[Web-based for preanesthesia evaluation record: a structured, evidence-based patient interview to assess the anesthesiological risk profile].
At present, providers at an Anesthesia Preoperative Evaluation Clinic (APEC) may have difficulties in gaining access to relevant clinical information, including external medical records, surgical dictations etc. This common occurence makes obtaining an informed consent by the patient after a complete pre-anesthetic assessment difficult. This form of patient information is subject to wide interindividual variations and, thus, represents a challenge for quality assurance. Insufficient or not completed pre-anesthetic assessments can lead to an untimely termination of an elective procedure.A web-based pre-anesthetic evaluation record moves the time point of the first contact to well before the day of admission. The current pre-anesthesia evaluation record is replaced by a structured interview in the form of a complex of questions in a specific hierarchy taking guidelines, standard operating procedures (SOP) and evidence-based medicine (EBM) into consideration. The answers to the complex of questions are then classified according to agreed criteria and possible scoring systems of relevant classifications. The endpoints result in procedural recommendations not only for the informing anesthesiologist but also for the patient. The standardized risk criteria can be used as core process indicators to check the process quality of the anesthesiological risk evaluation. Short-notice cancellations of elective operations due to incomplete premedication procedures will then be avoided with the help of such structured and evidence-based patient interviews with detailed assessment of the anesthesiological risk profile.The web-based anesthesia evaluation record (WAR) corresponds with the recommendations of the DGAI to carry out the staged information in analogy to the staged information of Weissauer. The basic practice is not changed by WACH. By means of WACH, the time point of the first contact with anesthesia is moved forward and occurs within a different framework. WACH has potential advantages for both patient and anesthesiologist, not least due to a higher patient safety.
Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité- Universitätsmedizin Berlin, Campus Mitte und Campus Virchow Klinikum.
Sylvia
S
Kramer
Alexandra
A
Lau
Michael
M
Krämer
Olafur Gunnarsson
OG
Wendler
Lutz
L
Müller-Lobeck
Christoph
C
Scheding
Manja
M
Klarhöfer
Walter
W
Schaffartzik
Tim
T
Neumann
Henning
H
Krampe
Claudia
C
Spies
D000465:Algorithms; D000758:Anesthesia / Q000592:standards*; D000777:Anesthetics / Q000009:adverse effects*; D057189:Checklist; D019317:Evidence-Based Medicine; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D020407:Internet; D007902:Length of Stay; D008487:Medical History Taking / Q000379:methods*; D008499:Medical Records; D010353:Patient Education as Topic; D017060:Patient Satisfaction; D019990:Perioperative Care; D011785:Quality Assurance, Health Care; D018570:Risk Assessment / Q000379:methods*
D000777:Anesthetics