Emotional and interpersonal factors are most important for patient satisfaction with anaesthesia

Cross-cultural adaptation and validation of the Iowa Satisfaction with Anesthesia Scale for use in Brazil: a cross-sectional study

BACKGROUND

The Iowa Satisfaction with Anesthesia Scale (ISAS) was developed to assess the satisfaction of patients undergoing sedation with monitored anesthesia care. This study aimed to cross-culturally adapt the ISAS instrument and evaluate the acceptability, validity, and reliability of the proposed Brazilian version (ISAS-Br).

METHODS

The cross-cultural adaptation process involved translation, synthesis, back-translation, expert committee review, pre-testing, and final review of the ISAS-Br. A cross-sectional study was conducted, involving 127 adult individuals undergoing ambulatory surgeries with moderate/deep sedation. The acceptability, reliability, and construct validity of the scale were assessed.

RESULTS

The cross-cultural adaptation process did not require significant changes to the final version of the scale. The ISAS-Br demonstrated excellent acceptability, with a completion rate of 99% and an average completion time of 4.6 minutes. Exploratory factor analysis revealed three factors: emotional well-being, physical comfort, and anxiety relief, with respective composite reliability coefficient values of 0.874, 0.580, and 0.428. The test-retest reliability of the ISAS-Br, measured by the intraclass correlation coefficient, was 0.67 (95% confidence interval [95% CI] 0.42 to 0.83), and the Bland-Altman plot showed satisfactory agreement between the measurements.

CONCLUSION

The proposed Brazilian version of the ISAS underwent successful cross-cultural adaptation according to international standards. It demonstrated good acceptability and reliability, regarding the assessment of temporal stability. However, the ISAS-Br exhibited low internal consistency for some factors, indicating that this instrument lacks sensitivity to assess the satisfaction of deeply sedated patients. Further studies are necessary to explore the hypotheses raised based on the knowledge of its psychometric properties.

A Four-Arm Randomized Clinical Trial of Topical Pain Control for Sentinel Node Radiotracer Injections in Patients with Breast Cancer

BACKGROUND

Radioactive tracer injections for breast cancer sentinel lymph node mapping can be painful. In this randomized trial, we compared four approaches to topical pain control for radiotracer injections.

METHODS

Breast cancer patients were randomized (9 April 2021-8 May 2022) to receive the institutional standard of ice prior to injection (n = 44), or one of three treatments: ice plus a vibrating distraction device (Buzzy®; n = 39), 4% lidocaine patch (n = 44), or 4% lidocaine patch plus ice plus Buzzy® (n = 40). Patients completed the Wong-Baker FACES® pain score (primary outcome) and a satisfaction with pain control received scale (secondary). Nuclear medicine technologists (n = 8) rated perceived pain control and ease of administration for each patient. At study conclusion, technologists rank-ordered treatments. Data were analyzed as intention-to-treat. Wilcoxon rank-sum tests were used to compare pain scores of control versus pooled treatment arms (primary) and then control to each treatment arm individually (secondary).

RESULTS

There were no differences in pain scores between the control and treatment groups, both pooled and individually. Eighty-five percent of patients were 'satisfied/very satisfied' with treatment received, with no differences between groups. No differences in providers' perceptions of pain were observed, although providers perceived treatments involving Buzzy© more difficult to administer (p < 0.001). Providers rated lidocaine patch as the easiest, with ice being second.

CONCLUSION

In this randomized trial, no differences in patient-reported pain or satisfaction with treatment was observed between ice and other topical treatments. Providers found treatments using Buzzy® more difficult to administer. Given patient satisfaction and ease of administration, ice is a reasonable standard.

Patient satisfaction with divided anesthesia care

BACKGROUND

Up to now, no prospective cohort study using a validated questionnaire has assessed patients' expectation and perception of divided anesthesia care and its influence on patient satisfaction.

OBJECTIVE

We assessed patient satisfaction with divided anesthesia care in a district general hospital in Switzerland. We hypothesized that patient expectations, combined with their perceptions of the (un)importance of continuous anesthesia care would influence patient satisfaction.

MATERIAL AND METHODS

A total of 484 eligible in-patients receiving anesthesia from October 2019 to February 2020 were included and received preoperative information about divided care via a brochure and face-to-face. The primary outcome was the assessment of patient satisfaction with divided anesthesia care using a validated questionnaire. In group 1 continuity of care was considered important but not performed. In group 2 continuity was ensured. In group 3 continuity was regarded as not important and was not performed. In group 4 patients could not remember or did not answer. A psychometrically developed validated questionnaire was sent to patients at home after discharge.

RESULTS

A total of 484 completed questionnaires (response rate 81%) were analyzed. In group 1 (n = 110) the mean total dissatisfaction score was 25% (95% confidence interval [CI] 21.8-28.1), in group 2 (n = 61) 6.8% (95% CI 4.8-8.7), in group 3 (n = 223) 12.1% (95% CI 10.7-13.4), and in group 4 (n = 90) 15% (95% CI 11-18); ANOVA: p < 0.001, η = 0.43. Of the patients 286 (59%) considered continuity of care by the same anesthetist relatively unimportant (34%) or not important at all (25%). The other 40% considered it important (22%) or very important (18%).

CONCLUSION

Despite receiving comprehensive preoperative information about divided anesthesia care, 40% of patients still considered continuity of care by the same anesthetist important. We recommend further research evaluating whether and how patient expectations can be modified towards the common practice of divided care and patient satisfaction can be increased.

Patient Satisfaction Survey on Perioperative Anesthesia Service in University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2021

Background

Patient satisfaction is a crucial component in determining the quality of healthcare in anesthesia services. This study aimed to assess patient satisfaction and associated factors on perioperative anesthesia services.

Methods

Institutional-based cross-sectional study was conducted from May 16 to June 22, 2021, at the University of Gondar Comprehensive Specialized Hospital. Data were entered into Epi-data version 3.1 and exported to STATA version 14.1. The strength of the association was presented using an adjusted odds ratio with a 95% confidence interval, and a p value <0.05 was considered as statistically significant.

Results

A total of 398 patients were included in this study with a response rate of 98%. The overall proportion of patients who were satisfied with perioperative anesthesia service was 74% (95% CI: 69–78). Patients who received regional anesthesia were 2.8 times satisfied than those who received general anesthesia (AOR = 2.8, 95% CI: 1.42–5.36). Patients who obtained adequate information was 3.14 times (AOR = 3.14, 95% CI: 1.71–5.74) satisfied than that of the counterpart. Adults who did not feel pain during induction of anesthesia were 2.7 times (AOR = 2.7, 95% CI: 1.43–5.08) satisfied than an adult who felt pain during induction of anesthesia. Conclusion and Recommendations. The overall patients' satisfaction on perioperative anesthesia service was 74%. Patients who underwent operation with regional anesthesia, obtained adequate information about anesthesia, visited by anesthetists after operations, did not have nausea/vomiting, did not feel pain during induction, and patients who did not feel pain immediately after operation were satisfied than the counterparts. We recommended that the anesthetists must give attention to reduce the factors that decrease the satisfaction level of the surgical patients.

Patient satisfaction with regional anaesthesia and general anaesthesia in upper limb surgeries: An open label, cross-sectional, prospective, observational clinical comparative study

Background and Aims:

An important assessment of the quality of health care is patient satisfaction. However, only few studies are available which look into this aspect. The primary objective of this study was to compare patient satisfaction between regional anaesthesia (RA) and general anaesthesia (GA) in patients undergoing upper limb surgeries. The length of hospital stay and duration of analgesia between the two techniques were the secondary objectives.

Methods:

This cross-sectional study was carried out in a tertiary care teaching hospital. Patients aged between 18 years and 60 years, of physical status American Society of Anesthesiologists (ASA) grade 1–3, undergoing upper limb surgeries were included in the study. Patient satisfaction with anaesthesia was assessed in patients receiving GA and RA, with 100 patients in each group, at least 24 h after the surgery with a 10-item predesigned peri-operative questionnaire. The continuous variables were compared between the groups using Mann–Whitney–Wilcoxon test, and for categorical variables Chi-square test was used.

Results:

The patients in group RA showed significantly higher satisfaction scores than those in GA (P < 0.001) with respect to all the 10 items of the questionnaire and the total score. Duration of analgesia was also significantly longer in RA than GA (P < 0.001). Duration of hospital stay was also significantly longer in GA than in RA (P < 0.001).

Conclusions:

RA for upper limb surgeries provides better patient satisfaction than GA, along with a longer duration of analgesia and lesser duration of hospital stay.

Primer on adult patient satisfaction in perioperative settings

The topic of patient satisfaction has gained increasing importance over the past decade. Due to the impact of patient satisfaction on health care quality, understanding factors that predict satisfaction is vital. The purpose of this review is to examine the literature and identify factors related to patient perioperative satisfaction as well as predictive variables that, if modified, can enhance satisfaction scores of patients undergoing surgery. Our review reports that patient satisfaction scores are affected by modifiable factors such as clinician-patient communication, information provision to patients, and operational function of a hospital. Non-modifiable factors affecting patient satisfaction scores include patient demographics such as gender, age, and education. In order to enhance patient perioperative satisfaction, we suggest that anesthesiologists and surgeons focus their efforts on enhancing their communication skills and providing information that is appropriately tailored to the understanding of their patients.

Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postoperative analgesia in laparoscopic gastric sleeve resection: a randomized single blinded case control study

BACKGROUND

Pain following bariatric surgery can be quite troublesome and prolongs recovery. Transversus abdominis plane (TAP) block is a new regional anesthetic technique to reduce postoperative pain and is an important part of current analgesic regimen for many abdominal surgeries. The primary objective of our study was to assess the efficacy of the TAP block in controlling postoperative pain in laparoscopic sleeve gastrectomy. Secondary outcomes assessed in this study were postoperative nausea and vomiting (PONV), time to ambulate, readiness for discharge, and whether it leads to improved patient satisfaction.

METHODS

This is a prospective single blind randomized controlled study. A total of 60 patients were included in the study. Patients were allocated in two groups, using a computer generated randomization sequence using http://www.randomization.com . Test group included 30 patients who received Ultrasound-guided transversus abdominis plane (USG-TAP) block along with systemic analgesia and the Control group included 30 patients who received only systemic analgesia. Postoperatively patients were evaluated for pain and satisfaction using VAS scores and 'Capuzzo' satisfaction score, respectively.

RESULTS

Sixty patients were enrolled in the study after fulfilling the eligibility criteria. No patient was lost to follow-up. The difference of VAS scores between test (TAP) and control (Non-TAP) was statistically significant both at rest and on movement. The patient satisfaction score in TAP group was higher than the control group (p value < 0.001). The patients who received TAP block showed earlier readiness for discharge, early ambulation, early resumption of bowel activity, and decreased incidence of PONV as compared to the non-TAP group.

CONCLUSION

USG-guided TAP block is a feasible, minimally invasive technique and can be a part of an effective multimodal analgesia in morbidly obese patients undergoing bariatric surgery. Limitations of this study would be the small sample size and the study being Single-blinded.

A matter of perspective - Objective versus subjective outcomes in the assessment of quality of recovery

Current post-operative recovery assessment exists as a dichotomy, maintaining objectivity whilst providing relevance to patient-centred care. Both objective and subjective measures are utilised in modern recovery assessment and are best viewed as complimentary. At institutional and provider levels, performance indicators are utilised as surrogates for quality of recovery but only if these indicators are assessed in the clinical context from which they are derived. Patient-reported outcomes prioritise the patient's perspective of symptoms and care, which are the most important aspects at the time of assessment but are limited by their susceptibility to response shift and recall bias. Ideally, quality of recovery is assessed using objective measures in concert with measures of clinical complexity and in parallel with patient-reported outcomes.

Perioperative experiences of anesthesia reported by children and parents

BACKGROUND

The Sprint National Anaesthesia Project reported feedback from adults but not from children. We developed questionnaires for children and parents, and conducted a survey of perioperative anesthetic experiences in a large pediatric hospital.

METHODS

Patients undergoing elective general anesthesia were selected randomly each weekday over 10 weeks. Parents and children were approached within 4 hours after awakening, and were asked to complete a short questionnaire. Personal or patient identifiable data were not collected. Questionnaires were processed by optical mark reading technology and descriptive data analysis was performed.

RESULTS

Seven hundred and forty parents and 250 children completed questionnaires. The most common symptoms reported by parents were thirst and hunger (76%), drowsiness (75%), sore throat (41%), and pain of the surgery (38%). Sixty-four percent of children felt worried or scared about something before the procedure: common worries were about the "anesthetic," "procedure," or "needles/cannula." Fifty-five percent reported postoperative pain. Thirty-nine children (15.6%) remembered something between going to sleep and waking up although distress was not reported; of these, the most common experiences remembered included hearing voices (34%), feeling sore (20%), and being worried (14%). Twenty-two parents (2.9%) had any complaint and most were about fasting instructions. Only 3 parents would not recommend the anesthetic service.

CONCLUSION

This study shows that the experiences of children and their parents are similar to those of adults reported by the Sprint National Anaesthesia Project. Thirst (and hunger), anxiety, and pain continue to be common problems for many children. This feedback may help direct interventions and research to improve the pediatric patient and parent experience with anesthesia.

A person-centred approach in medicine to reduce the psychosocial and existential burden of chronic and life-threatening medical illness

The psychiatric, psychosocial, and existential/spiritual pain determined by chronic medical disorders, especially if in advanced stages, have been repeatedly underlined. The right to approach patients as persons, rather than symptoms of organs to be repaired, has also been reported, from Paul Tournier to Karl Jaspers, in opposition and contrast with the technically-enhanced evidence-based domain of sciences that have reduced the patients to 'objects' and weakened the physician's identity deprived of its ethical value of meeting, listening, and treating subjects. The paper will discuss the main psychosocial and existential burden related to chronic and advanced medical illnesses, and the diagnostic and therapeutic implications for a dignity preserving care within a person-centred approach in medicine, examined in terms of care of the person (of the person's whole health), for the person (for the fulfilment of the person's health aspirations), by the person (with physicians extending themselves as total human beings), and with the person (working respectfully with the medically ill person).

[The practice of postanesthesia visits - a questionnaire study]

BACKGROUND AND OBJECTIVE

Regular postanesthesia visits allow the detection of anesthesia related complications and increase patient satisfaction. Consequently, the performance of postanesthesia visits has been recommended after certain types of anesthesia. However, no data is available concerning the current practice of postanesthesia visits. Therefore, this study was designed to investigate quantity, organization, contents, significance and problems of postanesthesia visits in Germany.

METHODS

For this prospective closed-design survey, a questionnaire, consisting of 13 questions, was designed and tested for objectivity, reliability and validity. Subsequently, 3955 registered anesthesiologists were contacted via email to answer this survey.

RESULTS

Return rate was 31.4%; 958 questionnaires were included in the study. Only a small portion of patients was estimated to receive a postanesthesia visit (median: 20.0%). In hospitals with a specific postanesthesia visit service, this number was significantly higher (median: 65.0%, p<0.001) vs. no postanesthesia visit service. Postanesthesia visits usually lasted less than 5minutes (60.0%), and were typically conducted on the day of surgery (48.0%), after regular working hours (55.0%). 38.0% of the respondents reported to detect perioperative complications intermittently during their visits. While 98.0% of all respondents believe that postanesthesia visits improve the quality of their own work, 86.0% of the participants complain a lack of time for this task.

CONCLUSIONS

Our survey indicates that current working conditions prevent a regular postanesthesia visit routine. Considering the high appreciation of postanesthesia visits by anesthesiologists, as well as the relevant incidence of postoperative complications detected during these visits, it seems desirable to consider organizational improvements for postanesthesia care.

Evaluating the Implementation of a Preemptive, Multimodal Analgesia Protocol in a Plastic Surgery Office

Many patients undergoing plastic surgery experience significant pain postoperatively. The use of preemptive, multimodal analgesia techniques to reduce postoperative pain has been widely described in the literature. This quality improvement project evaluated the implementation of a preemptive, multimodal analgesia protocol in an office-based plastic surgery facility to decrease postoperative pain, decrease postoperative opioid consumption, decrease postanesthesia care time, and increase patient satisfaction. The project included adult patients undergoing surgical procedures at an outpatient plastic and cosmetic surgery office, and the protocol consisted of oral acetaminophen 1,000 mg and gabapentin 1,200 mg. Using a pre-/postintervention design, data were collected from patient medical records and telephone interviews of patients receiving the standard preoperative analgesia regimen (preintervention group: n = 24) and the evidence-based preemptive, multimodal analgesia protocol (postintervention group: n = 23). Results indicated no significant differences between the pre- and postintervention groups for any of the outcomes measured. However, results showed that patients in both groups experienced moderate to severe pain postoperatively. In addition, adverse side effects such as dizziness and drowsiness were higher in the postintervention group than in the preintervention group. Although this quality improvement project did not meet the goals it set out to achieve for patients undergoing plastic surgery, it did illustrate the substantial presence of pain after surgical procedures. Thus, clinicians need to continue to focus on identifying targeted treatment plans that use multimodal, non-opioid-based strategies to manage and prevent postoperative pain.

High rate of burnout among anaesthesiologists in Belgrade teaching hospitals: Results of a cross-sectional survey

BACKGROUND

Decisions by anaesthesiologists directly impact the treatment, safety, recovery and quality of life of patients. Physical or mental collapse due to overwork or stress (burnout) in anaesthesiologists may, therefore, be expected to negatively affect patients, departments, healthcare facilities and families.

OBJECTIVES

To evaluate the prevalence of burnout among anaesthesiologists in Belgrade public teaching hospitals.

DESIGN

A cross-sectional survey.

SETTING

Anaesthesiologists in 10 Belgrade teaching hospitals.

MAIN OUTCOME MEASURES

Burnout was assessed using Maslach Burnout Inventory-Human Services Survey.

RESULTS

The response rate was 76.2% (205/272) with the majority of respondents women (70.7%). The prevalence of total burnout among anaesthesiologists in Belgrade teaching hospitals was 6.34%. Measured level of burnout as assessed by high emotional exhaustion, high depersonalisation and low personal accomplishment was 52.7, 12.2 and 28.8%, respectively. More than a quarter of the studied population responded in each category with symptoms of moderate burnout. We detected that sex, additional academic education, marital status and working conditions were risk factors for emotional exhaustion and depersonalisation. Ageing increased the likelihood of burnout by 21.3% with each additional year. Shorter professional experience and increased educational accomplishment increased the risk of total burnout by 272%.

CONCLUSION

Burnout rates in Belgrade teaching hospitals among anaesthesiologists are higher than in foreign hospitals. Emotional and/or physical breakdowns can have serious effects when these individuals care for patients in extremely stressed situations that may occur perioperatively. Causes for burnout should be examined more closely and means implemented to reverse this process.

Clinical prediction model to identify vulnerable patients in ambulatory surgery: towards optimal medical decision-making

BACKGROUND

Ambulatory surgery patients are at risk of adverse psychological outcomes such as anxiety, aggression, fatigue, and depression. We developed and validated a clinical prediction model to identify patients who were vulnerable to these psychological outcome parameters.

METHODS

We prospectively assessed 383 mixed ambulatory surgery patients for psychological vulnerability, defined as the presence of anxiety (state/trait), aggression (state/trait), fatigue, and depression seven days after surgery. Three psychological vulnerability categories were considered-i.e., none, one, or multiple poor scores, defined as a score exceeding one standard deviation above the mean for each single outcome according to normative data. The following determinants were assessed preoperatively: sociodemographic (age, sex, level of education, employment status, marital status, having children, religion, nationality), medical (heart rate and body mass index), and psychological variables (self-esteem and self-efficacy), in addition to anxiety, aggression, fatigue, and depression. A prediction model was constructed using ordinal polytomous logistic regression analysis, and bootstrapping was applied for internal validation. The ordinal c-index (ORC) quantified the discriminative ability of the model, in addition to measures for overall model performance (Nagelkerke's R (2) ).

RESULTS

In this population, 137 (36%) patients were identified as being psychologically vulnerable after surgery for at least one of the psychological outcomes. The most parsimonious and optimal prediction model combined sociodemographic variables (level of education, having children, and nationality) with psychological variables (trait anxiety, state/trait aggression, fatigue, and depression). Model performance was promising: R (2)  = 30% and ORC = 0.76 after correction for optimism.

CONCLUSION

This study identified a substantial group of vulnerable patients in ambulatory surgery. The proposed clinical prediction model could allow healthcare professionals the opportunity to identify vulnerable patients in ambulatory surgery, although additional modification and validation are needed. (ClinicalTrials.gov number, NCT01441843).

Evaluation of a continuous monitoring and feedback initiative to improve quality of anaesthetic care: a mixed-methods quasi-experimental study

Background

This study evaluated the impact of a continuous quality monitoring and feedback initiative in anaesthesia.

Objectives

To conduct a quasi-experimental evaluation of the feedback initiative and its effect on quality of anaesthetic care and perioperative efficiency. To understand the longitudinal effects of passive and active feedback and investigate the mechanisms and interactions underpinning those effects.

Design

Mixed-methods evaluation with analysis and synthesis of data from longitudinal qualitative interviews, longitudinal evaluative surveys and an interrupted time series study.

Intervention

Continuous measurement of a range of anaesthetic quality indicators was undertaken in a London teaching hospital alongside monthly personal feedback from case summary data to a cohort of anaesthetists, with follow-up roll-out to the whole NHS trust. Basic feedback consisted of the provision of passive monthly personalised feedback reports containing summary case data. In the enhanced phase, data feedback consisted of more sophisticated statistical breakdown of data, comparative and longitudinal views, and was paired with an active programme of dissemination and professional engagement.

Methods

Baseline data collection began in March 2010. Implementation of basic feedback took place in October 2010, followed by implementation of the enhanced feedback protocol in July 2012. Weekly aggregated quality indicator data, coupled with surgical site infection and mortality rates, was modelled using interrupted time series analyses. The study anaesthetist cohort comprised 50,235 cases, performed by 44 anaesthetists over the course of the study, with 22,670 cases performed at the primary site. Anaesthetist responses to the surveys were collected pre and post implementation of feedback at all three sites in parallel with qualitative investigation. Seventy anaesthetists completed the survey at one or more time points and 35 health-care professionals, including 24 anaesthetists, were interviewed across two time points.

Results

Results from the time series analysis of longitudinal variation in perioperative indicators did not support the hypothesis that implementation of basic feedback improved quality of anaesthetic care. The implementation of enhanced feedback was found to have a significant positive impact on two postoperative pain measures, nurse-recorded freedom from nausea, mean patient temperature on arrival in recovery and Quality of Recovery Scale scores. Analysis of survey data demonstrated that anaesthetists value perceived credibility of data and local relevance of quality indicators above other criteria when assessing utility of feedback. A significant improvement in the perceived value of quality indicators, feedback, data use and overall effectiveness was observed between baseline and implementation of feedback at the primary site, a finding replicated at the two secondary sites. Findings from the qualitative research elucidated processes of interaction between context, intervention and user, demonstrating a positive response by clinicians to this type of initiative and willingness to interact with a sustained and comprehensive feedback protocol to understand variations in care.

Conclusions

The results support the potential of quality monitoring and feedback interventions as quality improvement mechanisms and provide insight into the positive response of clinicians to this type of initiative, including documentation of the experiences of anaesthetists that participated as users and codesigners of the feedback. Future work in this area might usefully investigate how this type of intervention may be transferred to other areas of clinical practice and further explore interactions between local context and the successful implementation of quality monitoring and feedback systems.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Content validity testing of questions for a patient satisfaction with general anesthesia care instrument

INTRODUCTION

Patient satisfaction with any health care experience is the result of a complex set of interactions between the patient and the health system in which care is received. Measuring patient satisfaction allows quantification of the congruence between the expectations of care and the care that is received. It is important to quantify satisfaction with care because it involves the patient in the care experience and decreases the potential gap between expected and actual care delivered over time. Despite the benefits of measuring satisfaction with anesthesia care, this outcome has been historically understudied possibly because of a lack of reliable tools that measure the construct.

PURPOSE

The purpose of this study was to test the content validity of items derived from an integrated review of studies that measured patient satisfaction with anesthesia care.

METHODS

The content validity of the questions was tested using an expert panel. A total of 13 nurse anesthetists consented to participate in the study as expert panel members. Each expert panel member evaluated the items for content validity on a 4-point scale. Both an Individual Content Validity Index (I-CVI) and a Scale Content Validity Index (S-CVI) were calculated.

RESULTS

All I-CVI scores were greater than 0.8. The range of I-CVI was 0.833 to 1.0. The average scale Content Validity Index (S-CVI/ave) was 0.979.

CONCLUSION

High content validity of all items was supported by an expert panel of anesthesia providers. The high level of agreement among raters related to the content of the general anesthesia statements supports progressing to the next step in instrument development.

Quality control and assurance in anesthesia: A necessity of the modern times

The advent of newer developments in anesthesia techniques and current clinical scenario has necessitated assurance of quality anesthesia services delivery. Numerous factors including availability of newer drugs, availability of newer advanced monitoring gadgets, increased awareness among the patient population, implementation of newer medico-legal laws and professional competitiveness has mandated a quality control and assurance in anesthesia. These domains of quality control are adapted from public health and are being incorporated into daily anesthesia practice in a gradual and phased manner. Quality control and assurance can be assessed and measured with certain quality indicators, which are also helpful in determining the perioperative outcome in anesthesia and surgical practice. Patient's perception about various anesthetic procedures, drug effects and recovery state are the prime underlying basis for assessing the quality assurance and control. At the same time, a positive impact of feedback mechanism cannot be under-emphasized while aiming for improvement in delivery of quality anesthesia services. The current review is aimed at highlighting the important aspects associated with quality assurance and quality control in anesthesia practice.

Feeling safe during an inpatient hospitalization: a concept analysis

AIM

This paper aims to explore the critical attributes of the concept feeling safe.

BACKGROUND

The safe delivery of care is a high priority; however; it is not really known what it means to the patient to 'feel safe' during an inpatient hospitalization. This analysis explores the topic of safety from the patient's perspective.

DESIGN

Concept analysis.

DATA SOURCES

The data bases of CINAHL, Medline, PsychInfo and Google Scholar for the years 1995-2012 were searched using the terms safe and feeling safe.

METHODS

The eight-step concept analysis method of Walker and Avant was used to analyse the concept of feeling safe. Uses and defining attributes, as well as identified antecedents, consequences and empirical referents, are presented. Case examples are provided to assist in the understanding of defining attributes.

RESULTS

Feeling safe is defined as an emotional state where perceptions of care contribute to a sense of security and freedom from harm. Four attributes were identified: trust, cared for, presence and knowledge. Relationship, environment and suffering are the antecedents of feeling safe, while control, hope and relaxed or calm are the consequences. Empirical referents and early development of a theory of feeling safe are explored.

CONCLUSION

This analysis begins the work of synthesizing qualitative research already completed around the concept of feeling safe by defining the key attributes of the concept. Support for the importance of developing patient-centred models of care and creating positive environments where patients receive high-quality care and feel safe is provided.

Patient-Satisfaction Measures in Anesthesia

Patient satisfaction is an important measure of the quality of health care and is used as an outcome measure in interventional and quality improvement studies. Previous studies have found that there are few appropriately developed and validated questionnaires available. The authors conducted a systematic review to identify all tools used to measure patient satisfaction with anesthesia, which have undergone a psychometric development and validation process, appraised the quality of these processes, and made recommendations of tools that may be suitable for use in different clinical and academic settings. There are a number of robustly developed and subsequently validated instruments, however, there are still many studies using nonvalidated instruments or poorly developed tools, claiming to accurately assess satisfaction with anesthesia. This can lead to biased and inaccurate results. Researchers in this field should be encouraged to use available validated tools, to ensure that patient satisfaction is measured and reported fairly and accurately.

Verbal information about anesthesia before scheduled surgery - contents and patient satisfaction

OBJECTIVE

The contents of information for patients before medical procedures are outlined by legislation and guidelines. The amount and form are less regulated. Our aim was to evaluate the contents of verbal information provided by anesthesiologists in a long-established preoperative clinic, and how satisfied patients are with it.

METHODS

A questionnaire based on legislation and the DISCERN quality criteria for information on treatment choices was sent to patients who recently had anesthesia for elective hysterectomy in our hospital (n=372), and to the anesthesiologists involved (n=24).

RESULTS

Preoperative information was regarded as sufficient by 82% of the patients and rated good by 65%. Information on the benefits of anesthesia, its risks, and effects on the quality of life was considered satisfactory by 74%, 49%, and 49%, respectively. Only 54% received enough information on lifestyle interventions to reduce their individual risks. Of the anesthesiologists, 33% had a policy to tell about risks on request only.

CONCLUSION

Verbal information was highly appreciated by the patients, but only two-thirds rated its quality as good, and half were satisfied with the information concerning risks.

PRACTICE IMPLICATIONS

More attention has to be focused on how to offer information on risks and self-help interventions to reduce them.

An integrative review of factors related to patient satisfaction with general anesthesia care

Surgery is typically performed using one or more types of anesthesia. An important patient outcome related to the anesthetic, and a measure of quality from the patient's perspective, is patient satisfaction with anesthesia care. Currently, no psychometrically validated instruments that measure patient satisfaction with general anesthesia care are available in the United States. This integrative review focuses on identifying factors related to adult patients' satisfaction with general anesthesia care. We found the most frequently mentioned modifiable factors related to patient satisfaction were information provided and pain or discomfort. The only nonmodifiable factor with sufficient evidence to include in future studies on instrument development is the patient's age. This review provides information that can help in the design and implementation of quality improvement initiatives and in the development of an instrument to measure patient satisfaction with general anesthesia care.

Using quality indicators in anaesthesia: feeding back data to improve care

After recent UK policy developments, considerable attention has been focused upon how clinical specialties measure and report on the quality of care delivered to patients. Defining the right indicators alone is insufficient to close the feedback loop. This narrative review aims to describe and synthesize a diverse body of research relevant to the question of how information from quality indicators can be fed back and used effectively to improve care. Anaesthesia poses certain challenges in the identification of valid outcome indicators sensitive to variations in anaesthetic care. Metrics collected during the immediate post-anaesthetic recovery period, such as patient temperature, patient-reported quality of recovery, and pain and nausea, provide potentially useful information for the anaesthetist, yet this information is not routinely fed back. Reviews of the effects of feeding back performance data to healthcare providers suggest that this may result in small to moderate positive effects upon outcomes and professional practice, with stronger effects where feedback is integrated within a broader quality improvement strategy. The dominant model for use of data within quality improvement is based upon the industrial process control approach, in which care processes are monitored continuously for process changes which are rapidly detectable for corrective action. From this review and experience of implementing these principles in practice, effective feedback from quality indicators is timely, credible, confidential, tailored to the recipient, and continuous. Considerable further work is needed to understand how information from quality indicators can be fed back in an effective way to clinicians and clinical units, in order to support revalidation and continuous improvement.

Greek surgical patients' satisfaction related to perioperative anesthetic services in an academic institute

BACKGROUND

Patient satisfaction is an increasingly appreciated measure of outcome for health care procedures. The purpose of this study was to evaluate Greek surgical patients' satisfaction with perioperative anesthetic services and to determine which factors maximize satisfaction level through all phases of perioperative care.

METHODS

Adult Greek patients admitted for elective surgery in an academic hospital were included in the study. Three separate questionnaires were constructed: Q1 (patients who underwent general anesthesia alone or combined with epidural) and Q2 (patients who received regional anesthesia alone) covered perioperative anesthetic care; Q3 covered postoperative analgesia services in the ward (patient-controlled analgesia or epidural analgesia) provided by our anesthesiologist-centered analgesia care team. Principal component analysis with varimax rotation was used separately for each questionnaire, and extracted factors were entered into multiple logistic regression with patient satisfaction as the dependent binary variable. Statistical significance level was set at P < 0.05.

RESULTS

Three hundred and forty-five patients were included. Q1 questionnaire (answered by 282 patients) included four dimensions: communication with the anesthesiologist, sense of cold/shivering, pain, and nausea. Q2 questionnaire (answered by 63 patients) included three dimensions: communication with the anesthesiologist, sense of cold/shivering, and nausea/anxiety. Q3 questionnaire (answered by 237 patients) included five dimensions: anesthesiologist intervention upon symptoms, pain, care by the anesthesiologist/physical activity, nausea/vomiting, and anesthesiologist behavior. The communication dimension score in Q1 and Q2, sense of shivering in Q2, and pain management and anesthesiologist behavior dimension scores in Q3 were significantly associated with patient satisfaction. Overall satisfaction rates were high (according to the questionnaire, the observed percentage was in the range of 96.3%-98.6%).

CONCLUSION

Greek surgical patients reported high satisfaction with perioperative anesthesia care. Interaction between patient and anesthesiologists during all periods of study, absence of shivering in regional anesthesia, and adequate postoperative pain control in the ward were significant predictors of patient satisfaction in the present Greek surgical population.

Interaction between anaesthetists, their patients, and the anaesthesia team

Communication is a key skill for anaesthetic practice. The 'non-informational' aspects of communication, such as non-verbal elements and the degree to which the style of communication reflects the implied relationship between the sender and the recipient, are relevant to interactions both between anaesthetists and patients and to interactions with other members of staff in the team. Communication and interaction between members of the anaesthesia team in isolation has received less attention than communication in the operating theatre during surgery. Most aspects of such communication are informally learned and developed with experience. Studies of communication at induction of anaesthesia have used qualitative methods to identify a range of styles of talk. This is nominally directed at the patient but also serves to unite and co-ordinate the team to ensure the patient's smooth, safe progress into anaesthesia. In particular, the use of positive words and phrases seems to benefit patient comfort and safety. On emergence, a more limited range of communication styles is found. Handover of the recently anaesthetized patient to recovery room staff is often brief and distracted by concurrent patient-related activities. Both information about the patient, and responsibility for the patient's continuing care, have to be transferred. The handover event also serves as an opportunity to review the care the patient has received and plan for further progress. Anaesthetists and nurses use unspoken and implicit negotiation strategies to achieve the aims of handover without compromising future collaborative work. This is in contrast to the more formalized handover approaches in other safety-critical settings.

Communication between anaesthesiologists and patients: how are we doing it now and how can we improve?

PURPOSE OF REVIEW

The purpose of this review is to present and bring together the relatively small body of recent work on anaesthesiologist-patient communication.

RECENT FINDINGS

Anaesthesiologists and patients may have different 'agendas' during their consultations, with anaesthesiologists focusing more on information and patients more on the emotional aspects of care. As effective communication implies a two-way process, anaesthesiologists should be aware of this. Communication can make good use of written media, video, E-mail and telephone as well as face-to-face interaction. The content of communication, both verbal and nonverbal, is critical but much of this is learned informally despite the recent interest in teaching communication skills. Some recent studies have observed and described how communication is actually performed in practice and these are a useful starting point for reflection and experiment. The few studies to examine whether communication can improve outcomes for patients have all produced broadly positive findings. Communication with children, communicating about risk and dealing with the aftermath of anaesthetic disasters are also reviewed specifically.

SUMMARY

Communication between anaesthesiologists and patients is essential for effective clinical practice. Some practical suggestions are made and pointers to further reading given.

Current world literature

This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 February 2008 and 31 January 2009 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.

Is it possible to measure and improve patient satisfaction with anesthesia?

Satisfaction cannot be considered as an objective indicator of the quality of anesthesia care, but it remains the best way to assess the outcome from the point of view of the patient. Patient satisfaction offers the opportunity for evaluating nontechnical aspects of medical care, in particular interpersonal relationships arising from specific episodes of care. Satisfaction is usually defined as the result of the comparison between expectations and perceived outcome. If improving patient satisfaction with anesthesia becomes one of the aims of a health service, anesthetists have to consider that when patients have an improved anesthesia experience, their expectations are exceeded, which in turn increases the expectations for subsequent anesthetics. A continuous quality improvement process is needed to maintain patient satisfaction at the highest level.

Anesthesia outside the operating room in the office-based setting

PURPOSE OF REVIEW

The majority of anesthesia services provided outside the operating room or ambulatory surgery center is in the office-based setting. This review will focus on three areas that are critical to office-based anesthesia: safety, quality of care and patient satisfaction.

RECENT FINDINGS

Data obtained from the State of Florida office-based surgery adverse event data repository indicate that, even with The American Society of Anesthesiology I patients, there remains opportunity to improve outcomes. Careful patient selection remains critical, especially the patient with a history of sleep apnea. While general anesthesia remains the gold standard, expanded use of local anesthesia, regional blocks and variation on sedation techniques offer alternatives that may reduce risks but still maintain a high quality of care. While there is limited office-based anesthesia satisfaction data, limiting postoperative nausea and vomiting remains a major patient satisfier of which an occurrence rate of zero may be possible.

SUMMARY

There is rapid growth for the need of safe and high quality office-based anesthesia. To meet these needs, a special set of skills is required, which may require expanded exposure and experience during training. An office-based anesthesia central data repository is needed for benchmarking and identifying areas for improvement. Finally, with advances in surgical technology, there is a need for focused research in office-based anesthetic techniques and modalities and patient satisfaction.

Patient satisfaction with postoperative pain management--effect of preoperative factors

Patients often suffer from inadequate treatment of postoperative pain. The purpose of this study was to survey the factors affecting patient satisfaction with postoperative pain management. A questionnaire with 41 items was given on the third postoperative day to 102 patients undergoing major orthopedic or vascular surgery. Intensity of pain was assessed using a 10-cm visual analogue scale (VAS) and given analgesics were recorded. Nurses (n = 74) working on the wards received a questionnaire concerning attitudes toward management of pain. The questionnaires were returned by 75.5% of the patients and 86.3 % of the nurses. Mean VAS on all wards was 2 (scale 0-10). Twenty-eight percent of the patients agreed having hard pain during the day of the operation and 39.3% during the first postoperative night. Eighty percent of the patients were satisfied with pain management, and their satisfaction correlated significantly with received preoperative information (p < .01) and preoperative well-being (p < .01). There is discrepancy between the amount of experienced pain and values of the frequent VAS recordings, which does not seem to be due to the nurses' attitudes toward pain. Preoperative interview is important tool to receive and give information concerning postoperative pain management.

Factors predictive of patient satisfaction with anesthesia

BACKGROUND

In this multicenter prospective study, we identified factors associated with satisfaction with anesthesia in patients staying in hospital at least 24 h after surgery.

METHODS

The study was performed in six centers. Inpatients aged more than 18 yr, who underwent a wide range of common surgical procedures, were asked to answer a 10-item instrument to measure patient satisfaction with anesthesia (mean score range, 0-10) and some specific questions, and to rate their perceived health (score, 0-10). Anesthesia staff members were invited to self-compile a Maslach Burnout Inventory.

RESULTS

The satisfaction evaluation questionnaire was returned by 1290 patients (mean age, 61 +/- 16 yr; males, 54.4%). The mean global satisfaction score was 8.7 (95% CI: 8.7-8.8), being <9 in 632 (49%) and > or =9 in 658 (51%) patients. The Maslach Burnout Inventory was returned by 55 anesthesiologists and 68 nurses. Multivariate regression identified five variables as significant predictors of a mean global satisfaction of >/=9: 1) having been treated in a service with perioperative nurses specifically dedicated only to anesthesia; 2) having been treated where anesthesia information leaflets were provided preoperatively; 3) having received more than two anesthesiologist visits after surgery; 4) having a perceived health score >8.5; and 5) being older that 70 yr. No relationship was found between staff burnout and patient satisfaction.

CONCLUSIONS

Inpatient satisfaction can be improved by an organization in which surgical suite nurses are dedicated only to anesthesia, a written anesthesia information leaflet is given during the preoperative visit and postoperative visits are enhanced.

Melatonin does not reduce anxiety more than placebo in the elderly undergoing surgery

Melatonin has been reported to reduce preoperative anxiety. We performed this study to compare preoperative anxiety in elderly patients receiving melatonin (M) or placebo (P). Anxiety was measured in patients aged >65 yr by a numerical rating scale (range, 0-10). Each patient was randomized to receive M 10 mg or P orally: 71 patients were in group P and 67 in group M. The median (quartiles) anxiety level was 5 (2-8) before and 3 (1-7) 90 min after premedication in group M and 5 (3-6) and 3 (1-5) in group P, respectively. M and P reduce anxiety in elderly patients to a similar degree.

[Assessment of patient satisfaction after regional anaesthesia in two institutions]

OBJECTIVES

This study was designed to assess patient satisfaction after regional anaesthesia for limb surgery.

METHODS

An anaesthesia satisfaction questionnaire was developed, validated (Kappa coefficient) and submitted to 314 patients operated in two institutions (one university hospital with anaesthesiology residents and one specialised in orthopaedics with experienced anaesthesiologists). Items explored were information modalities, pain and anxiety during procedure and global satisfaction rated with four levels (very satisfied [VS], satisfied [S], partially satisfied [PS], non-satisfied [NS]). Patients were interviewed by telephone at postoperative D1 and D8 by a pharmacist student not involved in the patient's care.

RESULTS

Inspite of a high level of patient satisfaction at D8 (VS: 50%, S: 44%), some interesting aspects should be emphasised: a) sedation given before nerve block was not efficient to reduce anxiety and pain during procedure; b) VS levels decreased from D1 (56%) to D8 (50%) mainly because of late postoperative pain (after discharge) and discomforts; c) willingness to undergo the same nerve block again (294/314) was not correlated with patient's satisfaction since among PS and NS patients, a majority (9/15) wished for a block in case of renewed limb surgery; d) multivariate analysis showed that VS level was highly correlated with the quality of communication by the anaesthesiologist mainly for informations about pre and postoperative periods. No correlation was found with pain level during procedure; e) satisfaction levels were not different in the two institutions.

CONCLUSION

This study has emphasised some important factors of patient satisfaction which were not sufficiently taken into account in our daily practice.

Patient satisfaction with anaesthesia care: What is patient satisfaction, how should it be measured, and what is the evidence for assuring high patient satisfaction?

Patient satisfaction is a part of outcome quality. Many theories of satisfaction include patients' expectation. One definition of satisfaction is therefore the degree of congruence between expectation and accomplishment. The involvement of patients as well as experts is therefore an important step in the development of an instrument to measure patient satisfaction. Results of single-item ratings or overall satisfaction surveys are over-optimistic and do not represent the true indication of care. The construction of highly standardized (psychometric) questionnaires should include elements of content validity, criterion and construct validity, reliability and practicability. Based on the few available studies in anaesthesia, patient satisfaction is primarily determined by information and communication. There is great potential for improvement in this area. However, we do not know the best way to continuously improve patient satisfaction with anaesthesia care, or to what extent decisions should be shared between the anaesthetist and the patient.