Improvement of information gained from the pre-anaesthetic visit through a quality-assurance programme

Background. Pre-anaesthetic evaluation is a fundamental component of anaesthetic practice. The aims of the present study were to assess the quality of the preoperative anaesthetic information gathered and to observe the quality profile after the introduction of a standardized form. This occurred through a four-step quality assurance programme over a 4-yr period. Methods. The proportion of cases in which a complete recording of data was collected at the preoperative assessment was evaluated by searching in each patient's medical record for what was considered to be the minimum information required to provide satisfactory perioperative care. Fifteen criteria were selected. The recovery profile for each indicator and a global quality index (GQI expressed in I) for each patient's record were collected. In phase I, the existing situation was assessed. Next, a standardized pre-anaesthetic form (PAF 1) was designed and its implementation evaluated (Phase 2). Phase 3 was performed 16 months after implementation of PAF 1 to assess the long-term value. The form was revised (PAF 2) and its use evaluated again 6 months later (Phase 4). For each evaluation, the records of a I-month period were examined. Overall 1129 medical records were audited. Results. The GQI increased significantly from 62 to 88% with similar changes for both elective and emergency cases. The recovery profile was improved for most indicators. Conclusions. We conclude that the quality of information recorded from the pre-anaesthetic visit is improved by using a standardized form. This will hopefully help to improve patient outcome and facilitate computerization of the anaesthetic record.