31-Dec-2023 12:00 AM
98356
Bunare M1, Belay F2, Tageza T3*
Background: At pre-admission anesthesia clinics, the practice of patient assessment, documentation, and having a proper recording are indicating everyday tasks of an anesthesia providers. Proper record keeping is also related to improvement in the quality of care and client outcomes. The aim of current audit is to improve the practice of documentation among anesthesia professionals for outpatient surgical patients at the pre-admission anesthesia clinic at Hawassa University Comprehensive Specialized Hospital (HUCSH) in 2023.
Method: A clinical audit was employed at HUCSH pre-admission anesthesia clinic in 2023. Thirty-three predefined indicators were prepared according to the Association of Anaesthetists of Great Britain and Ireland, the Australian and New Zealand College of Anesthetists, and the Global Quality Index. Data was analyzed by using Statistical Program for Social Sciences version 24.
Results: Overall, 20 outpatient surgical patient charts in phase one and 18 charts in phase three were reviewed. In phase one, patient name, age, sex, medical history, preoperative diagnosis, vital signs, airway examination, cardiovascular examination, respiratory examination, American Society of Anesthesiologists (ASA) physical status, and final assessment were completed with higher completion rate (> 90%). Documentation of patient identification number, date of visit, allergy, weight, dental examination, risks explained, recommendations, and signature had a <50% completion rate. However, in phase three there was a significant improvement in almost all indicators, with documentation of the patient identification number, date of visit, allergy, weight, dental examination, risks explained, recommendations, and signature improved from <50% to >90%, with a maximum of 100% and weight of 83% from 0%.
Discussion: The indicator with the greatest improvement was dentition, which improved from 0% to 94%. This improvement was due to implementation of an evidence-based pre-admission pre-anesthetic evaluation form with proper training and guidance for anesthesia providers.
Conclusion: We developed a pre-admission anesthesia evaluation form for documentation at an anesthesia clinic and followed its use. This audit illustrated that the implementation of these standards has a crucial role on the improvement of documentation practices toward the standard level.
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