Clinical audit on quality of preanesthesia evaluation
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
