|Year : 2015 | Volume
| Issue : 1 | Page : 16-21
The effect of teaching on the completeness of the anesthesia record charts for obstetric subarachnoid blocks in a low resource area hospital
Simeon Olugbade Olateju, Anthony Taiwo Adenekan, Afolabi Muyiwa Owojuyigbe
Department of Anaesthesia, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
|Date of Web Publication||15-Apr-2015|
Dr. Simeon Olugbade Olateju
Department of Anaesthesia, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife
Source of Support: None, Conflict of Interest: None
Background: Spinal anesthesia is a widely practiced anesthetic technique for cesarean delivery. Record charting and keeping during obstetric spinal anesthesia demand accuracy and completeness for patient's safety, medico-legal and research purposes. This study was conducted to evaluate the effect of teaching on improving audit of the anesthetic record charts for spinal anesthesia in obstetrics.
Materials and Methods: We retrospectively reviewed 100 anesthetic charts for spinal anesthesia in the obstetric theatre of our hospital. This was followed by a lecture given by a consultant anesthetist on the importance of the anesthesia record keeping with emphasis on obstetric spinal anesthesia. Immediately after the lecture, post teaching intervention audit of 400 anesthetic charts for obstetric spinal anesthesia in four consecutive periods of 100 charts each were done. Data collected were analyzed with SPSS version 16.0.
Results: A total of 500 anesthetic record charts were studied. Average percentage completion of anesthetic charts before the lecture (pre-intervention); first, second, third and fourth audit (post-intervention) were 56.1%, 70.1%, 78.1%, 81.3% and 87.7%, respectively. The level of improvement in the filling of the charts pre- and post-teaching intervention in the elective cases (54.72 vs. 83.69) and emergency cases (48.67 vs. 82.27) were statistically significant respectively (P < 0.05).
Conclusion: There was a significant improvement in the adequacy of documentation of anesthetic record chart for obstetric spinal anesthesia after a teaching intervention.
Keywords: Anesthetic record charts, audit, obstetric spinal anesthesia, teaching intervention
|How to cite this article:|
Olateju SO, Adenekan AT, Owojuyigbe AM. The effect of teaching on the completeness of the anesthesia record charts for obstetric subarachnoid blocks in a low resource area hospital. J Obstet Anaesth Crit Care 2015;5:16-21
|How to cite this URL:|
Olateju SO, Adenekan AT, Owojuyigbe AM. The effect of teaching on the completeness of the anesthesia record charts for obstetric subarachnoid blocks in a low resource area hospital. J Obstet Anaesth Crit Care [serial online] 2015 [cited 2019 Dec 12];5:16-21. Available from: http://www.joacc.com/text.asp?2015/5/1/16/155194
| Introduction|| |
Anesthetic record chart is a piece of information that is useful in monitoring the patient's safety during surgery and also serves as an essential mode of communication between relevant health care professionals. It is important in cases of legal enquiries which is more common in obstetric anesthesia than other sub-specialties. , However, it could be fraught with inaccuracies and incomplete data which may reduce its usefulness.  The clinical challenges in the course of obstetric anesthesia are that of maternal and neonatal outcomes which should be reflected in the anesthesia record chart. For a standard obstetric care service, it is important that regular data auditing is given a priority. The obstetric anesthetic chart should be concise with a complete record of the relevant preoperative history, peri-operative medications, vital signs, newborn parameters, and immediate postoperative care instructions.
Previous studies from developed countries on the components and the quality of anesthetic record chart in obstetric regional anesthesia have reported incompleteness as their major finding. , Appropriate education of personnel involved in charting anesthetic record has been found to improve its completeness and correctness.  Although, the various accredited departments for anesthesia training in West African sub-region may be giving formal and informal teaching on anesthesia record keeping, current training curricula of the two postgraduate training regulatory bodies in Nigeria shows that audit and communication including teaching and training on charting of the anesthesia records is not included in the junior residency program. , However, anesthesia record charts are often filled by this cadre of staff. 
An audit of anesthetic record charts for orthopedics in a Southern Nigerian hospital reported 52% completion.  Another related study done in a tertiary hospital in Lagos, Nigeria reported 6% completion of charts across several specialties.  There is increasing cases of litigation related to standard of obstetric services in Nigerian hospitals due to improving level of awareness among the populace. The quality and completeness of obstetric anesthesia record charts have not been previously studied in the sub-Saharan region to the best of our knowledge. Spinal anesthesia is the preferred technique for cesarean delivery in many hospitals. ,
This study aimed to assess the peri-operative percentage completion and adequacy of documentation of our anesthesia record chart for obstetric spinal anesthesia and the impact of the teaching intervention and regular communication on filling in the chart.
| Materials and Methods|| |
This study was conducted at a tertiary health institution in Nigeria after approval by the Ethics and Research Committee of the hospital.
We reviewed the contents of our anesthetic record chart against the minimum data set for an anesthetic record by the Royal College of Anesthetists and the Association of Anesthetists of Great Britain and Ireland (AAGBI)  and the suggested labor ward anesthetic charts of the Obstetric Anesthetists' Association (OAA).  The record charts of 100 patients that had spinal anesthesia in our obstetric theatre immediately preceding a lecture on anesthesia record charting and its importance in obstetric spinal anesthesia were reviewed by the investigators and these served as baseline (pre-teaching intervention group). The information on the charts was recorded as filled or not filled in a study proforma sheet. The data obtained from the chart and entered into the proforma sheet were: Name and age of patients, date of surgery, hospital number, names of anesthetists and surgeons. Others were summary of preoperative review, American Society of Anesthesiologists' (ASA) physical status classification, height and weight of the patient, preoperative pulse rate and blood pressure. Oxygen saturation, time of spinal block, dose of bupivacaine administered, intervertebral space used, level of spinal block, time of skin and uterine incision, delivery time, Apgar score, end of surgery time, intra-operative urinary output and postoperative remarks were included in the review.
Anesthetists (residents and consultants) involved with charting of anesthetic records were later educated using anesthetic chart for illustration with their relevance well explained. Thereafter, 400 consecutive anesthetic charts for spinal anesthesia in obstetrics were reviewed in four groups of 100 each as postintervention 1, 2, 3 and 4, respectively. Record charts for both elective and emergency cesarean sections under spinal anesthesia were used for the pre- and post-interventions excluding those that were converted to general anesthesia.
Pre-intervention data obtained from 100 charts were compared with 100 charts each in four groups of post-intervention data. The primary outcome was the effect of teaching on post-intervention audits. Continuous data were reported as mean, and categorical data were reported as numbers and percentages. Data between groups were compared using McNemar's test. All analyses and graph were done using SPSS (Statistical Package for Social Scientists) version 16.0. A P < 0.05 was considered statistically significant. Data analyses were performed by an independent statistician who was blinded to the study intervention.
| Results|| |
Five hundred and seventy-seven cesarean sections were done on women 15-48 years of age during the study period from January to October, 2012. Four hundred and seventy cases (81.5%) were emergencies and 107 (18.5%) were electives. Five hundred (86.7%) anesthesia record charts of successful spinal anesthesia were evaluated. [Table 1] shows between 99% and 100% completion of demographic data except for the weight and height. [Table 2] shows 98-100% completion of the documentation of clinical data, such as ASA classification, dose of bupivacaine and vertebral space used in both pre- and post-intervention audits. Documentation of 33% completion for oxygen saturation was still inadequate in the fourth post-intervention period, but some improvements were seen in the documentation of uterine incision time (61%) and immediate postoperative urinary output (70%). Others showed an initial sharp increase followed by a gradual increase in percentage completion after the lecture.
The mean value for the pre-intervention audit was 56.12, which rose to 87.7 in the post-intervention audit. Completion rates in the post-intervention audits were statistically significantly (P = 0.0001) when compared with the pre-intervention audit. Comparison of the mean percentage completion of charts in the pre- and post-intervention for elective (54.72 vs. 83.69) and emergency cesarean sections (48.67 vs. 82.29) were also statistically significant (P = 0.001) respectively.
| Discussion|| |
Adequate capturing of data during anesthesia is an essential component of a good anesthetic practice, necessary for audit and quality assurance. To facilitate this, guidelines have been designed for the anesthetists to use in monitoring patients and keeping records. ,, In low resource economies, written documentation is the main method of anesthesia record-keeping. This is likely to persist for a long time to come due to financial and technical challenges of implementing the electronic/computer based Anesthesia Information Management System despite the well documented superiority of the latter in literature. ,
The demographic data were 99-100% completed in all the audits except for the weight and height of patients. These are critical data in patients and staff's identification and are usually available on many records including the operation list, operation checklist, patient case notes, operation and anesthesia registers, and are essential for other formalities including handing over and patient transfer. They are basic items common to all anesthetic charts irrespective of specialty or technique used, and this has been taken very serious by our team even before the intervention, hence the 99-100%. Similar findings were noted by Desalu et al.  and Mato and Otokwala  with respect to these demographic data.
Weight and height were poorly documented at pre-intervention in our study probably because patients were already on the operation table when they were evaluated by the anesthetists conducting the anesthesia for that particular case. These two important parameters have been found to influence management and outcome of patients.  Drug dosage (including induction agents, muscle relaxants, local anesthetic, inotropes and vasopressor), fluid administration, tidal volume estimation, and body mass index (BMI) are some of the key features essential for perioperative care of the patient. The 1991-1992 National Confidential Enquiry into Peri-operative Deaths report of the United Kingdom showed that about 48% and 85% of patient had no record of their weight and height respectively.  The reviewers opined that these may reflect a poor quality of care. Although multiple drug usage is unusual following a successful spinal anesthesia, this cannot justify the initial poor documentation of weight of the patients observed in this study as also previously noted by others.  The course of any regional anesthesia cannot be absolutely predicted until successful completion of surgery and full recovery of patients from anesthesia. It is recognized that both spinal anesthesia and obesity significantly reduce respiratory function during cesarean section,  thus justifying the need for documentation of BMI in the anesthesia chart for easy calculation of medications if needed.
In an audit of preoperative assessment done by Simmonds and Petterson, a completion rate of 26.8% was recorded with little but no significant improvement in their record keeping after a re-audit.  Our study showed a significant improvement in the documentation from 10% in the pre-intervention audit to 70% post-intervention in the preoperative review summary. This improvement recorded is similar to preoperative assessment documentation by Desalu et al.  who reported on a pre- and re-audit (51% vs. 91%) respectively. The success in their study was associated to feedback on the first audit which was presented and discussed at a meeting before another audit.
Mato and Otokwala in their study of orthopedic surgery anesthesia charts reported 89.2% completion in the recording of date of surgery.  Desalu et al. study had a lower percentage of 77% in the first audit which was increased to 87% in the re-audit data.  However, there was a better result of between 99% and 100% in the charting of date of surgery in our study. In addition, our results also observed 99-100% in all audits for demographic data which included name, age, hospital number of patient, names of anesthetists and surgeons. This may be related to the fact that demographic data are common to all categories of anesthetic charts. In contrast, there was no record of names of patients in 100% of charts examined in a study done by Ulyatt et al.  The 100% documentation of names of anesthetists reported in our study is similar to a previous study by Mato and Otokwala.  Similarly, the 100% completion was observed for the names of surgical team in contrast to 36% in this study.  The record of names of anesthetic and surgical teams in the chart may be needed for clarification of any issues during morbidity, mortality or other related meeting concerning a patient. Desalu et al. reported an improvement in recordings regarding ASA status, preoperative pulse rate and blood pressure in their study (60% to 78%, 47% to 65% and 65% to 79% respectively).  Similarly, the results of our study showed improvement at post-intervention as shown in [Table 2].
Surprisingly, data specific to spinal anesthesia including block height and quality of block as well as those related to obstetrics (uterine incision time, delivery time and Apgar score) were poorly recorded at pre-intervention audit suggesting they were probably not assessed. They may reflect the low standard of care with respect to our obstetric services in the developing economies.  Anesthesia care provider, as key player in good obstetric service must pay attention to detail in the care of patients. The OAA has published audit standards for anesthetic record keeping during cesarean sections.  Varma in a retrospective study on anesthetic records for cesarean section reported that 82.6% had block height recorded.  This result was similar to 88% found in another obstetric study.  Level of spinal block was not recorded in anesthetic charts in our pre-intervention; but after teaching, the percentage completion subsequently increased from 33% to 69%. In addition, documentation of outcome of regional block testing was initially 52% which became 99% in the last audit, which was higher than 82.7% reported by Varma.  In addition, documentation of vertebral space, name and dose of local anesthetic agent used may give an insight to reasons for partial, incomplete or a failed spinal block. Varma also reported low completion rates regarding time of skin incision (22.3%), uterine incision (7.1%) and delivery (76%).  Documentation of these last two data was initially poor in our study, but appreciable improvement was recorded from 0% to 61% and 13-85%, respectively after the teaching program. Complete record of skin and uterine incision and delivery time including the Apgar score of the newborn is likely to be useful in case of medico-legal litigations.
Postoperative orders are needed for continuing care with the intention to detecting early complications and minimizing its consequences. In a research project funded by the Victorian Surgical Consultative Council (VICC), 26% of postoperative orders were not documented  compared to 88% in our study at pre-intervention audits. This led to the development of a postoperative orders format by the VICC, which may be written on the anesthetic chart or as part of the general postoperative instructions. The documentation of postoperative remarks on our charts subsequently improved at post-intervention audits which were expected to help patients' management at the recovery room and ward.
Documentation was found to be significantly better in the elective procedures than emergency cases in this study and corroborated by other studies. , This was because there is usually more time available for documentation at pre-, intra- and post-operative period in elective than emergency procedures. Whatsoever, urgency of surgery should not be an excuse for inadequate documentation, hence the need for proper education with regard to this.
The mean of 56% completion of anesthetic charts observed in our study before the teaching program is better than the completion rates of 29.9% reported by Raff and James  although their study was not limited to obstetric anesthesia only. Nevertheless, our results are short of the value of 100% as recommended by AAGBI.  Incomplete information about a patient during the peri-operative period may be taken as negligence in case there is any intra-operative complications. In the present study, the performance of the anesthetists in the filling of anesthetic charts was better after a teaching intervention on anesthetic record keeping. Earlier literatures have reported similar improved outcomes after teaching. ,
As spinal anesthesia technique is becoming more popular in obstetrics, anesthetists must pay attention to detail in their documentation. Although cases of litigations are rare in emerging economies including Nigeria, they may become an issue in the near future as the population becomes increasingly informed. It is essential that all postgraduate students of anesthesia should be made aware of the recording of the details of the anesthesia technique used, intraoperative events, interventions and perioperative hemodynamics.
| Conclusion|| |
This study confirmed adequate demographic data documentation pre- and post-intervention in our obstetric anesthetic practice. In addition, significant improvement in our anesthetic documentation at post-intervention in the majority of other vital data was established. It is suggested that periodic teaching on the importance of the anesthetic record should be incorporated in the teaching schedules of the trainees.
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[Table 1], [Table 2]