Quality of pre-anesthesia assessment: a clinical audit in a tertiary care hospital in Pakistan

Objective: To assess the current status of pre-operative anesthesia assessments in a tertiary care hospital and to determine possible changes that would lead to improvement in patient safety in the perioperative period. Study Design: Clinical audit. Methodology: This audit was conducted at a tertiary care hospital in Pakistan, over a six-month period, from 1 January 2024 to 30 June 2024. Pre-operative anesthesia assessment records of 601 patients were reviewed, and records of 100 patients were selected randomly each month. The audit was based on 22 General Quality Indicators (GQI) such as the patient particulars, the medical history of the patient, anesthesia history and details of the procedure/s carried out. Data were analyzed using IBM SPSS Statistics software Version 26. Descriptive statistics were used to examine the frequency and percentage of data completeness of each indicator. The relationship of the completeness rates to categorical variables was determined by chi-square tests. Results: Documentation completeness varied across the 22 indicators. Indicators such as Name of Patient, Age and Gender achieved 100% completeness while critical areas like Anesthesia History and drug history/Medication in use had completeness rates below 30%, indicating significant gaps. Indicators were categorized as ‘Completely Filled’, ‘Adequately Filled’, ‘Moderately Filled’ and ‘Poorly Filled’. Findings will be presented to the Anesthesia Department, with plans for a follow-up audit to track improvements. The completion level of documentation also differed with some of the 22 indicators as follows. Key components, including Name of Patient, Age and Gender, were 100% complete while essential data, including Anesthesia History and Medications in use, had completeness less than 30%. This was done by creating Categories which included ‘Completely Filled’ (90-100%), ‘Adequately Filled’ (80-89%), ‘Moderately Filled’ (70-79%) and ‘Poorly Filled’ (<70%). Recommendations will be made to the Anesthesia Department. Conclusion: The following audit identifies where there is compliance and where there are gaps regarding pre-operative anesthesia documentation. Despite meeting some special criteria, important deficiencies persist in the documentation of the history of anesthetic use and medication administration. The above deficiencies could be rectified through practice of standard documentation procedures and training of workers, enhancing patient safety and quality of care. Recommendations: Implementing structured templates that provide targeted staff training and conducting regular follow-up audits are recommended to increase the completeness and quality of pre-operative assessments. Abbreviations: GQI: General Quality Indicators Keywords: pre-operative assessment; anesthesia documentation; clinical audit; patient safety; tertiary care hospital; quality improvement; General Quality Indicators (GQI). Citation: Zahid MA, Jauhar S, Ali P, Khan MR, Rehman MA, Hasan MF. Quality of pre-anesthesia assessment: a clinical audit in a tertiary care hospital in Pakistan. Anaesth. pain intensive care 2025;29(5):260-267. DOI: 10.35975/apic.v29i5.2849 Received: January 07, 2025; Revised: January 12, 2024; Accepted: January 14, 2025