Indicateur de tenue du dossier anesthésique dans les établissements de santé d’Aquitaine

Abstract

Assessing the quality of anaesthesia records according to the criteria of the reference frame of professional practices evaluation proposed by the French Anaesthetists College (Cfar) in 2005. Retrospective, multicentric study. Fifty anaesthesia records were randomly selected from each of the 64 health care settings in Aquitaine with an inpatient surgery activity. Survey sampling was based on hospital stays longer than 24h occurring during the second half of 2005 and including a surgical procedure under anaesthesia, excepting local anaesthesia or regional analgesia for labour and delivery. Information regarding the 10 evaluation criteria defined by the Cfar and the French National Authority for Health were gathered. For each setting, the mean completion of the 50 records was rated by a global indicator defined by the number of criteria in conformity divided by the number of relevant criteria. Three thousand one hundred and ninety-three anaesthetic files were screened. The completion of criteria varied between 1 and 92% with a wide dispersion for some criteria according to settings. Completions of airway assessment, preanaesthetic visit and perianaesthetic incidents/accidents were lower than 50%. The median conformity rate of the global indicator was 57%. This study brings information concerning the clinical relevance of anaesthesia records and preoperative evaluation practices.