Clinical Audit on Documentation Completeness After Regional Nerve Block at Hawassa University Comprehensive Specialized Hospital

Abstract

Background: A regional nerve block is a type of anesthesia in which local anesthetic medications are injected near a nerve to prevent nerve impulse transmission. Recording what a professional does is one of the indicators of excellent practice. Documentation and recordkeeping assist professionals in reducing unethical behaviour, becoming aware of ethical issues at work, reducing patient complications, and improving service. The goal of this clinical audit is to assess the level of documentation after regional nerve block according to standards at Hawassa University Comprehensive Specialized Hospital. Methods: This clinical audit was conducted retrospectively on the completeness of documentation after regional nerve block for patients who received regional nerve block for analgesia and anesthesia purposes between April 20, 2023, and May 15, 2023, as part of quality improvement. For data collection, a checklist is created based on NYSORA, ASRA, and AAGBI guidelines. Result: Of the 67 record sheets, documentation of patient identity (sex, age, and name) (80.6%), availability of standard monitoring (n=45, 67.2%), name of nerve block (n=48, 71.6%), use of local anesthesia (n=41, 61.2%), and baseline vital signs (n=43, 64.2%) were recorded above 60%. However, the level of documentation of allergies and coagulation history, test dose, time-out performed before needle insertion, post-procedure instructions to the patient or parents, dose of epinephrine, events during the procedure, starting and ending time of the procedure, and adjuvants used were not recorded. Conclusion and recommendation: The practice of recording after peripheral nerve blocks at Hawassa University Comprehensive Specialized Hospital falls below the standard. This could be due to the lack of a separate sheet for peripheral nerve block and a lack of awareness. As a result, all anesthetists who will be involved in regional nerve blocks should receive training, and the standards should be re-audited to ensure compliance.