Assessment of Manual Intraoperative Anesthesia Record-Keeping Practice at Dilla University Referral Hospital, Dilla, Ethiopia

Zemedkun, Abebayehu; Mulugeta, Hailemariam; Getachew, Hailemariam; Destaw, Belete; Mola, Simeneh; Milkias, Mesay

doi:10.2147/oas.s298387

Cited by 7 publications

(13 citation statements)

References 13 publications

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“…Our finding correlates with other studies conducted. 5 Demographic data like name, age and gender had more than 80% completion rate in this study. Some studies conducted in Africa have published results where these parameters had a poor completion rate, especially for the name of the patient.…”

Section: Discussionmentioning

confidence: 72%

“…This could be because of a structured intraoperative form, that we use, drug route and timing is not mentioned, nevertheless, it should have been recorded. 5,8 The completion rate of variables like ventilator parameters, fresh gas flow, total fluid given, urine output, check of pressure points, intraoperative critical events, status of patient on transfer were poor that is below 50%. This poor documentation is sub-par of expected completion rate.…”

Section: Discussionmentioning

confidence: 99%

“…Sub par documentation of manual record system has been documented in many previously conducted studies. 5,[7][8][9][10] Incomplete notes and abbreviations are a source of weak defense during litigations. Apart from that, information derived from record forms is of extreme value to subsequent practitioners who may give anesthesia services to the patient.…”

Section: Discussionmentioning

confidence: 99%

“…Some studies conducted in Africa have published results where these parameters had a poor completion rate, especially for the name of the patient. 5,7 This could be because of long names in the African continent. However, inpatient number and ward or bed number were fully recorded only in 63.9% and 48.5%.…”

Section: Discussionmentioning

confidence: 99%

“…All record forms filled for elective surgeries performed were included. Based on a previous study, 5 where the completion rates of records were 50%, the sample size for our study was calculated using the formula: n= Z 2 × (p × q) / e 2 = (1.96) 2 x 0.5 x (1-0.5) / (0.05) 2 =384.16 =385 Where, n= required sample size p= proportion of completeness of anesthesia record form (50%) according to the previous study 5 q= 1-p e= margin of error, 2% Z= 1.96 at 95% Confidence Interval…”

Section: Methodsmentioning

confidence: 99%

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Manual Anesthesia Record Keeping at a Tertiary Care Center: A Descriptive Cross-sectional Study

et al. 2021

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Introduction: Intraoperative record form is one of the cardinal parts of anesthesia practices. Ideally, it should contain complete information about patients under anesthesia and intraoperative events. It serves as valuable information for subsequent patient management, research, or during medicolegal conditions. The objective of this study was to assess the practice and completeness of manual intraoperative anesthesia record keeping. Methods: A descriptive cross-sectional study was conducted from May 1 to July 31, 2021, in the postoperative ward of Kathmandu Medical College, which is a multispecialty tertiary care center. Approval from the ethical committee of Kathmandu Medical College Teaching Hospital was obtained (Reference: 2603202105) before conducting the study. Convenience sampling was used. The data were entered in Microsoft Excel and statistical analysis was done using Statistical Package for the Social Sciences version 20. Point estimate was done at 95% Confidence Interval and data present in numbers and percentages. We devised forty-two variables, which included demographics, personal identifiers, intraoperative events, anesthesia and airway management, intraoperative parameters, monitoring and medication. Results: The overall completion rate was 202 (52.59%) (47.6-57.57 at 95% Confidence Interval). Out of 42 variables, the completion rate of 14 variables was less than 50%. Among those were important parameters such as known allergies 94 (24.4%), Body mass index 50 (13%), intraoperative saturation of oxygen 104 (27%), intraoperative electrocardiogram recording 107 (27.8%), total fluid volume administered 45 (11.7%), patient status on transfer 84 (21.8%) had poor completion rate. Conclusions: Our intraoperative record form shows poor completion rate, which was similar to other studies. many important variables were missing and had incomplete data.

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Section: Discussionmentioning

confidence: 72%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Manual Anesthesia Record Keeping at a Tertiary Care Center: A Descriptive Cross-sectional Study

et al. 2021

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Assessment of manual perioperative anesthesia record-keeping practice: A multicenter; descriptive cross-sectional study, Ethiopia, 2022

Misganaw

Seyoum²

2022

International Journal of Surgery Open

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Objective: This study aimed to assess the practice of manual perioperative anesthesia record-keeping in Debre Markos and Debre Berhan Comprehensive Specialized hospitals from May to June 2022. Methods: A descriptive study was undergone from May 1 to June 30, 2022 at two Hospitals that are under Amhara regional health bureau. To retrieve and analyze manual anesthesia record-keeping practice, a checklist was developed from manual perioperative anesthesia record sheet of study hospitals and the American society of anesthesiologists which comprises indicators with corresponding predefined components. The checklist comprised questions with three alternatives “complete” for full data recorded, “incomplete” for partial data recorded, and “No” for totally missed data. SPSS version 22 was used to analyze the data. Result: The name of the anesthetist was recorded as our expectation which means 100% complete. The name of the surgeon was the second most frequently recorded preoperative related indicator with a completion rate of 98.4%. Other preoperative indicators like last food/drink, current/previous medications, alcoholic/cigarette hx, pregnancy, cardiovascular, other system, and laboratory also not recorded in an eligible way. The anesthesia record completion rate was below fifty percent in many intraoperative indicators. Conclusion: and recommendation: Most of the perioperative anesthesia recording indicators were found poorly recorded or below the standards. Information about preoperative patient condition and identity, intraoperative drug administrations, monitoring related information, and postoperative orders regarding pain and fluid management are among inadequately/illegibly recorded indicators. We recommend different interventional strategies like training, refresher course on the importance of the anesthetic record, and regular feedback for anesthetists improves the practice of manual anesthesia record-keeping. Highlights

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Simulation-based perioperative anaesthesia information management practice: cross-sectional study

Admassie,

Ferede,

Mekonnen

et al. 2023

Annals of Medicine &Amp; Surgery

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Background: Perioperative anaesthesia record completeness is very essential skill of the anaesthesia profession at the time of operation in the health setting. During perioperative, anaesthesia care sometimes there may be missing important information of the patient, medication taken or planned. This study aimed to improve perioperative anaesthesia information management practice. Methodology: Pre-interventional and post-interventional cross-sectional study was conducted from 21 June to 25 July 2022 on 164 anaesthesia record filled by 51 anaesthesia care provider in pre-interventional and post-interventional phase. Data were collected using a semi-structured questionnaire and the data entered by Epi-data software (version 4.6) and analyzed by using SPSS version 26. For all indicators, the projected completion rate was 100%. Indicators with completion rates of greater than 90% were classified as acceptable, while those with completion rates of 50% were seen as urgently needing improvement. Results: Pre-interventional result: among all indicators, none of the indicators had 100%, completeness rate. Postoperative nausea and vomiting management orders, the names of the surgeon and anaesthetist, the location of the intravenous cannula, the maintenance of anaesthesia, the total amount of fluid supplied, the content of the consent discussion, and null per ose status, age, and weight of the patient were some of the markers that were identified below average (50%) and in need of significant improvement. Post-interventional result: when compared with the pre-interventional result, their documentation skills were improving after discussions with stakeholders and the relevant bodies; however, none of the indicators attained 100% completion rate. Conclusion and recommendation: Even after the interventions, the desired completion rate was not attained. As a result, it requires ongoing instruction on perioperative anaesthesia information management according to the standard perspectives.

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Assessment of Manual Intraoperative Anesthesia Record-Keeping Practice at Dilla University Referral Hospital, Dilla, Ethiopia

Cited by 7 publications

References 13 publications

Manual Anesthesia Record Keeping at a Tertiary Care Center: A Descriptive Cross-sectional Study

Manual Anesthesia Record Keeping at a Tertiary Care Center: A Descriptive Cross-sectional Study

Assessment of manual perioperative anesthesia record-keeping practice: A multicenter; descriptive cross-sectional study, Ethiopia, 2022

Simulation-based perioperative anaesthesia information management practice: cross-sectional study

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