Perioperative Documentation Research Articles

6302051 Strengthening Perioperative documentation: The ALCOA+ approach in Obstetric Anaesthesia record keeping

6302051 Strengthening Perioperative documentation: The ALCOA+ approach in Obstetric Anaesthesia record keeping

Intraoperative Hypotension Is Associated with Postoperative Nausea and Vomiting in the PACU: A Retrospective Database Analysis

Multiple risk factors for postoperative nausea and vomiting (PONV)-a very distressing and outcome-related complication-have been identified, including female sex, absence of a history of smoking, history of PONV, and postoperative opioid use. Evidence of association of intraoperative hypotension with PONV is contradictory. A retrospective analysis of the perioperative documentation of 38,577 surgeries was conducted. The associations between different characterizations of intraoperative hypotension and PONV in the postoperative care unit (PACU) were investigated. First, the relationship between different characterizations of intraoperative hypotension with regard to PONV in the PACU was investigated. Secondly, the performance of the optimal characterization was assessed in an independent dataset derived via random split. The vast majority of characterizations showed an association of hypotension with the incidence of PONV in the PACU. In a multivariable regression, time with a MAP under 50 mmHg showed the strongest association with PONV in terms of the cross-validated Brier score. The adjusted odds for PONV in the PACU were estimated to be 1.34 times higher (95% CI: 1.33-1.35) when a MAP was under 50 mmHg for at least 1.8 min than when a MAP remained above 50 mmHg. The finding indicates that intraoperative hypotension may yet be another risk factor for PONV and therefore emphasizes the importance of intraoperative blood pressure management not only in patients at risk for cardiovascular complications but also in young and healthy patients at risk of PONV.

Bones, groans and sending patients home: Perioperative opioid-related harm reduction strategy utilisation in a regional New South Wales (NSW) hospital.

Perioperative initiation of opioids continues to be a major contributor to chronic use, misuse and diversion in regional areas. There is considerable effort to mitigate harm through avoiding excessive prescribing and reducing the risk of persistent postoperative opioid use. Improving perioperative documentation practices has been reported to ensure appropriate opioid initiation and de-escalation. It has not been established whether these strategies are utilised in regional hospitals. A retrospective observational study of perioperative opioid prescribing and documentation practices in Goulburn Base Hospital, a regional centre in the Southern New South Wales (NSW) Local Health District. Data were collected from 110 records and validated for adult patients undergoing elective total knee replacement (TKR) or total hip replacement (THR) from 12 January 2020 to 13 January 2021. To observe perioperative opioid prescribing and utilisation of harm reduction strategies in a regional hospital. 65% of patients were opioid naïve (ON). Preoperative pain assessments and patient education were completed in 23% and 15% of records, respectively. Postoperative opioids were prescribed for 99% of patients, with 74% prescribed a slow-release (SR) formulation. 50% of patients were discharged with an SR prescription. Inadequate postoperative pain control was reported in 21% of patients. Of the 103 patients prescribed opioids on discharge, only 20% included a de-escalation plan and only 35% of discharge summaries included dose and quantity of opioids supplies. This study has identified underutilisation of perioperative harm reduction strategies despite the potential to improve appropriate initiation and de-escalation of opioids. These findings highlight opportunities for improvement in regional hospitals.

Guidelines in Practice: Patient Information Management.

Patient information management can involve paper and electronic documentation. Because the patient's health care record (HCR) is a legal document, it must provide an accurate representation of care. The record contains protected health information and must be secure. In addition, the documentation must adhere to local, state, and federal regulations and facility policies; it also may incorporate recommendations from national professional guidelines. The AORN "Guideline for patient information management" was recently updated and provides evidence-based best practices for comprehensive perioperative documentation that aligns with the nursing workflow. This article includes an overview of patient information management and discusses recommendations for health information technology, the patient HCR, perioperative record design, documentation and nursing workflow, informed consent documentation, order documentation, modifying patient HCRs, education, policies and procedures, and quality. Perioperative nurses should review the guideline in its entirety and apply the recommendations for patient information management as applicable to their individual roles.

TU6.8 An Audit of Day case surgery for cholecystectomy

Abstract Aims To compare the trust-wide performance with the standard by the British Association of Day Surgery in the management of cholecystectomy Methods 4 months of Electronic data of patients undergoing elective laparoscopic cholecystectomy in 2020 was analyzed. Those who had emergency cholecystectomy were excluded. Results 112 of 145 total patients were female and 33 were male. The age range was 18–82 Around 65% of patients were sent home the same day. 51 Patients ended up being admitted. 33 of these were Pre-booked as inpatients' intent. 39% (13/33) had no specific reason for being booked as an inpatient. The rest Majority had medical issues quoted as the reason for booking.35% (18) of the 51 admitted patients were actually brought in as day-case lap-chole. 6 of these were admitted for perioperative surgical issues and 8 had no documented reason. The Mean length of stay was 2.56 days(0–13). Our Performance was noted to be 10% lower than the BADS standard. Conclusion Relatively more patients are being treated as inpatients than the recommended standard. About 1/4th of those who were inpatient had no specific/genuine grounds to be kept in. There is a need for improvement in pre and perioperative documentation to explain the reason for inpatient management. Development of inpatient surgery booking criteria and adherence to set criteria.

Pitfalls in Perioperative Documentation, Compliance with the EMR

<h3>Background Information</h3> In 2018, Perianesthesia nurses at Delnor Hospital embarked on a documentation quality improvement initiative. A team of nurses collaborated to promote consistency in standardized documentation within The American Society of Perianesthesia Nurses (ASPAN) guidelines by enhancing electronic documentation. A workgroup was developed with representation from Pre-op, Phase I, Phase II, Professional Development, and Perioperative Leadership with both surgical areas within Delnor. The team established documentation guidelines based ASPAN standards. Education was developed along with an audit tool to measure compliance. Baseline data from the start of the project in 2018 identified documentation compliance was less than 62% for all areas. A goal was established to improve compliance to 85%. After three months of audits, all three areas achieved the goal and exhibited significant improvement. With continued audits and peer coaching provided by the documentation committee compliance was achieved. However, after the pandemic hit sustainment of the goal decreased in compliance. <h3>Objectives of Project</h3> The committee focused on reeducation of the team and audits to reestablish the expectation, hold staff accountable and get back to the targeted goal. <h3>Process of Implementation</h3> A pre-learning audit was completed to determine baseline data and where reeducation was needed. The education was disseminated to the staff in the three phases of care. The documentation guidelines and education were added to the orientation binder for new staff. Twenty audits were completed monthly per area for three consecutive months. The re-introduction of the project was received positively and the staff felt empowered with knowledge, increased confidence on appropriate assessment/documentation, and improved communication through the Perioperative setting. It was identified that staff who were non-compliant, were the ones who were resistant to the initial project and fell back to old habits. <h3>Statement of Successful Practice</h3> The committee realized that accomplishing the goal is important but identified that sustainment is the most crucial aspect of the project. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> The documentation group will continue to monitor documentation, provide additional education for compliance and focus next on case-specific assessment/documentation.

Assessing the completeness of perioperative anesthetic record documentation in a tertiary hospital

Background and Objective: Many previous studies assessing the completeness of perioperative documentation of surgical patients were reported to be inadequate and unsatisfactory. The aim of this study was to compare the perioperative anesthetic record (PAR) at our tertiary care institution to a standard guideline and have an audit of its completeness.&#x0D; Methodology: It was a prospective, observational study, done in the general operating theater of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). We compared our PAR to the American Society of Anesthesiologists (ASA) policy statement on documentation of anesthesia care. We audited the completeness of PAR documentation of 358 patients by using a self-generated checklist which was created in accordance to the PAR parameters. A total of 44 parameters were studied covering three phases; preoperative, peroperative and post-operative phases.&#x0D; Results: Although the UKMMC PAR varied from the ASA guidelines, various salient parameters were identical in both. None of the perioperative forms were completely filled throughout the three perioperative phases. Out of 44 parameters studied, only 2 parameters were completely filled, which were medications administered and fluid therapy.&#x0D; Conclusion: Parameters given in the UKMMC PAR varied with the ASA guidelines and the documentation was found to be only partially complete. Hence, necessary modification of the current PAR in our institution, and the stress on filling it completely is needed to improve the quality of perioperative anesthetic documentation.&#x0D; Keywords: Audit; Completeness; Perioperative; Anesthetic record; Documentation&#x0D; Citation: Bolhan HA, Yahya N, Izaham A, Mat WRW, Rahman RA, Musthafa QA. Anaesth. pain intensive care 2020;24(6):---&#x0D; Received: 23 April 2020, Reviewed: 17 August 2020, Revised: 18 October 2020, Accepted: 27 October 2020

Efficacy of Multimodal Intervention Strategies in Improving Perioperative Documentation at a Rural Tertiary Care Centre.

ObjectiveTo assess the efficacy of intervention strategies in improving perioperative anaesthetic documentation.MethodsThis interventional study was conducted at our hospital over a period of 5 months, i.e. from October 2016 to February 2017. The subjects were anaesthetic consultants. The perioperative anaesthetic documentation of patients who received general anaesthesia was studied by retrospectively reviewing 100 patient charts before the application of intervention strategies. Intervention measures included lecture sessions, posters and handouts to highlight the important parameters to be documented. Later, another set of 100 patient charts of cases who received general anaesthesia from the same group of anaesthetic consultants were retrospectively reviewed. The recommendations of the Australia and New Zealand College of Anaesthetists were taken as the gold standard. A point-based scoring sheet was used for evaluation. Data were analysed using Microsoft Excel, and the statistical test used was the Mann–Whitney U Test.ResultsDocumentation standards were significantly improved in the post intervention group compared to the pre intervention group. Furthermore, documentation scores were lower in emergency cases compared to elective cases in both groups.ConclusionMultimodal intervention strategies resulted in higher perioperative documentation scores, and scores were lower in emergency cases than in elective cases in both groups.

Improvement in perioperative anesthesia documentation for fetal interventions.

Improvement in perioperative anesthesia documentation for fetal interventions.

Improving Perioperative Knowledge, Self-Efficacy, and Performance in Labor and Delivery Nurses: A Quality Improvement Project.

The obstetrical unit utilized a training product (Periop 101: A Core Curriculum OB) to enhance the knowledge, self-efficacy, and performance of nurses circulating for cesarean births. Knowledge was measured using product provided testing. Self-efficacy was assessed using a modified perioperative self-efficacy scale, and performance was evaluated by analyzing documentation accuracy and incident reports. Results demonstrated improvements in perioperative knowledge, self-efficacy, and documentation as well as a reduction in incident reports.

Peri-Operative Anaesthetic Documentation: A Report of Three Sequential Audits on the Quality of Outcomes, with an Insight Into Surrounding Legal Issues

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. 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. 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. 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.

Improvement of surgical wound classification following a targeted training program at a children's hospital

BackgroundInaccurate assignment of surgical wound class (SWC) remains a challenge in perioperative documentation. The purpose of our intervention was to increase the accuracy of SWC through a targeted training program directed toward pediatric surgeons and nurses. MethodsA retrospective electronic medical record (EMR) chart review of 400 operations was performed according to NSQIP criteria during specified periods in 2014 and 2017, assessing SWC errors before and after a training program and posting of reference materials in operating rooms at a 165-bed children's hospital. After each operation, nurses confirmed SWC with the surgeon before recording the value in the EMR. Differences in proportions of misclassified SWC were evaluated with a chi-square test. ResultsFollowing the educational program, misclassified SWC improved from 70/200 (35.0%) to 18/200 (9.0%), p < 0.001. Misclassified SWC for appendectomies improved from 46/95 (48.4%) to 12/108 (11.1%), p < 0.001. ConclusionsAccurate SWC assignment in the EMR was improved by an educational program and posting of materials to aid assignment, as well as enhanced communication between surgeons and nurses at the conclusion of each operation. We present the first known attempt to list all pediatric surgery procedures according to SWC. Accurate SWC allows stratification of risks and more effective targeted interventions. Level of evidenceLevel III.

The effect of data-entry template design and anesthesia provider workload on documentation accuracy, documentation efficiency, and user-satisfaction

IntroductionCurrently, there are few evidence-based guidelines to inform optimal clinical data-entry template design that maximizes usability while reducing unintended consequences. This study explored the impact of data-entry template design and anesthesia provider workload on documentation accuracy, documentation efficiency, and user-satisfaction to identify the most beneficial data-entry methods for use in future documentation interface design. MethodologyA study using observational data collection and psychometric instruments (for perceived workload and user-satisfaction) was conducted at three hospitals using different methods of data-entry for perioperative documentation (auto-filling with unstructured data, computer-assisted data selection with semi-structured documentation, and paper-based documentation). Nurse anesthetists at each hospital (N = 30) were observed completing documentation on routine abdominal surgical cases. ResultsAuto-filling (61.2%) had the lowest documentation accuracy scores compared to computer-assisted (81.3%) and paper-based documentation (76.2%). Computer-assisted data-entry had the best documentation efficiency scores and required the least percentage of the nurse anesthetists’ time (9.65%) compared to auto-filling (11.43%) and paper-based documentation (15.23%). Paper-based documentation had the highest perceived workload scores (M = 288, SD = 88) compared to auto-filling (M = 160, SD = 93, U = 16.5, p < 0.01) and computer assisted data-entry (M = 93, SD = 50, U = 4.0, P < 0.001). ConclusionsAuto-filling with unstructured data needs to be used sparingly because of its low documentation accuracy. Computer-assisted data entry with semi-structured data needs to be further study because of its better documentation accuracy, documentation efficiency, and perceived workload.

Recent guidelines in preoperative assessment, premedication&amp;perioperative documentation

Introduction: The corner stone of an effective preoperative evaluation are the history and physical examination, which should include a complete account of all medications taken by the patient in the recent past, and responses and reactions to previous anesthetics.Premedication is the administration of medication before anesthesia. Premedication is used to prepare the patient for anesthesia and to help provide optimal conditions for surgery. The anesthetic record is usually the sole documentation of an anesthetist’s interaction with his or her patient. Aim of the work: This work aims to review the recent guidelines in preoperative assessment, premedication and perioperative documentation to reach a conclusion and a protocol of management that can be applicable in our hospital. Materials and methods: This is a clinical review of recent guidelines in preoperative assessment ,premedication ,perioperative documentation based on explore other protocols and researches. The strategy followed in doing this review is as follow; Exploring the data allowed for the recent guidelines in preoperative assessment, premedication, perioperative documentation 1-Sites to be visited. 2-Recent searches in the last 5 years. 3-Search terms including preoperative assessment, patient preparation ,premedication ,perioperative documentation, anesthetic record . 4-Bibliographies of articles are also searched for relevant articles. 5-English language studies and full text studies will be preferred. Conclusion: The goals of the preanesthesia evaluation are twofold: first, to ensure that patients can safely tolerate anesthesia for planned surgical procedures; and second, to mitigate risks associated with the overall perioperative period, such as postoperative pulmonary or cardiac complications. The patient’s comorbidities and planned procedure must be considered when managing medications in the perioperative period. Accurate and thorough documentation is an essential element of high quality and safe medical care, and accordingly a basic responsibility of physician anesthesiologists.

Using an Electronic Perioperative Documentation Tool to Identify Returns to Operating Room (ROR) in a Tertiary Care Academic Medical Center

The metric "Unplanned returns to operating room (ROR)" is being tracked in surgical quality dashboards; 70% of unplanned RORs may be related to surgical complications. With increasing regionalization of trauma and complex surgical care at tertiary care academic centers, it is unclear if a simple ROR metric is a valid assessment of surgical quality at such centers. A real-time electronic tool was used to identify all RORs-planned and unplanned-in a high-volume, high-complexity academic surgical practice at Mayo Clinic-Rochester within 45 days of the index operation. Analysis by ROR type and indication was performed. During the analysis period (June 2014-February 2015) 44,031 operations were performed, with 5,552 subsequent RORs (13%). Of all RORs, 51% (n = 2,818) were planned staged returns, 29% (n = 1,589) were unrelated, 15% (n = 830) were unplanned and 6% (n = 315) were planned because of previous complications. Overall, unplanned reoperations were uncommon (n = 830, 2% of all operations). The most common indications for unplanned RORs included "other" (32%, n = 266), bleeding related (24%, n = 198) and wound complications (20%, n = 166). In a high-volume, high-complexity academic surgical practice, RORs occurred after 13% of cases. Unplanned returns were infrequent and usually were associated with complications; most RORs were planned staged or unrelated returns. A simple ROR metric that does not consider planned/unrelated returns is likely not a valid surgical quality measure. Electronic tools designed specifically to identify in real-time RORs, associated indication, and clinical validation should provide more reliable data for public reporting and quality improvement efforts.

Does regional audit improve practice in the management of urological cancers?

Objective: The effect of a regional audit is underreported and uncertain. Across the North West of England we have conducted annual regional audits of urological cancer care for over 20 years. Methods: We reviewed the data from four complete audit cycles (prostate, testis, bladder and kidney) to ascertain the change in adherence to agreed guidelines. Adherence to guidelines was pooled across cancer types and the following domains. Preoperative investigation, planning and counselling Perioperative and intraoperative care Follow-up regimen and documentation Difference in adherence to guidelines was expressed as an absolute percentage change and statistical significance was determined using Fisher’s exact test. Results: Over the four complete audit cycles 3659 case notes were reviewed totalling 20,470 observations. The four separate audits generated 42 guidelines which were equally assessable between audit cycles (prostate (nine), testis (seven), bladder (18) and kidney (eight)). Overall, adherence to guidelines between the original and follow-up audit improved from 63.4% to 73.4% ( p &lt; 0.05). Adherence improved across all cancers; however, this was not equal across all domains. Marked improvements were seen in preoperative investigation (+13%, p &lt; 0.05), planning and counselling and follow-up and documentation (+12%, p &lt; 0.05). A non-significant rise of 0.1% was seen in guidelines pertaining to intraoperative care ( p = 0.95). Conclusions: A regional audit has overseen and documented an improvement in practice in urological cancer within the region studied. Although the mechanisms leading to this are likely to be complex, we suggest that the audit process per se is likely to contribute to this improvement rather than merely document it.

Does Perioperative Documentation Transfer Reliably?

In the complex and multiphasic perioperative process, there are many opportunities to transfer information between providers and settings. Previous studies have shown that information transfer and communication are vital to minimize risks in the perioperative setting. The aim of this study was to explore the incidence of failure to communicate vital information as the patient progressed through the six phases of the perioperative process. The systematic sample included ambulatory surgery patient records from one quarter. A failure to communicate rate was calculated as 10.2% for the 5586 entries. In the absence of a comprehensive electronic health record, a consistent method for information transfer must be used to minimize risks.

A Hybrid Approach to Intravenous Lead Management: The UNC Experience

Background Since November 2010, physicians at the University of North Carolina (UNC) have taken a unique approach to cardiovascular implantable electronic device (CIED) lead extraction: the cardiac surgeon and electrophysiologist (EP) collaborate to extract and reimplant leads. This study compares this new shared technique with EP-only and surgeon-only extraction. Methods Lead extraction operative notes and perioperative documentation from 2007–2012 were reviewed. In the standard and surgeon-only approaches the respective EP or surgeon performs the entire procedure. In the hybrid approach the cardiac surgeon does the lead extraction and the EP completes the reimplantation; both physicians are engaged for the entire case. Results Over the study period 28 patients underwent hybrid extraction, 35 underwent standard extraction, and 8 patients underwent surgeon-only extraction. Patients undergoing hybrid lead extraction had a significantly higher rate of invasive pressure monitoring (89% vs 6%, P P P P Conclusions This review suggests that a hybrid, collaborative approach to intravenous CIED lead management can provide excellent patient outcomes and practice growth.

Perioperative anesthetic documentation: Adherence to current Australian guidelines

Purpose:The lack of adequate perioperative documentation has legal implications and can potentially affect the quality and safety of patient care. Despite the presence of guidelines, the adequacy of perioperative documentation in Australasia has not been adequately assessed. The aim of this study is to assess the adequacy of anesthetic documentation on the pre and intraoperative encounters and to test the hypotheses that documentation is incomplete in the settings of emergency vs. elective procedures, regional vs. general anesthesia, and manual vs. electronic documentation.Materials and Methods:The study was an observational retrospective study in the setting of a 250-bed teaching hospital in metropolitan Adelaide, Australia. The perioperative records of 850 patients were analyzed. A scoring system was designed, based on a policy statement from the Australian and New Zealand College of Anesthetists and a survey of the hospital anesthetists. Scored and categorical data was analyzed using Chi-square test. Numerical data was analyzed using student t-test. The null hypothesis was accepted or rejected at 0.05 significance.Results:There were significant deficiencies in the adequacy of preanesthetic and intraoperative records. This has been shown to be true in all cases. Documentation was found to be poorer in the emergency setting when compared to elective cases (median scores 15 vs. 21 P = 0.03) as well as documentation of airway assessment for cases done solely under regional anesthesia (42 vs. 85%, P = 0.05). There were no significant differences in the adequacy of electronic vs. manual records (P = 0.92).Conclusion:There are significant deficiencies in the adequacy of perioperative records. This has been shown to be true in all cases, but is especially so in emergency cases and for patients having only regional anesthesia.

Continuity of Transfer of Information in Perioperative Documentation Systems

Continuity of Transfer of Information in Perioperative Documentation Systems