Key result
Sequential clinical audits significantly improved the proportion of appropriately documented pre-operative anaesthetic records from 16.3% in 2009 to 43.8% in 2014.
Why the study?
Do regular audits improve the quality of peri-operative anaesthetic documentation?
Observational (n=1,788)
No
Do regular audits improve the quality of peri-operative anaesthetic documentation?
Absolute Event Rate: 43.8% vs 16.3%
p-value: p=<0.001
Regular audits on anaesthetic record keeping can lead to an improvement in the standards of peri-operative documentation.
May support sequential audits to raise anaesthetic documentation standards; leaves open generalizability and need for controlled trials.
OBJECTIVE: The aim of the audits was to assess contemporary performance, with comparison of the same against previous outcomes, to gauge trends in clinical practice. This allowed for completion of the audit cycle, as well as the ability to analyse and consistently improve the quality of care delivered to our patients. METHODS: We undertook three prospective audits on the quality of peri-operative anaesthetic documentation in the years 2009, 2011 and 2014, respectively. Anaesthetic records for patients undergoing elective as well as emergency surgical procedures were assessed for 'adequacy of peri-operative documentation' based on a combination of select criteria outlined by the Royal College of Anaesthetists and the Australian and New Zealand College of Anaesthetists. RESULTS: A total of 1000 anaesthetic records were analysed in 2009, followed by a review of 412 records and 376 documents in 2011 and 2014 respectively. In the year 2014, 43.8% of pre-operative anaesthetic records were 'appropriately' documented. This was in stark comparison to 16.3% and 25.9% in the years 2009 and 2011, respectively. The quantity of 'adequately' documented intra-operative records increased to 35.1% in 2014, in comparison to 25.5% and 22.7% in 2009 and 2011, respectively. There was an overall improvement in the standards of peri-operative documentation in consecutive audits. CONCLUSION: We propose that regular audits on 'anaesthetic record keeping' can lead to an improvement in the standards of this often overlooked, but essential scope of our practice.
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Curtis et al. (2018) conducted an observational in Peri-operative anaesthetic documentation (n=1,788). Sequential clinical audits vs. Baseline audit (2009) was evaluated on Appropriately documented pre-operative anaesthetic records (p=<0.001). Sequential clinical audits significantly improved the proportion of appropriately documented pre-operative anaesthetic records from 16.3% in 2009 to 43.8% in 2014.
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