对术前评估的质量进行估量改进
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Measuring and Improving the Quality of Preprocedural Assessments
背景与目的
麻醉医生通过术前评估来改善接受侵入性手术患者围手术期的护理。提前进行这些评估的麻醉医生在术中如若不关心病人，将为确保病情检查的工作与对初级麻醉护理团队的需要相符合增添额外的复杂性。在这项研究中，由其他的麻醉医生通过对此麻醉医生的术前评估质量进行比较以评价对麻醉护理团队的满意度。
方 法
使用一个电子质量保证工具对2014年1月9日到2014年10月21日手术当天的病人进行术前评估质量评级。用户可以把评估登等级分为“模范”、“满意”或“不满意”。提供免费文本以供填入任何评价质量等级。接受过临床麻醉相关训练的评论家将所有评论归类为“肯定的”、“建设性的”或“中立的”，并对数据收集前3个月提交的67个“建设性”意见进行深入的图标记录审查，以进一步分析术前评估中存在的缺陷。2014年5月，麻醉医生将参加一个中间时间点的调查，并对术前评估的过程和相应评估给予反馈。
结 果
分析了37611例麻醉下实施的手术案例。对其中17522（46.6%）例的术前评估进行了等级评估，3828（21.8%）例被麻醉医生评为“模范’’，“13454（76.8%）例为“满意”，240（1.4%）例为“不满意”。在整个研究期间每月“不满意”的评分比例范围从3.1%到0%不等，而中间时间点调查表明，麻醉实施者给予的不满意评价比例约占11.5%。术前评估在住院患者的评级显着优于门诊患者的入院前门诊检查或电话访视（P<0。0001）。给予“不满意”评级最常见的原因是基于对“信息缺失”的不满（49.2%）。图表记录回顾显示：实际上，术前评估中最常见的缺陷是相关信息的不完善（67个中有35，占52.2%）。
结 论
麻醉实施者对医疗机构绝大多数的日间手术术前评估质量的评价是满意或规范。这一观点源自对个案调查和中间时间点调查的总结。然而，麻醉实施者们对整体术前评估质量“不满意”评价比例比对单个术前评估质量“不满意”评价比例更糟。对实施者的评论进行分析使我们能够确定具体的、可操作的改进区域。其他机构可应用该方法来确定术前评价过程的系统性缺陷。
原始文献摘要
Farah Manji,Kelsey McCarty,Vanessa Kurzweil et al.Measuring and Improving the Quality of Preprocedural Assessments.Anesth Analg 2017;124:1846–54.
BACKGROUND: 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.
METHODS: 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.
RESULTS: 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%).
CONCLUSIONS: 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.
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