An analysis of peripheral nerve block documentation at a tertiary hospital in Johannesburg, South Africa

Abstract

Background The practice of regional anaesthesia (RA) has become a standard for majority of practitioners involved in patients’ pain management. The exponential growth in the field has brought with it a rise in the incidence of associated complications and the litigation that follows. Incomplete documentation has been found to contribute to 16% of medicolegal claims. This study aims to be the first published audit on the documentation of peripheral nerve blocks (PNB) in South Africa, potentially resulting in the implementation of a standardised regional anaesthesia procedure form. Methods A quantitative, descriptive, retrospective study design was followed. Convenience sampling was used to obtain information related to documentation of peripheral nerve blocks recorded during the study period of 2019 at a tertiary hospital in Johannesburg, South Africa. Using a peer-reviewed checklist, adapted from the international expert panel Delphi consensus project for effective documentation in regional anaesthesia, a sample of 684 anaesthetic charts was audited to assess adequacy of completion. Results The overall score for chart completion was 51.8%. There were statistically significant differences in chart completion rates between those charts which documented the; block performer’s name (p = < 0.01), presence of a supervisor (p = < 0.01), and block outcome (p = < 0.01). Results also identified a statistically significant association between documented intra-operative complications and the documentation of patients’ baseline vitals (p = 0.048). Conclusion The documentation practices of peripheral nerve blocks are poor. Although the risks of major RA-associated complications may seem low – they are real, and anaesthetists must endeavour to mitigate these risks as far as possible. PNB documentation is improved in the presence of a confident and skilled performer that is willing to document their name and outcome of their work, as well as when directly supervised by a senior – likely as a result of direct input on documentation or by boosting the performer’s competence. Anaesthetists may fear the iv negative consequences of complications (such as litigation) and thus appropriate awareness for and comprehensive documentation of such complications improves overall chart completion standards.