Clinical audit on quality of preanesthesia evaluation

Salman Shahzad, FCPS, MSc (Pain Medicine)1, Tahira Younas, FCPS2, Eitzaz-ud-Din Khan, DA, MCPS, FCPS3
Author affiliations: 
  1. Senior Registrar; E-mail: doctorsalmanshahzad@hotmail.com; Phone: +92-333-4590374
  2. Senior Registrar; E-mail: tahira_younas@hotmail.com; Phone: +92-321-9628023
  3. Consultant Anesthesiologist / Chairman, Department of Anesthesiology; E-mail: eitzaz1@gmail.com; Phone: +92-331-7674446
Department of Anesthesiology, Pakistan Kidney and Liver Institute & Research Center, One PKLI Avenue, DHA, Phase-6, Lahore, Pakistan

Correspondence: Dr. Salman Shahzad, Senior Registrar, Department of Anesthesiology, Pakistan Kidney and Liver Institute & Research Center, One PKLI Avenue, DHA, Phase-6, Lahore, Pakistan; E-mail: doctorsalmanshahzad@hotmail.com; Phone: +92-333-4590374

Abstract
Background: Preoperative evaluation (PAE) gives in-depth view of patient’s clinical condition and helps match mode of anesthesia accordingly. This study was planned to assess the quality of documentation in pre-anesthesia assessment form (PAAF) completed during preoperative assessment.
Methodology:  This descriptive study was conducted at Pakistan Kidney and Liver Institute and Research Center (PKLI & RC) Lahore. Pre-Anesthesia assessment forms of patients operated from 1st January to 31st December 2019 were reviewed. A 22-components modified Global Quality Index (GQI) was used to assess the quality of PAAF. Descriptive statistical analysis was performed using SPSS version 25.
Results: Completion was excellent (100 %) in only one indicator; eighteen indicators had an acceptable completion rate (90-99 %) while three indicators were completed in < 90 % PAAF. Consent was the only component complete in 100% PAAF. Documentation of age (25%), past medical history (89.4%) and fasting status (88.4%) were the least documented aspects of PAAF. The average completion rate was 93.5 ± 5.2 % and all 22 indicators of GQI were completed in 14.3% PAAF.
Conclusion:  Our audit shows that majority of PAAF are complete and all its components have been well documented. Only few elements were not recorded in some PAAS. Further education and audit will be required to achieve complete documentation.
Key words: Preanesthesia assessment; Preoperative evaluation; Documentation; Global Quality Index
Citation: Shahzad S, Younas T, Khan EUD. Clinical audit on quality of preanesthesia evaluation. Anaesth. pain intensive care 2021;25(1):15-20;
DOI: 10.35975/apic.v25i1.1429
Received: 31 October 2020, Reviewed: 22 December 2020, Accepted: 23 December 2020

Introduction
Pre anesthesia evaluation (PAE) is an essential component of patients undergoing anesthesia for various surgical reasons.1 PAE gives anesthesiologists an in-depth view of the patient’s current medical condition, past adverse events due to anesthesia or surgery and expected anesthesia challenges in the upcoming surgery.2 It enhances patient safety, operation theater resource utilization, reduces delays and cancellation on the day of surgery.3 Optimum preoperative assessment enhances communication among healthcare professionals and ensures the continuity of the care.4 Presence of PAE and informed consent in the patient’s chart is essential for both medico-legal purposes and quality assurance. Ethical guidelines of The American Society of Anesthesiologists (ASA) states that “it is an ethical responsibility of anesthesiologists to provide a preoperative evaluation to their patients and should be accessible in the patient record.5 An Australian incident monitoring study has reported that poor pre‐operative evaluation and preparation was directly related to increased morbidity and mortality.6 Factors such as workload, availability of information, practitioners’ experience, interest and availability of standard assessment policy can affect the preoperative documentation.7 Presence of a standardized PAE tool can improve the quality of information and enhance patient’s outcome.8
Pakistan Kidney and Liver Institute and Research Center (PKLI & RC) maintains a policy of pre-anesthesia assessment as well as a standard Pre-Anesthesia Assessment Form (PAAF) which is based on current international standards as well as Punjab Healthcare Commission (PHC) standards. The objective of this study was to assess the quality of pre-anesthesia evaluation by checking the documentation in pre-anesthesia assessment form completed during the preoperative assessment at PKLI & RC.

Methodology
This hospital-based descriptive study was carried out at Pakistan Kidney and Liver Institute & Research Center (PKLI & RC), Pakistan. After permission from the Institutional Review Board, PAAF used at PKLI &RC (ANAES-F0001-V3) for preoperative assessment of patients before surgery was reviewed. The identities of the anesthesiologists and patients were kept confidential. Patients operated the operation theater of PKLI & RC were included in this audit. Patients operated under local anesthesia were excluded from this study.
A checklist based on the Global Quality Index (GQI) with 22 indicators was used to assess the quality of assessment which has been used previously.9 Each component was labeled as “complete” if it had full or adequate information documented, “incomplete” if inadequate or partial documentations, “illegible” for Information not clear enough to read and understand or “blank” if a component had no documentation (Table I). The primary outcome of this audit was to determine the percentage completion of individual GQI indicators and the overall percentage of complete PAAF which was
Table I: Modified GQI indicators and criteria
Indicator Predefined Components For Completeness
Name of Patient First and last name present
Age Value & unit present
Gender Mentioned
Date of visit Date/month/year mentioned
Anesthesiologist’s Name Name present
Past medical history Previous or coexisting illness with duration & treatment mentioned
Preoperative diagnosis Diagnosis present
Surgical procedure Surgical procedure present
Anesthetic history Surgical procedure, anesthesia type, time and any complication mentioned
Medications Type, dose, and route
Allergies Trigger and extent of reaction mentioned
Fasting Status Either fasting status mentioned or advised
Preoperative Vitals At least heart rate, BP, O2 Saturation and temperature
Weight Value with unit
Airway assessment At least mallampati view, thyromental distance, jaw slide, and neck movement
Dental status Status documented (healthy, non-natural, broken, loosen or lost or artificial)
Cardiovascular examination At least auscultation note
Respiratory examination At least auscultation note
ASA class ASA Class mentioned
Pre-medication advice Type, dose, and route
Anesthesia Plan Anesthesia plan mentioned
Consent Signed and available
.
calculated by dividing the number of complete indicators by total GQI. A total of 1230 patients were operated from 1st January till 31st December 2019. A sample size of 293 cases was calculated taking a population of 1230, a confidence interval of 95% and 5% margin of error. The sample was collected through a random number table. Data were checked, coded and analyzed by SPSS V.25 (IBM Corporation, New York, United States). Descriptive analysis was performed for individual GQI indicators and results were presented as frequency and percentage while overall PAAF completion rate was presented as means and SD. A completion rate of 100% was rated as excellent for all indicators. A completion rate of 90-99% was marked as acceptable. A completion rate of < 90% was marked as a critical area needing further improvement.

Results
Out of 22 indicators, documentation of only one was marked as excellent, 18 were acceptable while 3 were marked as critical. Consent was complete in 100% of PAAF, whereas age, past medical history and fasting status were documented in < 90% of cases. Details of individual indicators are given in Table 2.

Table 2: Completion of Individual GQI Indicators
Indicators n (%) Complete Incomplete Illegible Absent Assessment
Name of Patient 289 (98.7) 3 (1.0) 1 (0.3) Acceptable
Gender 290 (99.0) 3 (1.0) Acceptable
Age 74 (25.3) 1 (0.3) 218 (74.4) Needs Improvement
Preoperative diagnosis 290 (99.0) 3 (1.0) Acceptable
Surgical procedure 291 (99.3) 2 (0.7) Acceptable
Date of Visit 292 (99.7) 1 (0.3) Acceptable
Anesthesiologist name 292 (99.7) 1 (0.3) Acceptable
Past medical history 262 (89.4) 30 (10.2) 1 (0.3) Needs Improvement
Anesthetic history 289 (98.6) 4 (1.4) Acceptable
Medication history 272 (92.8) 1 (0.3) 20 (6.8) Acceptable
Allergies 290 (99.0) 3 (1.0) Acceptable
Fasting status 259 (88.4) 34 (11.6) Needs Improvement
Preoperative vitals 287 (98.0) 5 (1.7) 1 (0.3) Acceptable
Weight 288 (98.3) 2 (0.7) 3 (1.0) Acceptable
Airway assessment 265 (90.4) 25 (8.5) Intubated 2 (0.7) 1 (0.3) Acceptable
Dentation 286 (97.6) 7 (2.4) Acceptable
CVS examination 284 (96.9) 9 (3.1) Acceptable
Respiratory examination 284 (96.9) 9 (3.1) Acceptable
ASA class 291 (99.3) 2 (0.7) Acceptable
Premedication 276 (94.2) 17 (5.8) Acceptable
Anesthesia plan 283 (96.6) 10 (3.4) Acceptable
Consent 100 (100.0) Excellent
.
The average completion rate of PAAF was 93.5 ± 5.2%. Forty-two (14.3%) PAAF were 100% complete while a significant number (67) of PAAF were <80% complete. (Figure 1)

Discussion
A standard pre-anesthesia assessment is key for efficient and safe anesthesia practice.10 Inadequate preoperative assessment can lead to poor communication and can be a contributing factor for unplanned high dependency and intensive care unit admissions.11,12 Moreover, good medical practice demands a physician to document all essential aspects of a patient’s medical history as a standard of care.13 Therefore, it is essential to fully document accurate information in the preoperative assessment.
The mean completion rate for our sample of 293 PAAF was 93.5 ± 5.2% with a minimum of 68.2%.
A6-Fig1
These results go beyond the previous report by Mokgwathi et al.14 who reported a modified GQI score of 72.2 ± 13.9%. He used a 15-item GQI whereas we used 22-components GQI. This difference could be due to the continuous supervision of junior staff in our pre-anesthesia clinic.
There are several essential components of patient history that need to be documented in the preoperative assessment. These include comorbidities, allergies, routine medication, vitals and most importantly airway assessment.15 The use of a structured PAE form and health management information system (HMIS) ensures that each component is documented. Edwards et al.16 have reported a high completion rate in anesthesia information management system (AIMS) technology as compared to a handwritten anesthetic record. Marco et al.17 concluded that structured forms for preanesthetic evaluation had a higher completion rate than non-structured.
Patient identification is the basic component of PAE and correct patient identification can prevent error and serious harm to the patients.18 In our study, the patient's name was present in 98.6% of cases. Illegible writing in non-structured handwritten form is a major reason for poor patient identification. Preoperative diagnosis and surgical procedure along with patient’s name assist in correct identification.19
Our results demonstrated that the weight of the patient was mentioned in 98.3% of PAAF. It helps in the determination of drug doses, dose adjustment in case of an obese patient, calculation of perioperative fluid administration, adjustment of ventilatory settings and assessing airway equipment size. Contrary to our finding, Mokgwathi et al. found a very low (34.7%) recording of patients' weight.20
Baseline blood pressure, heart rate, respiratory rate, oxygen saturation and temperature are necessary to document in preoperative assessment.20 Interestingly, in this study, there is a 98.0% completion rate of vital signs. Alteration or deviation from the baseline vital signs especially blood pressure measurement could be due to anxiety or perhaps the patient might skip taking the recommended prescription and must be taken into account before surgery.
Medication history in terms of drug name, doses, routes or any adverse drug reactions should be inquired and documented. This is imperative because of possible drug reactions, interaction and cross-sensitivity with anesthetic drugs could have potentially life-threatening consequences.21 Our study revealed that medications were documented in 92.8% of cases. Swart et al.22 estimated about 67.9% of preoperative assessments had mentioned medication history. In this audit, documentation of allergic history was complete in 99.0% of PAAF. A similar high (92.6%) documentation rate has been reported.23 Allergic drug reaction accounts for 1:10,000-20,000 in anesthesia, common causative agents include neuromuscular blocking agents, antibiotics and latex.24
Questioning regarding the last oral intake is a compulsory component of preoperative assessment. This determines the risk of pulmonary aspiration, helps to modify the plan of anesthesia accordingly.25 This audit revealed that fasting status or advice was present in 88.4% of cases. This is contrary to previous studies where a very low rate of fasting status was reported.22,23 This difference could be due to the format of our PAAF where fasting status is written immediately beside the final clearance. This makes documentation of fasting status easy but despite this, competition is less than the acceptable target of our study.
A preoperative assessment is not considered optimum without airway assessment. Airway assessment tests have variable sensitivity and specificity, hence multiple tests are performed in order to increase the accuracy of difficult airway prediction.26 In our study, airway assessment was present in 90.4% of cases while it was incomplete in 8.5% of PAAF. Some studies have revealed higher airway assessment documentation27 while others have reported a much lower assessment.22 Dental condition and denture assessment were present in 97.6% of PAAF.
Determination of the cardiopulmonary status of the patient is another essential part of preoperative assessment because perioperative cardiovascular complications are the leading cause of perioperative morbidity and mortality.28,29,30 In this study, cardiovascular assessment is completed in 96.9 % of the cases, which is almost in line with Mokgwathi et al.14 who determine a 100% documentation rate while Swart et al. reported a lower rate (74.1%).22
Preoperative assessment results in the patient’s categorization into American Society of Anesthesiologists (ASA) classification to quantify the risk associated with surgery and anesthesia and formulation of anesthesia plan which is based on the patient’s clinical condition.31 In this study, 99.3% of patients were classified according to ASA. Fortunately, 96% of the PAAF had mentioned a proposed anesthesia plan. Consent was taken in 100% of cases after explaining this to the patient. This is because of multi-level checks to ensure complete documentation of patients undergoing surgery.
There are certain factors that affect the adequate preoperative assessment. An assessment usually by junior doctors and residents, limited staff responsible for assessment, time constraint and workload may hinder the efficiency. In addition, there is always a chance that certain essential elements can be missed in the unstructured, especially paper-based assessment. Our study has a relatively high completion rate because patients are assessed in the designated preoperative clinic for elective cases, senior doctors supervise the junior doctors, regular training, and use of a structured PAAF. This audit has highlighted key areas that will be focused on in order to overcome deficient areas.
There are certain limitations to this study. Firstly, the sample size is composed of elective cases. Time constraints and clinical conditions in emergency cases affect the documentation which ultimately affects the quality of assessment. Secondly, premedication details are not always mentioned because PAAF does not specify medication details. Continuation of routine medicine for comorbid conditions and any specifically indicated medication such as aspiration prophylaxis and anxiolytics were not always specified. Despite this, the results of our study are supporting because documentation about the majority of indicators was acceptable.

Conclusion
Our study elaborates that consent is the only the component documented in all pre-anesthesia assessment forms whereas the quality of preoperative assessment is acceptable in the majority of pre-anesthesia assessment forms. Documentation of certain indicators such as age, past medical history and fasting status need to be improved.

Conflict of interest
The authors declare no conflict of interest. No financial support was involved

Authors’ contribution
SS: Study conception planning and drafting, acquisition of data and analysis, drafting of manuscript.
TY: Drafting the audit, data collection and analysis, manuscript writing
EK: Planning and facilitation of audit, data collection and analysis, final approval of manuscript

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