Documentation of individualized preoperative risk assessment: a multi-center study

Area of Science:

• Perioperative Medicine
• Surgical Outcomes Research
• Patient Safety

Background:

• Individual surgical risk assessment (ISRA) is crucial for shared decision-making, informed consent, and clinical management.
• The utilization rates of ISRA tools and documentation practices remain largely unknown.
• This study aimed to quantify the documentation of ISRAs in surgical patient records.

Purpose of the Study:

• To determine the rate of physician-documented ISRAs in patients with poor surgical outcomes.
• To analyze factors influencing ISRA documentation, including patient demographics and surgical characteristics.

Main Methods:

• Retrospective chart review of 140,756 non-obstetric surgical patients across 22 hospitals (2017).
• Statistical analysis using two-sample proportion tests and logistic regression.
• Evaluation of documentation by surgeons versus anesthesiologists and impact of age, sex, race, ASA class, and surgery type.

Main Results:

• Only 0.54% of patient records (756/140,756) met inclusion criteria.
• ISRA was documented in 16.08% of surgeons' notes versus 4.76% of anesthesiologists' notes (p < 0.0001).
• Higher documentation rates observed for cardiac surgeons, elective procedures, and patients over 65; named ISRA tools were rare (1.3%).

Conclusions:

• The documented rate of individual surgical risk assessment is critically low.
• Surgeons document ISRAs more frequently than anesthesiologists, but overall rates require significant improvement.
• Enhancing the rate and quality of ISRA documentation is essential for robust perioperative informed consent and patient care.