We conclude that the quality of information recorded from the pre-anaesthetic visit is improved by using a standardized form. This will hopefully help to improve patient outcome and facilitate computerization of the anaesthetic record.

Br J Anaesth 2002; 88: 280–3

Keywords: anaesthesia; risk, management; surgery, preoperative period; anaesthesia, audit; records, medical


    Introduction
 Top
 Abstract
 Introduction
 Methods and results
 Results
 Comment
 References
 
Surgical mortality and morbidity are not only the consequences of the surgical procedure itself, but also of the patient’s preoperative physical status.14 The preoperative anaesthetic visit is aimed primarily at detecting these medical conditions and assessing their severity. Subsequent preoperative optimization of the patient’s condition reduces perioperative and anaesthesia-related risks.5 6 The preoperative anaesthetic visit also serves to guide the most appropriate anaesthetic technique and to provide patient information. This visit is thus a fundamental step of the surgical process7 8 and this has been recognized in France by a law enacted in 1994 that makes the preoperative visit mandatory before every anaesthetic administration,9 at least 2 days before surgery for non-emergency procedures.9

Despite the recognized medical and financial importance of this visit,8 there are neither detailed guidelines, nor any definition of what is the minimum/necessary information required. Most anaesthesia departments, aware of the importance of this information, have created their own preoperative assessment forms in order to standardize the information recorded. The usefulness and effectiveness of this strategy have, however, never been assessed. The only available literature relates to the pre-anaesthetic questionnaire.10 The aims of the present study are to assess the proportion of complete recording of data collected at the preoperative assessment and to observe the quality profile after the introduction of a standardized form through a four-step quality assurance programme over a 4-yr period.


    Methods and results
 Top
 Abstract
 Introduction
 Methods and results
 Results
 Comment
 References
 
Description of the process
This programme was started in November 1995, in a university teaching hospital in the suburbs of Paris (France) where the pre-anaesthetic visit and the anaesthetic itself are usually not provided by the same doctor.

The first step was to assess the existing situation. At that time pre-anaesthetic information was written on the reverse side of the anaesthesia record sheet. The quality of the pre-anaesthetic information was evaluated by searching each anaesthetic medical record for what was considered to be the minimum information required to provide satisfactory perioperative care. Fifteen criteria were selected after a detailed analysis of the anaesthetic literature. These criteria were those which appear repeatedly in the literature associated with an increased perioperative risk/odds ratio >2 (Table 1A) among general surgery patients. Every pre-anaesthetic assessment related to an anaesthetic procedure performed in January 1995 was retrospectively assessed (phase 1).


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Table 1 Criteria incorporated in the global quality index (GQI). a: criteria used during the first three phases of the quality assurance programme. b: criteria added in the fourth phase. ASA=American Society of Anesthesiologists; ICU=intensive care unit; NSAIDs=non-steroidal anti-inflammatory drugs
 
The second step (phase 2) began by designing a specific pre-anaesthetic assesment form (PAF 1) which was introduced after approval in a staff meeting. This form contained not only the 15 predefined criteria but also several others which were judged useful by the anaesthetic team. The anaesthetic records of November 1995 (i.e. 1 month after implementation of PAF 1) were retrospectively reviewed. The results of this second assessment were communicated to the medical team during a staff meeting and although results did not show a 100% improvement, the majority of the medical team believed that it was too early to propose any change in PAF 1.

A third assessment (phase 3) was thus performed on the files of January 1997 (i.e. 16 months after implementation of PAF 1) to assess the long-term profile. Again results of this survey were communicated to the medical team and it was decided to modify the form to improve the readability and to include additional information. Ten new criteria were added because the medical literature published since the beginning of the programme had demonstrated new clinically relevant criteria, and also because recent French legal obligations regarding patient information required us to modify our practice (Table 1B). The pre-anaesthetic assessment form version 2 (PAF 2) also asked for more detailed descriptions of previously used criteria.

Phase 4 consisted of an assessment of all anaesthesia records of March 1999 (i.e. 6 months after implementation of PAF 2). The new criteria defined in phase 4 were recorded but could not be compared to previous data.

Data recordings and statistical analysis
Fourteen of the 15 first quality criteria were recorded as ‘yes’ or ‘no’ while risk factors for difficult intubation were quoted as a percentage (four factors were required on PAF 1 and six criteria on PAF 2).

For each PAF, a global quality index (GQI) was calculated with the following formula:

GQI=100x(ab)/a

where a is the total number of criteria selected (i.e. a=15) and b is the number of criteria lacking. Comparisons between the four steps were made using chi-square analysis or non parametric tests (Mann–Whitney U test or Kruskall–Wallis test as appropriate). Statistical significance was set at a P value less than 0.05.


    Results
 Top
 Abstract
 Introduction
 Methods and results
 Results
 Comment
 References
 
Overall, 1129 anaesthetics were performed. Nine hundred and sixty-four patients’ clinical records could be found (85%) and reviewed. The surgical case mix was similar in all four phases. Emergency surgery was significantly less frequent in phase 1. The GQI observed for the whole population studied, including both elective and emergency cases increased significantly during the study (Figure 1). The recovery profile was modified by the programme for each indicator.



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Fig 1 Global quality index (GQI) profile during the four phases.

 

    Comment
 Top
 Abstract
 Introduction
 Methods and results
 Results
 Comment
 References
 
The main finding of this study is that the quality of information recorded from the pre-anaesthetic visit is improved by using a standardized form. Indeed, human beings are consistently unable to perform repeatedly the same complex task without forgetting to collect one or several points of information. For example, in our institution, before the start of the programme, even well-trained anaesthesiologists did not record arterial blood pressure in 24% of cases and any risk factors for difficult intubation were not recorded in 6.8% of cases. This occurred despite the fact that they were aware that these questions were fundamental parts of their pre-anaesthetic assessments. Thus, even when the theoretical usefulness is accepted, the practical application is often imperfect8 and this is a main goal of quality-assurance programmes.

This study had two weaknesses. First, it does not answer the question as to whether improving the quality of the pre-anaesthetic assessment improves patients outcome or perioperative care. However, it has been shown by the Australian Incident Monitoring Study that inadequate preoperative assessment and management were associated with a six fold increase in mortality.7 The three most common contributing factors were inadequate airway assessment, imperfect patient data transmission, and inadequate patient evaluation. Moreover, deficiencies in written notes in medical records were the most common breakdown in patients’ data communication.7 The second weakness is that analysis of medical records was made retrospectively. However, we assessed written information (i.e. the only objective knowledge that the attending anaesthesiologist could find at the arrival of the patient in the operating room). Moreover, the criteria to be assessed had been determined before looking at the medical records.

The overall quality index increased from 62 to 88% during the four phases of the programme. Almost every indicator was better recorded and none was worse in phase 4 compared to phase 1. We believe that two main factors should be discussed when assessing the profile of this change. First, a learning curve effect induced a transient decline in recording several indicators. It is interesting to note that this transient negative effect was seen only for indicators which were well recorded in the absence of a specific form and for which the margin of improvement was small. Conversely, indicators which were frequently not documented before the programme showed an immediate and sustained improvement. Second, the design of the form and its practical presentation also played a significant role, particularly for those indicators which were given more space on the form (open questions) or were asked by a specific question. By contrast, reduction of the space on the form for recording the date of the pre-anaesthetic assessment visit resulted in a decrease in the percentage of forms with a recorded date.

In conclusion, this programme resulted in a marked improvement in the proportion of complete recording of data collected at the preoperative assessment. Given the conclusions of previous reports,7 this suggests that such a programme may lead to improvement in patient outcome, though this was not evaluated in this study.


    References
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 Abstract
 Introduction
 Methods and results
 Results
 Comment
 References
 
1 Howell SJ, Sear YM, Yeates D, Goldacre M, Sear JW, Foex P. Risk factors for cardiovascular death after elective surgery under general anaesthesia. Br J Anaesth 1998; 80: 14–9[ISI][Medline]

2 Forrest JB, Rehder K, Cahalan MK, Goldsmith CH. Multicenter study of general anesthesia. III. Predictors of severe perioperative adverse outcomes. Anesthesiology 1992; 76: 3–15[ISI][Medline]

3 Pedersen T, Eliasen K, Henriksen E. A prospective study of risk factors and cardiopulmonary complications associated with anaesthesia and surgery: risk indicators of cardiopulmonary morbidity. Acta Anaesthesiol Scand 1990; 34: 144–55[ISI][Medline]

4 Khuri SF, Daley J, Henderson W, et al. Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg 1997; 185: 315–27[ISI][Medline]

5 Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 1999; 341: 1789–94[Abstract/Free Full Text]

6 Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999; 340: 937–44[Free Full Text]

7 Kluger MT, Tham EJ, Coleman NA, Runciman WB, Bullock MF. Inadequate pre-operative evaluation and preparation: a review of 197 reports from the Australian Incident Monitoring Study. Anaesthesia 2000; 55: 1173–8[ISI][Medline]

8 Roizen M. Preoperative evaluation. In: Miller R, ed. Anesthesia. New York: Churchill Livingston Inc., 1994; 827–82

9 Décret no 94–1050 du 05/12/94 relatif aux conditions techniques de fonctionnement des établissements de santé en ce qui concerne la pratique de l’anesthésie et modifiant le code de santé publique. J Officiel Rép Française 1994: 17383–5

10 Roizen MF, Coalson D, Hayward RS, et al. Can patients use an automated questionnaire to define their current health status? Med Care 1992; 30 [Suppl. 5]: MS74–84





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