Minerva Anestesiologica 2020 Dec 15

DOI: 10.23736/S0375-9393.20.14828-4

Copyright © 2020 EDIZIONI MINERVA MEDICA

lingua: Inglese

Audit of international intraoperative haemotherapy and blood loss documentation on anaesthetic records

Florian PIEKARSKI ¹ ✉, George ZHONG ², Vanessa NEEF ¹, Jan KLOKA ¹, Florian WUNDERER ¹, Patrick MEYBOHM ³, Kai ZACHAROWSKI ¹, Florian J. RAIMANN ¹

¹ Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany; ² Department of Anaesthesia, Concord Repatriation General Hospital, Sydney, Australia; ³ Department of Anaesthesia and Critical Care, University Hospital Würzburg, Germany

BACKGROUND: Anaesthetic records facilitate information transmission to the next healthcare professional and should contain all relevant information of perioperative care. While most anaesthesia societies provide guidelines for record content, important topics like haemotherapy and haemostatic therapy are not well represented. We consider the quality of anaesthetic records with regard to the documentation options for haemotherapy and haemostatic therapy. A secondary objective was to examine guidelines for appropriate recommendations.
METHODS: Anaesthetic records of international anaesthesiology departments were evaluated for the presence of 20 defined fields associated with haemotherapy, haemostatic and fluid therapy as well as intraoperative diagnostics and monitoring. International guidelines were reviewed for appropriate recommendations.
RESULTS: A total of 98 anaesthetic records from 8 countries and guidelines of six anaesthesia societies were analysed. Data fields for red blood cell transfusion have been found in 29.3% (95% CI 0.20 to 0.38), ABO-testing in 6.1% (95% CI 0.01 to 0.11) and indication for transfusion in 2.0% (CI 0.00 to 0.05) of records. Most records contain fields for blood loss (94.4%; 95% CI 0.91 to 0.99) and diuresis (87.9%; 95% CI 0.81 to 0.94). International guidelines that were analysed do not cover the topic of transfusion, but most give recommendations on basic monitoring, blood loss and fluid management documentation.
CONCLUSIONS: The majority of the evaluated anaesthetic records did not contain fields for relevant aspects of perioperative haemotherapy, haemostatic therapy and diagnostics. Guidelines and protocols for anaesthetic documentation should include these topics to ensure information transfer and patient safety.

KEY WORDS: Patient blood management; Haemotherapy; Anaesthetic record; Quality; Patient safety; Anaesthetic charts; Transfusion