Authors (including presenting author) :
Lo SL (1), Szeto L (1)(2), Lo WC (2), Choi WK(1)
Affiliation :
(1) Ambulatory Surgery Services, (2) Department of Anaesthesia & Operating Theatre Services, Tseung Kwan O Hospital
Introduction :
The purpose of pre-anaesthetic assessment is to assess patients’ health status and identify their anaesthetic risks in order to optimize their conditions before operations. Prior to the new system, manual input into the Clinical Management System (CMS) was required and was in the form of free text.
Objectives :
(1) To ensure comprehensive and accurate assessment via standardizing pre-anaesthetic assessment electronic form and introducing automated scoring tools.
(2) To enhance work efficiency through integrated systems and streamlined communication.
(3) To ensure patient safety throughout their peri-operative journey by means of a seamless quality of care to patients.
Methodology :
Prior to the system rollout, free text notes were used and led to inconsistencies in the assessment items. The new system enables a guided assessment to ensure assessment items are standardized and complete. With standardized inputs, risks are modeled based on scoring tools, e.g. STOP-Bang Score to assess risk of obstructive sleep apnea, thus making the assessment more objective. Moreover, it was time-consuming to gather data and input free text assessment before the system was introduced. The new system is integrated with multiple systems to retrieve up-to-date data, e.g. integration with Auto-Charting System for vital signs and with laboratory result module to retrieve lab results within the past 3 months, saving time and improving accuracy. The pre-anaesthetic assessment is uploaded to CMS, to be incorporated with the intra- and post-operative records, making the complete set of anaesthetic records easily accessible. The system allows subsequent edits, so the information on the form remains up-to-date, which enables better communication among healthcare professionals.
Result & Outcome :
With the new system, assessment becomes standardized to ensure assessment quality; scoring tools are introduced for better risk identification and stratification. In addition, work efficiency is enhanced as a result of shorter time required for the assessment and the readily accessible assessment history. In summary, it provides a communicable platform to ensure patent safety through a seamless quality of care to patient in their peri-operative journey.
