Exploratory analysis of deviations from formal procedures during preoperative anaesthetic evaluation

Abstract

Motivation --- The aim of this paper is to study deviations from formal procedures during preoperative anaesthetic evaluation and to investigate their possible association with the assumptions that anaesthesiologists make during the evaluation. The findings of this analysis can be applied for the identification of requirements and limitations for the standardisation of the task through supporting tools. Research approach --- Records of 100 consecutive preanaesthesia evaluations for elective surgery in a private hospital were retrospectively analysed. In addition, field observations were carried out in order to guide data collection and support the formulation of an initial framework for organizing our findings. This way, data analysis and fieldwork were interwoven, feeding each other. Findings/Design --- The review of 100 preanaesthesia evaluation records revealed that a significant number of them deviated from the normative course of action. Specifically, contrary to the stipulations of the prescribed procedure, in 26% of our cases, the evaluation was performed without having available the preoperative laboratory test results. Furthermore, the form provided for the documentation of the evaluation was scarcely filled-in (75% of the forms had less than 30 out of the 83 total fields completed. In the same time, free-text fields were extensively used, spilling over their content to other fields in 15% of the cases. Our findings are consistent with prior research which indicates that routine laboratory tests are not critical for the evaluation of the patient. Furthermore, the frequently completed fields coincide with the main findings of previous research on the opinions of anaesthesiologists regarding what variables they consider as important. A possible explanation for the observed deviations from formal procedures and low utilisation of standardized forms could be that anaesthesiologists are engaged in a thinking-acting process rather than in a process of information collection directed by a protocol. Standardisation efforts through supporting tools ought to be non-obstructive to this process. Research limitations/Implications --- Our research is limited by the modest sample size of 100 cases and input from a single hospital. Nevertheless, the questions raised and initial hypotheses formulated can be further tested with a larger sample size and different medical establishments. Originality/Value --- Anaesthesiologists have been leaders in applying lessons from Human Factors and Cognitive Ergonomics, but most effort was directed to the development of support tools and decision aids for the operating theatre. The research presented here aims at extending those lessons to the preanaesthesia related tasks. Take away message --- Deviations from the formal procedure during preoperative anaesthetic evaluation can be used for the identification of requirements and limitations for the standardisation of the task through supporting tools.