An audit of documented preoperative evaluation of surgery patients at Universitas Academic Hospital, Bloemfontein

Abstract

Background: The anaesthetic preoperative evaluation of a patient is the clinical foundation of  perioperative patient management, and can potentially reduce operative morbidity and enhance patient outcomes. Generally, anaesthetists complete a standardised preoperative anaesthetic record (PAR) form to improve the quality of the information obtained during their pre-anaesthetic visit. Previous studies reported an unacceptable standard of preoperative assessment recordkeeping. The aim of the study was to audit the documented preoperative anaesthetic evaluations of surgery patients at Universitas  Academic Hospital, Bloemfontein.
Methods: For this retrospective study a sample of 81 patients, who underwent surgery during May 2013, was randomly selected. The information obtained from the standardised PAR form in each patient’s file was audited using a self-generated checklist, based on the measures and criteria incorporated in the Global Quality Index.
Results: Although 100% of files retrieved contained the PAR form, none of these forms were fully completed according to the study checklist used. Criteria where less than 50% were completed correctly included: ‘per os’ status (1.2%), current medication (37.0%), preoperative diagnosis (38.3%),  preoperative vital signs (43.2%), American Society of Anesthesiologists Physical Classification (44.4%), airway assessment (45.7%), anaesthetic history and complications (48.2%) and special investigation  results (49.4%).
Conclusions: The documented preoperative evaluations were incomplete with regard to a number of criteria, as also found in studies conducted at two other national institutions. Training and evaluation regarding completion of preoperative assessment of patients by anaesthetists is needed at Universitas Academic Hospital.

Keywords: academic hospital, audit, preoperative anaesthetic record, surgery