Knowledge, safety, and teamwork: a qualitative study on the experiences of anaesthesiologists and nurse anaesthetists working in the preanaesthesia assessment clinic

Background

The preanaesthesia assessment clinic (PAC) has been shown to contribute to safe anaesthesia assessment in hospitals. In the PAC, patients are assessed with an interview and can also ask relevant questions about anaesthesia. The intention is to ensure that patients are comprehensively prepared for the surgery and hospital stay. Although earlier studies have assessed the effects of PAC, attitudes and satisfaction of the healthcare personnel working in PAC remain unknown. Thus, this study aimed to examine the experiences of anaesthesiologists and nurse anaesthetists working in PACs as well as to explore barriers and facilitators in this context.

Methods

A descriptive qualitative approach was used to explore the experiences of anaesthesiologists and nurse anaesthetists working in PACs. Thirteen semi-structured interviews were conducted using face-to-face, telephone, or digital platforms in five hospitals in west, south, and north Norway between 2020 and 2021. The interviews were transcribed and thematically analysed according to Braun and Clarke’s six-steps semantic reflexive analysis.

Results

Four themes and nine subthemes were identified through an active analysis process, including developing competence in clinical anaesthesia practice, identifying barriers and facilitators influencing collaboration and teamwork, improving patient safety and outcomes through structured assessment, and identifying other organisational factors affecting the delivery of healthcare to surgical patients.

Conclusions

Working in the PAC contributed to competence development among the personnel. Additionally, teamwork was considered important for the proper functioning of the PAC. Patient safety was perceived as improved owning to the structured assessment in PAC, with patients getting the opportunity to improve their knowledge and being more involved in the upcoming anaesthesia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01852-w.

Experience of operating an anesthesia preoperative evaluation clinic in South Korea: An observational study of surgeons' satisfaction

The benefits of an anesthesia pre-operative evaluation clinic (APEC) based on outpatients are well described in previous literatures. In the majority of hospitals in South Korea, preoperative anesthetic evaluation for surgical patients is limited to hospitalized patients on the day before surgery. Thus, we would like to share our institutional experience of implementing an APEC based on outpatients and report on the attitudes and satisfaction of the medical staff (surgeons).A 2-page survey was distributed to all specialists and resident physicians involved in surgery at a single university hospital during a 3-month period. A 5-point Likert scale of agreement and an open-ended question examined perceptions of APEC. A total of 123 questionnaires were distributed and 67 surveys were collected over a 3-month period with a 54.5% collection rate. The surgeons' perceptions of APEC are summarized in . It is difficult to state the tendency of surgeons' perception of the clinic, including workload, patient satisfaction, patient safety, necessity, cost-effectiveness, and efficiency through this survey. However, many surgeons chose to comment on suggestions to improve the quality of the APEC through the open-ended question.The surgeons' attitude and satisfaction to anesthetic services including APEC are an important component of achieving quality improvement. Although it is difficult to state the tendency of surgeons' perception of the clinic, including workload, patient satisfaction, patient safety, necessity, cost-effectiveness, and efficiency through this survey, continuous assessment and feedback may improve efficiency of the APEC and affect patient perception as well.

Clinical agreement in the American Society of Anesthesiologists physical status classification

Background

The American Society of Anesthesiologists physical status (ASA-PS) classification is not intended to predict risk, but increasing ASA-PS class has been associated with increased perioperative mortality. The ASA-PS class is being used by many institutions to identify patients that may require further workup or exams preoperatively. Studies regarding the ASA-PS classification system show significant variability in class assignment by anesthesiologists as well as providers of different specialties when provided with short clinical scenarios. Discrepancies in the ASA-PS accuracy have the potential to lead to unnecessary testing and cancelation of surgical procedures. Our study aimed to determine whether these differences in ASA-PS classification were present when actual patients were evaluated rather than previously published scenario-based studies.

Methods

A retrospective chart review was completed for patients >/= 65 years of age undergoing elective total hip or total knee replacements. One hundred seventy-seven records were reviewed of which 101 records had the necessary data. The outcome measures noted were the ASA-PS classification assigned by the internal medicine clinic provider, the ASA-PS classification assigned by the Pre-Anesthesia Unit (PAU) clinic provider, and the ASA-PS classification assigned on the day of surgery (DOS) by the anesthesia provider conducting the anesthetic care.

Results

A statistically significant difference was shown between the internal medicine and the PAU preoperative ASA-PS designation as well as between the internal medicine and DOS designation (McNemar p = 0.034 and p = 0.025). Low kappa values were obtained confirming the inter-observer variation in the application of the ASA-PS classification of patients by providers of different specialties [Kappa of 0.170 (− 0.001, 0.340) and 0.156 (− 0.015, 0.327)].

Conclusions

There was disagreement in the ASA-PS class designation between two providers of different specialties when evaluating the same patients with access to full medical records. When the anesthesia-run PAU and the anesthesia assigned DOS ASA-PS class designations were evaluated, there was agreement. This agreement was seen between anesthesia providers regardless of education or training level. The difference in the application of the ASA-PS classification in our study appeared to be reflective of department membership and not reflective of the individual provider’s level of training.

A qualitative analysis of the concepts of fidelity and adaptation in the implementation of an evidence-based HIV prevention intervention

Continued debate about the relative value of fidelity versus adaptation, and lack of clarity about the meaning of fidelity, raise concerns about how frontline service providers resolve similar issues in their daily practice. We use SISTA ('Sisters Informing Sisters on Topics about acquired immune deficiency syndrome'), an evidence-based human immunodeficiency virus (HIV) prevention intervention for African American women, to understand how facilitators and program directors interpret and enact implementation fidelity with the need for adaptation in real-world program delivery. We conducted 22 in-depth, semi-structured interviews with service providers from four agencies implementing SISTA. Facilitators valued their skills as group leaders and ability to emotionally engage participants as more critical to program effectiveness than delivering the intervention with strict fidelity. Consequently, they saw program manuals as guides rather than static texts that should never be changed and, moreover, viewed the prescriptive nature of manuals as undermining their efforts to fully engage with participants. Our findings suggest that greater consideration should be given to understanding the role of facilitators in program effectiveness over and above the question of whether they implement the program with fidelity. Moreover, training curricula should provide facilitators with transferable skills through general facilitator training rather than only program-specific or manual-specific training.

Preoperative evaluation: screening using a questionnaire

BACKGROUND AND OBJECTIVE

Prior to elective surgery it is essential to know in advance the patient’s clinical condition. The aim of this study was to compare the preoperative evaluation (POE) through questionnaire responses with preanesthetic evaluation by the anesthesiologist.

METHOD

Prior to their preoperative evaluation, patients answered a questionnaire with information regarding age, weight, height, scheduled surgery, past medical and surgical history, allergies, medications and doses used, social history (illicit drugs, alcohol, smoking), functional capacity and exercise tolerance. Preoperative evaluation was performed by an anesthesiologist who had no access to the questionnaire data or knowledge about the research. The questionnaire data were compared with the preoperative evaluation by two independent investigators, in order to answer the questions: 1) Was the questionnaire evaluation effective - could the patient undergo surgery without the need for face-to-face consultation? 2) Has been there any relevant information - ability to change the anesthetic approach - not assessed by the questionnaire, but assessed by the face-to-face consultation? 3) Has been there any information added by the health questionnaire that was missed by face-to-face consultation? For statistical analysis, the paired Student’s t-test was used for parametric data and chi-square test for categorical data, with p < 0.05 considered significant.

RESULTS

Of the 269 eligible patients there was one refusal, and four agreed to participate but did not complete the questionnaire, in addition to 52 losses, totaling 212 participants. Questionnaire data added to the consultation in 109 cases (51.4%). The screening questionnaire alone was effective for 144 patients (67.93%), with no need for consultation. The anesthesiologist evaluation referred patients for surgery on their fi rst visit in 178 opportunities (84%). In the identification of cases of non-referral to surgery, the questionnaire showed a negative predictive value of 94.4%, positive predictive value of 38.2%, sensitivity of 76.5%, and specificity of 76.4%. Statistically significant (P < 0.05) clinical factors associated with non-referral to surgery were: age over 65 years, BMI > 30, low functional capacity, hypertension, diabetes mellitus, asthma, renal failure, hepatitis, and ischemic heart disease.

CONCLUSION

The questionnaire was effective for screening patients who needed further evaluation and/or changes in treatment regimen prior to elective surgery. Moreover, the questionnaire added data not covered by clinical evaluation.

Preoperative evaluation: screening using a questionnaire

BACKGROUND AND OBJECTIVE

Prior to elective surgery it is essential to know in advance the patient's clinical condition. The aim of this study was to compare the preoperative evaluation (POE) through questionnaire responses with preanesthetic evaluation by the anesthesiologist.

METHOD

Prior to their preoperative evaluation, patients answered a questionnaire with information regarding age, weight, height, scheduled surgery, past medical and surgical history, allergies, medications and doses used, social history (illicit drugs, alcohol, smoking), functional capacity and exercise tolerance. Preoperative evaluation was performed by an anesthesiologist who had no access to the questionnaire data or knowledge about the research. The questionnaire data were compared with the preoperative evaluation by two independent investigators, in order to answer the questions: 1) Was the questionnaire evaluation effective - could the patient undergo surgery without the need for face-to-face consultation? 2) Has been there any relevant information - ability to change the anesthetic approach - not assessed by the questionnaire, but assessed by the face-to-face consultation? 3) Has been there any information added by the health questionnaire that was missed by face-to-face consultation? For statistical analysis, the paired Student's t-test was used for parametric data and chi-square test for categorical data, with p < 0.05 considered significant.

RESULTS

Of the 269 eligible patients there was one refusal, and four agreed to participate but did not complete the questionnaire, in addition to 52 losses, totaling 212 participants. Questionnaire data added to the consultation in 109 cases (51.4%). The screening questionnaire alone was effective for 144 patients (67.93%), with no need for consultation. The anesthesiologist evaluation referred patients for surgery on their first visit in 178 opportunities (84%). In the identification of cases of non-referral to surgery, the questionnaire showed a negative predictive value of 94.4%, positive predictive value of 38.2%, sensitivity of 76.5%, and specificity of 76.4%. Statistically significant (P < 0.05) clinical factors associated with non-referral to surgery were: age over 65 years, BMI > 30, low functional capacity, hypertension, diabetes mellitus, asthma, renal failure, hepatitis, and ischemic heart disease.

CONCLUSION

The questionnaire was effective for screening patients who needed further evaluation and/or changes in treatment regimen prior to elective surgery. Moreover, the questionnaire added data not covered by clinical evaluation.

The effect of hospital size and surgical service on case cancellation in elective surgery: results from a prospective multicenter study

BACKGROUND

Short-term case cancellation causes frustration for anesthesiologists, surgeons, and patients and leads to suboptimal use of operating room (OR) resources. In many facilities, >10% of all cases are cancelled on the day of surgery, thereby causing major problems for OR management and anesthesia departments. The effect of hospital type and service type on case cancellation rate is unclear.

METHODS

In 25 hospitals of different types (university hospitals, large community hospitals, and mid- to small-size community hospitals) we studied all elective surgical cases of the following subspecialties over a period of 2 weeks: general surgery, trauma/orthopedics, urology, and gynecology. Case cancellation was defined as any patient who had been scheduled to be operated on the next day, but cancelled after the finalization of the OR plan on the day before surgery. A list of possible cancellation reasons was provided for standardized documentation.

RESULTS

A total of 6009 anesthesia cases of 82 different anesthesia services were recorded during the study period. Services in university hospitals had cancellation rates 2.23 (95% confidence interval [CI] = 1.49 to 3.34) times higher than mid- to small-size community hospitals 12.4% (95% CI = 11.0% to 13.8%) versus 5.0% (95% CI = 4.0% to 6.2%). Of the surgical services, general surgical services had a significantly (1.78, 95% CI = 1.25 to 2.53) higher cancellation rate than did gynecology services-11.0% (95% CI = 9.7% to 12.5%) versus 6.6% (95% CI = 5.1% to 8.4%).

CONCLUSIONS

When benchmarking cancellation rates among hospitals, comparisons should control for academic institutions having higher incidences of case cancellation than nonacademic hospitals and general surgery services having higher incidences than other services.

Adherence to evidence-based guidelines for preoperative testing in women undergoing gynecologic surgery

OBJECTIVE

To examine adherence to evidence-based recommendations for preoperative testing and health care costs associated with excessive testing.

METHODS

An institutional review of women who underwent gynecologic surgery between 2005 and 2007 was performed. Data on the type of surgery, age, comorbidities, and perioperative testing was extracted. We noted the preoperative performance of chest X-ray, electrocardiogram, metabolic panel, complete blood count, coagulation studies, liver function tests, and urinalysis. Each test was classified as being guideline-based (appropriate) or non-guideline-based (inappropriate) as described by the National Institute of Clinical Excellence perioperative guidelines.

RESULTS

A total of 1,402 patients were identified. Ninety-five percent of patients underwent all of the guideline-recommended preoperative testing. Ninety percent of women underwent at least one nonindicated preoperative test. None of the 749 urinalyses, 407 liver function tests, or 1,046 coagulation studies performed was appropriate. Ninety-nine percent of the 427 chest X-rays ordered were inappropriate. Only 17% of metabolic panels, 36% of electrocardiograms, and 29% of complete blood counts were in accordance with evidence-based guidelines. Inappropriate perioperative tests led to a direct cost of more than $418,000. Of the inappropriate tests ordered, abnormalities were noted frequently but rarely changed management.

CONCLUSION

Adherence to evidence-based recommendations for preoperative testing is poor. Inappropriate preoperative tests represent a major health care expenditure.

LEVEL OF EVIDENCE

III.

Preoperative screening, evaluation, and optimization of the patient's medical status before outpatient surgery

PURPOSE OF THE REVIEW

Preoperative evaluation and optimization of a patient's medical condition are important components of anesthesia practice. With ever increasing numbers of patients with serious comorbidities having complex procedures as outpatients, the task of gathering information and properly preparing for their care is challenging. Improvements in assessment and management can potentially reduce adverse events, improve patient and caregiver satisfaction, and reduce costs.

RECENT FINDINGS

A growing body of literature and evidence-based practices and guidelines can assist clinicians who work in the expanding field of preoperative medicine. Care providers from various specialties in medicine are developing innovative methods, tools, and knowledge to advance science and processes. Data-driven practices are beginning to close the information gap that has plagued this field of medical practice.

SUMMARY

Preparation of patients before surgery is a necessary and vital component of perioperative medicine. Practices are developing to guide effective interventions that benefit patients and healthcare systems. Outpatients present special challenges to preoperative assessment.