Manji Farah, McCarty Kelsey, Kurzweil Vanessa, Mark Eden, Rathmell James P, Agarwala Aalok V
From the *Department of Anesthesia, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; †Department of Medicine, Boston Medical Center, Boston, Massachusetts; ‡Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; §Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts; ‖Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and ¶Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.
Anesth Analg. 2017 Jun;124(6):1846-1854. doi: 10.1213/ANE.0000000000001834.
Preprocedural assessments are used by anesthesia providers to optimize perioperative care for patients undergoing invasive procedures. When these assessments are performed in advance by providers who are not caring for the patient during the procedure, there is an additional layer of complexity in ensuring that the workup meets the needs of the primary anesthesia care team. In this study, anesthesia providers were asked to rate the quality of preprocedural assessments prepared by other providers to evaluate anesthesia care team satisfaction.
Quality ratings for preprocedural assessments were collected from anesthesia providers on the day of surgery using an electronic quality assurance tool from January 9, 2014 to October 21, 2014. Users could rate assessments as "exemplary," "satisfactory," or "unsatisfactory." Free text comments could be entered for any of the quality ratings chosen. A reviewer trained in clinical anesthesia categorized all comments as "positive," "constructive," or "neutral" and conducted in-depth chart reviews triggered by 67 "constructive" comments submitted during the first 3 months of data collection to further subcategorize perceived deficiencies in the preprocedural assessments. In May 2014, providers were asked to participate in a midpoint survey and provide general feedback about the preprocedural process and evaluations.
37,611 procedures requiring anesthesia were analyzed. Of the 17,522 (46.6%) cases with a rated preprocedural assessment, anesthesia providers rated 3828 (21.8%) as "exemplary," 13,454 (76.8%) as "satisfactory," and 240 (1.4%) as "unsatisfactory." The monthly proportion of "unsatisfactory" ratings ranged from 3.1% to 0% over the study period, whereas the midpoint survey showed that anesthesia providers estimated that the number of unsatisfactory evaluations was 11.5%. Preprocedural evaluations performed on inpatients received significantly better ratings than evaluations performed on outpatients by the preadmission testing clinic or phone program (P < .0001). The most common reason given for "unsatisfactory" ratings was a perception of "missing information" (49.2%). Chart reviews revealed that inadequate documentation was in reality the most common deficiency in preprocedural evaluations (35 of 67 reviews, 52.2%).
The overwhelming majority of preprocedural assessments performed at our institution were considered satisfactory or exemplary by day-of-surgery anesthesia providers. This was demonstrated by both the case-by-case ratings and midpoint survey. However, the perceived frequency of "unsatisfactory" evaluations was worse when providers were asked to reflect on the quality of preprocedural evaluations generally versus rate them individually. Analysis of comments left by providers allowed us to identify specific and actionable areas for improvement. This method can be used by other institutions to identify systemic deficiencies in the preprocedural evaluation process.
麻醉医护人员通过术前评估来优化接受侵入性操作患者的围手术期护理。当这些评估由在手术过程中不负责该患者护理的医护人员提前进行时，要确保检查结果满足主要麻醉护理团队的需求就会增加一层复杂性。在本研究中，要求麻醉医护人员对其他医护人员所做的术前评估质量进行评分，以评估麻醉护理团队的满意度。
2014年1月9日至2014年10月21日期间，使用电子质量保证工具在手术当天从麻醉医护人员处收集术前评估的质量评分。用户可以将评估评为“ exemplary（ exemplary）”、“ satisfactory（令人满意）”或“ unsatisfactory（不令人满意）”。对于所选的任何质量评分都可以输入自由文本评论。一名经过临床麻醉培训的评审员将所有评论分类为“ positive（积极）”、“ constructive（建设性）”或“ neutral（中性）”，并对在数据收集的前3个月提交的67条“ constructive（建设性）”评论引发的病历进行深入审查，以进一步对术前评估中察觉到的缺陷进行细分。2014年5月，要求医护人员参与一项中期调查，并就术前流程和评估提供总体反馈。
分析了37,611例需要麻醉的手术。在17,522例（46.6%）有术前评估评分的病例中，麻醉医护人员将3828例（21.8%）评为“ exemplary（ exemplary）”，13,454例（76.8%）评为“ satisfactory（令人满意）”，240例（1.4%）评为“ unsatisfactory（不令人满意）”。在研究期间，“ unsatisfactory（不令人满意）”评分的月度比例在3.1%至0%之间，而中期调查显示，麻醉医护人员估计不满意评估的数量为11.5%。入院前检查诊所或电话项目对住院患者进行的术前评估的评分明显高于对门诊患者进行的评估（P <.0001）。给出“ unsatisfactory（不令人满意）”评分的最常见原因是感觉“信息缺失”（49.2%）。病历审查显示，实际上术前评估中最常见的缺陷是记录不充分（67份审查中的35份，52.2%）。
我们机构进行的绝大多数术前评估在手术当天被麻醉医护人员认为是令人满意或 exemplary（ exemplary）的。这在逐例评分和中期调查中都得到了证明。然而，当要求医护人员总体反思术前评估的质量而不是单独对其进行评分时，察觉到的“ unsatisfactory（不令人满意）”评估的频率更高。对医护人员留下的评论进行分析使我们能够确定具体且可采取行动的改进领域。其他机构可以使用这种方法来识别术前评估过程中的系统性缺陷。
