Improving Documentation in Obstetric Anaesthesia

Obstetric anaesthesia is highly litigious, and the anaesthetic chart can be the only evidence available to demonstrate standard of care. Documentation becomes increasingly important when cases are brought many years later. Common themes in successful medical negligence claims include: consent; checking the block; and professionalism1, with note- keeping falling under this designation. It was noted during a notes review for a separate project that quality of documentation by anaesthetists was highly variable. In the wake of the Montgomery2ruling and subsequent change in consideration of consent we looked into this further.

METHODS

Electronic anaesthetic charts for caesarean section (non-elective) on SaferSleep system were analysed over a 30day period (1st to 30th November 2021). Data included documentation of consent of risk specific to the chosen anaesthetic technique; anaesthetic start and ready times; block height including time and dermatome; and presence of a motor block using Bromage scale.Results were presented to the anaesthetic department, alongside a teaching session around consent. We suggested prompts to set up on each anaesthetists SaferSleep login, and we agreed a minimum standard of documentation. Re-audit was undertaken from 1st to 30th June 2022

CONCLUSIONS

We have demonstrated overall improvement in quality of documentation, but did not reach 100% documentation of anaesthetic consent. We cannot infer from this that there was no discussion of risk, but acknowledge that in a medicolegal case the anaesthetist would have no evidence to support statements that a consent discussion had taken place. To improve our consent process we developed a take away slip with a QR code linking to an OAA Labour Pains information sheet. This was similar to that already in use for patients attending obstetric pre-assessment clinic for elective caesarean section. After discussions within the anaesthetic department it was noted that this was not the most environmentally friendly approach. We have therefore created a poster for display in each delivery suite room (left)

Agreed standards for documentation are displayed on the anaesthetic machines in obstetric theatre (right) as a prompt for anaesthetists. To pre-empt any deterioration in compliance with documentation standards following trainee changeover, an example anaesthetic chart and copy of the standard has been uploaded onto the MS Teams obstetric anaesthetic induction file.

We will re-audit in three months.