An audit of preoperative evaluation of general surgery patients at Dr George Mukhari Hospital

Abstract

Background: Preoperative evaluation of a patient is the fundamental component of anaesthetic practice. Inadequate documentation and record keeping on the preoperative evaluation form (PEF) can be a major obstacle to attaining good practice and improving patient outcomes following operative procedures. The aim of the study was to conduct an audit of the anaesthetic preoperative evaluation of general surgery patients at Dr George Mukhari Hospital (DGMH), Garankuwa. Method: This was a retrospective study, using a sample of 88 files of general surgery patients who underwent elective surgery during 2008 at DGMH. The proportion of complete information recorded on the PEF used at DGMH was compared with a modified standardised PEF that uses the Global Quality Index (GQI). Result: Seventy-five of the 88 files (85%) that were retrieved contained the PEF. The modified GQI scores for the sample of 75 patients ranged between 33.3-100%. The mean modified GQI score was 72.2 ±13.9%. The median was 73.3%, while the lower quartile was 60%, and the upper quartile, 80%. The GQI scores were low for the following criteria: preoperative diagnostic procedure (46.7%), medications prescribed by surgeons (46.7%), and preoperative fasting status (32%); and very low in terms of recording patients’ weight (34.7%) and the history of allergies (34.7%) reported during the preoperative assessment. The PEF was completed in full in line with the modified GQI score in only in 1.3% of the files. Conclusion: The overall quality of the preoperative evaluation was relatively incomplete with regard to a number of the modified GQI score criteria, suggesting the need for improvement in the completion of preoperative assessment of patients by anaesthetists at the hospital.

Keywords: anaesthesia, audit, records, medico-legal, preoperative evaluation