1Département dAnesthésie 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
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
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Abstract |
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Methods. The proportion of cases in which a complete recording of data was collected at the preoperative assessment was evaluated by searching in each patients 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 patients 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: 2803
Keywords: anaesthesia; risk, management; surgery, preoperative period; anaesthesia, audit; records, medical
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Introduction |
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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.
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Methods and results |
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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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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 (MannWhitney U test or KruskallWallis test as appropriate). Statistical significance was set at a P value less than 0.05.
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Results |
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Comment |
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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.
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References |
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