Patient satisfaction with anaesthesia and pre-anaesthetic information
*Tomasz Gaszyński, Jakub Jakubiak, Katarzyna Woźniak, Tamara Trafidło, Paweł Ratajczyk, Wojciech Gaszyński
Department of Anaesthesiology and Intensive Therapy, Medical University of Łódz
Background. Patient satisfaction with perioperative care plays an important role in the assessment of quality of care. Written evaluation forms are commonly used all over the world for this purpose. The purpose of this study was to assess the quality of perioperative care, with special attention being directed to anaesthesia-associated side effects.
Methods. Forty-two adult patients, of both sexes, scheduled for abdominal surgery, were asked to complete a questionnaire consisting of 11 questions on anaesthesia, side effects and the general quality of perioperative care. The results were analysed using the χ2 test, and p <0.05 was considered significant. The Pearson correlation coefficient was used for comparison.
Results. There was a strong correlation between the quality of the pre-anaesthesia visit, including the information obtained on possible complications and alternative methods of anaesthesia, and the assessment of quality of the anaesthesia service. Post-anaesthesia care facilities were also found to be of major importance for patients.
Conclusions. Adequate, detailed and easily understandable information plays a crucial role in patient’s satisfaction with anaesthesia. Special attention should be paid to the most common side effects and complications. Residents should be trained in communication in the early stages of their training.
In recent years, the issues related to quality in everyday life and in patient-oriented medical care have become increasingly popular. The notion of quality was introduced to medicine by Hippocrates. His rule „primum non nocere” evidences the interest in the quality of procedures performed by the medical personnel. In order to improve the medical care, health of patients and their satisfaction, medical institutions were obliged to implement and respect strictly defined standards, which frequently require high expenditures.
The quality of health care is associated with the evolution of modern society – higher consumptive awareness and requirements of patients, as well as growing competitiveness of individual constituents of health services. Limited financial resources, lack of a basket of guaranteed medical services, planned structural changes regarding the ownership of hospitals and a new system of contracting medical services impose the economic solutions in which the quality of services is not always prioritised.
Before the issue of quality of medical services is discussed, the term ‘services’ should be explained. In broad terms, services are ‘any intangible activities that do not result in ownership. Their production may or may not be tied to a physical product’ . Thus, the quality of services is a complex and multi-aspect notion whose measurements are extremely difficult for authorities of health care institutions. The quality measurements should answer the three key questions. What is the level of services offered in an institution? Is the quality of services improving? What should be done to improve this quality? Satisfaction of patients and clinical quality are important aspects of such measurements.
The aim of the study was to assess the opinions of patients hospitalized in the general surgery department after surgeries carried out under general or block anaesthesia regarding the quality of anaesthetic services provided by the institution in the light of post-anaesthesia adverse side effects. To achieve this aim, the following research questions were formulated: Do post-anaesthesia adverse effects affect the assessment of quality of hospital services? To what extent can the doctor-patient communication influence the evaluation of medical services? Can accommodation facilities and personnel attitudes towards patients affect the assessment of quality of anaesthetic services?
The study was approved by the Ethics Committee and included post-surgery patients of the Department of General Surgery and Transplantology, Teaching Hospital no. 1 in Łódź. The diagnostic survey was carried out to collect the data based on an anonymous questionnaire prepared for the purposes of the present study. The questionnaire contained 18 questions; 11 multiple-choice questions (yes, no, I do not know, I do not remember) and the remaining ones regarding the type of surgery, demographic data, number of hospitalisations and waiting time for health services. For calculations, the questions were categorised.
The results were statistically analysed using the basic average measures. In order to divide the answers provided, the relations between individual features were analysed using the test of independence χ2. The level of significance was set at p≤0.05. Moreover, the Pearson’s contingency coefficient (C) was computed, which measures the relation between non-measurable variables: C< 0.3 – a weak correlation, 0.3≤ C <0.6 – moderate and C ≥0.6 a strong correlation.
The study involved 42 patients, 25 (59.5%) males and 17 (40.5%) females. The majority of patients (76.2%) had been hospitalised in the past and 23.8% were hospitalised for the first time. The respondents were undergoing surgery due to cholecystolithiasis (16), obesity (7), inguinal hernia (2), abdominal hernia (4), acute pancreatitis (5), appendicitis (3), alimentary neoplasm (3), and lower extremity varices (2). Thirty–nine patients were subjected to general anaesthesia and three to block anaesthesia.
The questionnaire questions were answered as follows:
- Did the anaesthetist talk to you before anaesthesia? Yes – 83.3%. No – 14.3%. I do not remember – 2.4%.
- Were you informed about possible side effects of anaesthesia? Yes – 47.6%. No – 52.4%.
- Did you have any post-surgery complications? Yes – 28.6%. No – 71.4%. Anaesthesia-related adverse/side effects (respondents could list more than one) are presented in Fig. 1.
- Were you informed about the behaviour after recovery in the recovery room? Yes– 19.0%. No – 81.0%.
- Was the operating room properly equipped? Yes – 90.5%. No – 4.75%. I do not remember – 4.75%.
- Did the staff treat you individually and try to solve the reported problems? Yes – 100%.
- Were you able to consent to or refuse a given service or change of management during surgery? Yes – 100%.
- Were you provided with detailed information about alternative methods of anaesthesia Yes – 7.1%. No – 92.9%.
- If another anaesthetic procedure were necessary, would you choose the same method? Yes – 100%.
- How do you asses the quality of hospital services? Very good – 62.0%. Good – 31.0%. Average – 7.0%. The reservations reported by patients are presented in Fig. 2.
- Would you change your opinion about the quality of medical services if you were given more detailed information on possible anaesthesia-related side effects? Yes – 35.7%. No – 64.3%.
Three parameters were demonstrated to have moderate effects on the quality of anaesthetic services: adequate information about the anaesthetic procedure, information on alternative methods of management and equipment (Table 1).
The changes in the health care system introduced by the reform of 1999 resulted in increasingly common debates about the quality of medical services. Moreover, the rules of market competitiveness and possibility to choose service providers by patients have some impact. The ways of financing medical care institutions tend to aim at signing the quality-dependent contracts. Free choices of medical institutions, continuously growing number of non-public health care centres and longer lifespan changed the approach to the quality in health care .
The basic principles of quality management were elaborated by Deming. The definition of quality and suitable adjustment of tools for its measurement constitute the key elements. Each stage of management should be analysed and assessed. The benefits resulting from quality management are multiple and include better work organization, reduced general costs, effective use of resources as well as satisfaction of patients and better position on the market of medical services . The quality of medical services is assessed using appropriate tools, e.g. total quality management (TQM) , which in health care should involve awareness of the role of an internal client (patient), greater importance of prophylaxis, increased role of communication with patients, personnel self-control of their work .
The concept of quality-related management of medical services is also of importance in anaesthesiology and intensive therapy. In this field of medicine, standardised in many aspects of management, there are also relevant guidelines concerning medical procedures sensu stricto as well as quality-related guidelines in the light of legal regulations and patients` rights.
In Poland, the basic document defining the standards of management in anaesthesiology is the Ministry of Health decree of February 27, 1998 , which imposes a variety of responsibilities on the anaesthetist, including:
- familiarisation with the medical records of a patient at least 24 h before surgery;
- pre-surgery testing of the anaesthetic station and anaesthetic devices;
- properly marked infusion fluids, anaesthetics, compatibility tests of blood preparations;
- identification of the patient scheduled for surgery;
- continuous monitoring of basic vital functions;
- preparation of the anaesthesia protocol with the information about the agents used, doses, values of parameters of basic vital functions and complications, if have developed.
One anaesthetist should attend one anaesthetic station and be assisted by appropriately trained nurses. The patient can be handed over to another physician after informing him about the course of anaesthesia. If the anaesthetist has to leave the station to undertake life-saving procedures, he/she should evaluate whether this can be associated with the direct life-threatening risk to the patient anaesthetized and operated on.
According to the mentioned regulation, only a physician-anaesthetist can carry out all the activities connected with the anaesthetic procedure .
The anaesthesia-related standards were also defined by the American Society of Anesthesiology. They are concerned with the most critical issues in anaesthetic procedures. The first standard states that the trained personnel has to be continuously present during general or block anaesthesia and the course of the procedure should be supervised, which is essential as the patient’s condition may change rapidly and lack of immediate reaction is likely to result in tragic consequences. The second standard regards continuous monitoring of vital parameters of the patient under the care of the anaesthetist .
Besides the legal regulations on quality-related management, the measurable effect of medical services, i.e. patient’s assessment, is of great importance.
The studies evaluating the quality of medical services are difficult to carry out and require a holistic approach to the issues. The biggest difficulties are associated with the multi-aspect nature of the quality notion. Most research tools are patient-oriented and assess the patient’s satisfaction with the entire hospital stay. In our study, the questionnaire questions covered only some factors, which might have affected their satisfaction. They concerned both patient-anaesthetist contacts and activities related to anaesthesia and perioperative care. Our findings show that patients are more concerned with general impressions related to hospital stay (e.g. meals or facilities) than with complications they have. This is consistent with the commonly observed tendency of patients to put in claims and with an increasing number of compensation claims due to unpleasant post-anaesthesia experiences. All the correlations found in the study indicate that communication with the physician, talks and explanations concerning doubts are essential for patients. Thanks to adequate information provided the patient feels safer in the new and definitely uncomfortable hospital setting. Thus, besides the medical knowledge, based on the guidelines and regulations, the abilities to communicate with patients are of crucial importance.
Many studies stress that questionnaires evaluating the satisfaction of patients with anaesthetic services should be properly carried out. The questionnaire data obtained are greatly affected by the presence of the anaesthesiologist during its completion [8, 9, 10]. Lack of confidentiality prevents patients from expressing their opinions and suggestions concerning the quality of services . Moreover, the questionnaires are rarely carried out at some time intervals. It was demonstrated that the repeated completion of questionnaires after 2 weeks or 1 month provided more reliable information on quality problems and satisfaction of patients [9, 12, 13].
Our results reveal that the majority of anaesthesiologists did not provide detailed information on the method of anaesthetic management. Patients were not informed sufficiently or comprehensively enough about possible complications and alternative methods of management. Any possible complication whose incidence exceeds 1% should be discussed. The anaesthesiological examination should be performed at least one day before the planned procedure. Numerous studies demonstrate that the pre-anaesthesia visit alone is not sufficient to provide the patient with specifications of the service [14, 15]. In this context, the organization of anaesthesiological clinics seems grounded; the suitable examinations can be performed in them, which is not possible in a typical patient’s room setting.
The information should be provided in an easily understandable way, i.e. the physician should use comprehensible expressions adjusted to a particular patient. Brochures or videos can also be used; the latter were found particularly useful as a well-accepted means of communication in many social groups .
Information on alternative methods of anaesthetic management is an important element of respecting the patient’s rights. Our observations, however, show that the talks are carried out in such a way as to direct patient’s attention to the method of anaesthesia preferred by the anaesthesiologist, which is unacceptable considering the patient’s rights as well as professionalism or objectivity of the physician. Moreover, the method of management cannot be chosen based on procedure costs. For instance, an alternative to block anaesthesia, traditionally used in simple surgeries, is general anaesthesia with laryngeal devices for airway maintenance. Some patients prefer abolition of awareness during the procedure, which should be respected. Some minor complications associated with block anaesthesia are trivialised by physicians, e.g. urine retention, which can occur in 2.5% of patients after subarachnoid or epidural anaesthesia . Catheterisation of the urinary bladder may generate additional complications such as
infections. Patients, who remember such unpleasant experiences, prefer some other methods – in this case, general anaesthesia. Unfortunately, in some cases, patients are not informed about alternative methods of management because block anaesthesia is considered safer and cheaper than general anaesthesia. In fact, there are no differences in mortality and morbidity after general and block anaesthesia; the costs, on the other hand, should be assessed totally, including the cost of treatment of complications and not only the cost of a syringe for subarachnoid anaesthesia versus the cost of an laryngeal mask . Even a potential risk of complications may be the reason for a compensation claim.
In our study, two out of all anaesthetised patients were previously administered block anaesthesia. Their post-surgery experiences were bad; difficulties in passing urine or lying in bed in a forced position – the recovery room personnel believes that patients after subarachnoid anaesthesia should lie flat for at least several hours. This time general anaesthesia was suggested with the use of a laryngeal mask; thanks to that, the patients were satisfied and did not report any complaints or anaesthesia-related inconveniences. In their answers to the question about the next method of anaesthesia, if necessary, they chose general anaesthesia. The option suggested by the anaesthetist is not always satisfying for patients. They want to be anaesthetised with a different method during the next surgery , which results from the fact that they are not adequately informed about alternative methods of management and common opinions of anaesthetists on preferable methods of anaesthesia for particular procedures may differ from the patients` wishes. The studies assessing the degree of satisfaction of patients with the method of anaesthesia chosen by the anaesthetist did not reveal significant differences between block and general anaesthesia, thus the decision should be taken together with the patient, with his/her wishes considered, if possible .
An interesting observation of our study is that the development of complications had lower impact on assessment of services than lack of information about potential complications. On the other hand, our findings demonstrate that most patients are interested in the quality and number of devices necessary for a safe anaesthetic procedure. The patients` impressions about the equipment have a significant effect on the assessment of quality of anaesthetic services. This is confirmed by the fact that more and more patients know their rights and conditions in which the medical services should be provided.
The informed consent for anaesthesia is not only the consent for the procedure itself but also certain complications and inconveniences related to the suggested procedure of management . Therefore, patients should be provided with adequate information but also have time to re-think their decision and get rid of doubts. Unfortunately, due to work organisation and haste, in big centres, in particular, and different attending anaesthetist (one examining the patient before anaesthesia and another one administering anaesthesia), the evident aspects of respecting the patients` rights might be neglected.
1. The patient assessment of the quality of anaesthetic services after surgery is determined by the range and quality of information provided by medical personnel during the pre-operative period.
2. Information on potential risks of anaesthesia-related complications is less important for patients than alternative methods of anaesthesia.
3. Care facilities and equipment of operating rooms are found to be of relevance for patient assessment of the services provided.
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Katedra Anestezjologii i Intensywnej Terapii
Uniwersytetu Medycznego w Łodzi
ul. Kopcińskiego 22, 90-153 Łódź
tel./fax: +48 42 678 37 48
received: 24.11.2010 r.
accepted: 01.02.2011 r.