Factors Associated with the Completeness of Anesthesia Records in Three Referral Hospitals in Kinshasa, Democratic Republic of the Congo: A Multicenter Mixed-Methods Study
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Abstract
Notwithstanding the paramount significance inherent to anesthetic documentation, its incompleteness persists as a frequent phenomenon within environments characterized by resource constraints. The present investigation was undertaken with the dual objectives of evaluating the degree of completeness within anesthetic records and of identifying the factors correlated with their insufficiency in Kinshasa. A multicenter, cross-sectional study, utilizing mixed-methodological approaches, was conducted at the Cliniques Universitaires de Kinshasa, the Hôpital de l'Amitié Sino-Congolaise, and the Hôpital Saint Joseph de Limete. In total, 422 anesthetic records were subjected to examination, and 61 anesthesia providers were consulted. The assessment of documentary completeness was executed by means of a score validated through expert consensus via the Delphi method. Statistical analyses were performed utilizing the SPSS 26 software, employing the Chi-square test, ANOVA, and multivariate logistic regression. The mean completeness score was established at 72,3 %. While the sections pertaining to administered medications and medical receipts exhibited the highest rates of completeness, postoperative monitoring and the traceability of signatures were identified as the least complete components. Furthermore, a significant difference was demonstrated between the various institutions (F = 162,53; p < 0,001). The inadequacy of continuous professional development has been correlated with a significant elevation in the risk of incompleteness (ORa = 11.02 ; p = 0.043), whereas the implementation of systematic surveillance (ORa = 0.107 ; p = 0.010), alongside the existence of a formalized, written hospital policy (ORa = 0.116 ; p = 0.012), were demonstrated to constitute protective factors. Consequently, the reinforcement of continuous training, rigorous supervision, and institutional policies proves imperative to facilitate the enhancement of both documentary quality and the safety of anesthetic care.
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References
1. American Society of Anesthesiologists. (2018). Statement on documentation of anesthesia care. American Society of Anesthesiologists. Consulté sur American Society of Anesthesiologists
2. Benson, M., & Junger, A. (2012). A survey of user acceptance of electronic anesthesia records. Korean Journal of Anesthesiology, 62(4), 350–357. https://doi.org/10.4097/kjae.2012.62.4.350 DOI: https://doi.org/10.4097/kjae.2012.62.4.350
3. Debora, T., Silaen, M., Nasution, S., et al. (2021). Analysis of factors affecting the quality of inpatient medical records at Royal Prima Hospital Medan. International Journal of Health and Pharmaceutical Research, 2, 132–143. DOI : https://doi.org/10.51601/ijhp.v2i1.17 DOI: https://doi.org/10.51601/ijhp.v2i1.17
4. Ehrenfeld, J. M., Li, G., Grant, B., St. Jacques, P., & Shotwell, M. S. (2020). Patient satisfaction survey scores are not an appropriate metric to differentiate anesthesiologist performance. Journal of Clinical Anesthesia, 65, 109814. https://doi.org/10.1016/j.jclinane.2020.109814 DOI: https://doi.org/10.1016/j.jclinane.2020.109814
5. European Society of Anaesthesiology and Intensive Care. (2022). Guidelines and recommendations for safe anaesthesia practice in Europe. ESAIC.
6. Falcon, D., François, P., Jacquot, C., & Payen, J. F. (1999). Évaluation de la qualité des dossiers d'anesthésie. Annales Françaises d'Anesthésie et de Réanimation, 18(3), 360–367. https://doi.org/10.1016/S0750-7658(99)80063-X DOI: https://doi.org/10.1016/S0750-7658(99)80063-X
7. Gelb, A. W., Morriss, W. W., Johnson, W., & Merry, A. F. (2018). World Health Organization–World Federation of Societies of Anaesthesiologists International Standards for a Safe Practice of Anesthesia. Anesthesia & Analgesia, 126(6), 2047–2055. https://doi.org/10.1213/ANE.0000000000002927 DOI: https://doi.org/10.1213/ANE.0000000000002927
8. George, M., Menon, G. D., & Vergis, S. (2020). Effectiveness of multimodal intervention strategies to improve perioperative documentation in a rural tertiary care center. Turkish Journal of Anaesthesiology and Reanimation, 48(6), 473–476. 10.5152/TJAR.2020.23682 DOI: https://doi.org/10.5152/TJAR.2020.23682
9. Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., French, S. D., O'Brien, M. A., Johansen, M., Grimshaw, J., & Oxman, A. D. (2012). Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, (6), CD000259. https://doi.org/10.1002/14651858.CD000259.pub3 DOI: https://doi.org/10.1002/14651858.CD000259.pub3
10. Joint Commission International. (2023). Joint Commission International accreditation standards for hospitals (8th ed.). Joint Commission International.
11. Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA, 297(8), 831–841. https://doi.org/10.1001/jama.297.8.831 DOI: https://doi.org/10.1001/jama.297.8.831
12. Limpoon, S., Seangrung, P., & Nimmankiatkul, S. (2023). Factors influencing anesthesia record completeness: A cross-sectional study. Annals of Medicine and Surgery, 85(11), 5433–5438. DOI : 10.1097/MS9.0000000000001336 DOI: https://doi.org/10.1097/MS9.0000000000001336
13. Mellin-Olsen, J., Staender, S., Whitaker, D. K., & Smith, A. F. (2010). The Helsinki Declaration on Patient Safety in Anaesthesiology. European Journal of Anaesthesiology, 27(7), 592–597. https://doi.org/10.1097/EJA.0b013e32833b1adf DOI: https://doi.org/10.1097/EJA.0b013e32833b1adf
14. Misganaw, A., & Seyoum, F. (2022). Assessment of manual perioperative anesthesia record-keeping practice: A multicenter descriptive cross-sectional study. International Journal of Surgery Open, 46, 100526. https://doi.org/10.1016/j.ijso.2022.100526 DOI: https://doi.org/10.1016/j.ijso.2022.100526
15. Ndiaye MD, Gueye M, Ndour SB, Niang N, Fall NG, Fall K. (2020) Completeness of information in electronic compared with paper-based patients’
records in a maternity setting in Dakar, Senegal. Int J Reprod Contracept Obstet Gynecol 2020;9:1429-33. DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20201200 DOI: https://doi.org/10.18203/2320-1770.ijrcog20201200
16. Organisation Mondiale de la Santé. (2021). Global patient safety action plan 2021–2030: Towards eliminating avoidable harm in health care. World Health Organization.
17. Preckel, B., Staender, S., Arnal, D., Brattebø, G., Feldman, J. M., Ffrench-O'Carroll, R., Fuchs-Buder, T., Goldhaber-Fiebert, S. N., Haller, G., Haugen, A. S., Hendrickx, J. F. A., Kalkman, C. J., Meybohm, P., Neuhaus, C., Østergaard, D., Plunkett, A., Schüler, H. U., Smith, A. F., Struys, M. M. R. F., Subbé, C. P., Wacker, J., Welch, J., Whitaker, D. K., Zacharowski, K., & Mellin-Olsen, J. (2020). Ten years of the Helsinki Declaration on Patient Safety in Anaesthesiology. European Journal of Anaesthesiology, 37(7), 521–610. https://doi.org/10.1097/EJA.0000000000001244 DOI: https://doi.org/10.1097/EJA.0000000000001244
18. Pronovost, P., et al. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355(26), 2725–2732. https://doi.org/10.1056/NEJMoa061115 DOI: https://doi.org/10.1056/NEJMoa061115
19. White, M. C., Barki, B. J., Lerma, S. A., Couch, S. K., Alcorn, D., & Gillerman, R. G. (2018). A prospective observational study of anesthesia-related adverse events and postoperative complications occurring during a surgical mission in Madagascar. Anesthesia & Analgesia, 127(2), 506–512. https://doi.org/10.1213/ANE.0000000000003512 DOI: https://doi.org/10.1213/ANE.0000000000003512
20. Yee, M. S., & Tarshis, J. (2023). Anesthesia quality indicators to measure and improve your practice: A modified Delphi study. BMC Anesthesiology, 23, 256. https://doi.org/10.1186/s12871-023-02195-w DOI: https://doi.org/10.1186/s12871-023-02195-w