Talk Description
Introduction:
The anaesthetic record is essential to safe patient care. Its primary purpose is to document the contemporaneous clinical management of a patient, but also plays a key role in education, research, quality assurance and medicolegal proceedings. The Australian and New Zealand College of Anaesthetists (ANZCA) have produced professional guidelines that set the expected standard for intraoperative documentation for general anaesthesia:
· PG06(A) Guideline on the anaesthesia record 2020 [1]
· PG18(A) Guideline on monitoring during anaesthesia 2017 [2]
A 2013 Australian observational retrospective study found that 73% of intraoperative records were non-compliant with ANZCA guidelines, with significantly poorer documentation during emergency cases (P=0.03), attributed to lack of time associated with emergent cases [3]. However, no previous publication has explored the influence of time on adherence to ANZCA intraoperative documentation guidelines.
The aims of this audit:
1. To quantify adherence to ANZCA intraoperative documentation guidelines of an Australian teaching hospital
2. To assess the influence of key covariates on adherence, including:
1. Time (Case duration and timing within 24-hour shift cycle)
2. Acuity (Elective vs Emergency)
3. Experience (Consultant vs Trainee)
3. To explore the implications and causes of non-adherence, as well as potential solutions
Methods:
All written anaesthetic records from general surgical cases that underwent a general anaesthetic between January 1st and 31st 2024 inclusive were sampled from scanned electronic records in a retrospective cohort design. Patient data was collated and analysed using a scoring system utilising key variables from relevant ANZCA guidelines to allow for objective measurement of adherence. This clinical audit was reviewed by the Monash Health Research Office and deemed exempt from Human Research Ethics Committee review (email confirmation on 1st March 2024).
Results:
Of the 100 anaesthetic records analysed, intraoperative documentation was incomplete in 93% of cases - independent of specific anaesthetic operator and type of surgery performed. Median completion score across all assessed variables was 84.8%, with five variables consistently scoring less than 90% completion: neuromuscular monitoring, temperature monitoring, breathing system and circuit, inhalational/intravenous monitoring, and position and protective measures.
Case duration did not linearly correlate with documentation completion. Timing of surgery across the 24-hour shift cycle yielded similar median completion scores.
Despite a lower median completion score (80.0% vs 85.7%), documentation of elective cases produced an almost two-fold increase in percentage of complete intraoperative anaesthetic records (11.1% vs 6.1%), compared to emergency cases.
Consultants and trainees produced similar median completion scores (84.6% and 86.7%, respectively), as well as percentage of complete intraoperative documentation records (6.8% and 8.3%, respectively).
Discussion:
These findings suggest that patients may be at increased risk of avoidable adverse events of general anaesthesia, including postoperative residual curarisation, iatrogenic hypo/hyperthermia, accidental awareness, and pressure injuries.
Time and operator experience appear to have minimal association with documentation completion; however, the acuity of surgery may play a role.
Potential causes of non-adherence include lack of equipment, awareness, and accountability. Possible solutions may include nursing-led application of monitoring, use of automated neuromuscular monitoring devices and regular auditing of intraoperative records.
Conclusion
This audit demonstrates major discrepancies between intraoperative anaesthetic records of an Australian teaching hospital and the expected standard specified in ANZCA guidelines. Non-adherence could have significant consequences for the patient, the anaesthetist, and the public trust of the profession.
Conflicts of interest:
None.
References:
1. PG06(A) Guideline on the anaesthesia record 2020 Short title: The anaesthesia record.
2. PG18(A) Guideline on monitoring during anaesthesia 2017 Short title: Anaesthesia monitoring.
3. Elhalawani I, Jenkins S, Newman N. Perioperative anesthetic documentation: Adherence to current Australian guidelines. J Anaesthesiol Clin Pharmacol. 2013;29(2):211–5.