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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.55 no.4 Campinas July/Aug. 2005
Evaluation of the anesthetic management of children and adolescents in a teaching hospital*
Evaluación del servicio anestésico del niño y del adolescente en un hospital universitario
Andressa Simões Aguiar, M.D.I; Norma Sueli Pinheiro Módolo, TSA, M.D.II; Yara Marcondes Machado Castiglia, TSA, M.D.III; Bruno Augusto Moura Bruschi, M.D.IV
IGraduanda da FMB - UNESP Bolsista
IIProfessora Adjunta da UNESP, Universidade Estadual Paulista, CET/SBA do Departamento de Anestesiologia da Faculdade de Medicina de Botucatu
IIIProfessora Titular, CET/SBA da FMB - UNESP
IVME3 do CET/SBA do Departamento de Anestesiologia da FMB - UNESP
BACKGROUND AND OBJECTIVES: Anesthetic
quality and patients' satisfaction has been increasingly praised. Our objective
was to evaluate anesthetic management of children and adolescents in our Hospital,
by interviewing parents and/or tutors.
METHODS: 230 parents or tutors of children and adolescents submitted to anesthesia in the period April-December 2003 were interviewed during the postoperative visit through a four-item questionnaire: children and adolescents and their parents or tutors identification (item 1); explanations during preanesthetic evaluation (item 2) about anesthesia (item 3) and post-anesthetic recovery (PACU) (item 4). Person informing respondents was identified and the presence of post-anesthetic complications made known. Respondents have scored the Anesthesiology Department from 0 to 10.
RESULTS: Survey was answered by mothers in 189 (82.2%) of cases. Most respondents (114, 75.6%) were aged 20 to 39 years, were married (148, 64.3%), and 140 (60.9%) had no job. Anesthesiologists have introduced themselves to 89%; for 37% and 77.4% they have explained the importance and duration the fasting period; 82% were informed about anemia; 90% were informed about allergy; 46.8% were informed about PACU importance; 42.2% were explained about length of stay; 72.9% were informed about the health status of their children. There have been no concerns for 49%, 58% and 58%, respectively about pre, intra and post-anesthetic period; 78.9% would like to have been with their children at PACU arrival. Pre, intra and post-anesthetic concerns were related to patients' age and gender - no concern whatsoever for most respondents - and to respondents' education - the better the education the lower the number and diversity of reported concerns. Scores to the Anesthesiology department were mostly between 7 and 10 (97.4%).
CONCLUSIONS: The Anesthesiology Department provides satisfactory services, in spite of communication failures, which are easy to solve and depend more on Department's willingness than on scientific knowledge.
Key Words: ANESTHESIA, Pediatric
JUSTIFICATIVA Y OBJETIVOS: Calidad en
anestesia y satisfacción de los pacientes han tenido acentuado destaque.
Nuestro objetivo fue evaluar el servicio anestésico de niños y adolescentes
de nuestro Hospital, entrevistando sus responsables.
MÉTODO: Fueron entrevistados 230 responsables de niños y adolescentes sometidos a la anestesia en el período comprendido entre abril y diciembre de 2003. Se realizó entrevista en la visita pos-operatoria a través de un cuestionario con cuatro partes: identificación de los niños y adolescentes y sus responsables (parte 1); aclaraciones en la visita pre-anestésica (parte 2), referente a la anestesia (parte 3) y a la recuperación pos-anestésica (SRPA) (parte 4), determinándose quien daría las informaciones a los entrevistados y se hubiese complicación en el pos-anestésico. El responsable atribuyó nota de 0 a 10 al Servicio de Anestesiología.
RESULTADOS: La pesquisa fue respondida por la madre en 189 (82,2%) casos. La mayoría de los entrevistados, 114 (75,6%), tenía entre 20 y 39 años, era casada (148 a 64,3%) y 140 (60,9%) no tenían ocupación. Para 89%, anestesiologista se identificó; para 37% y 77,4%, aclaró sobre la importancia y tiempo del ayuno; 82%, sobre anemia; 90%, alergia; 46,8%, importancia de la SRPA; 42,2%, tiempo de permanencia; 72,9%, estado de salud de su niño. No hubo aprehensiones para 49%, 58% y 58%, respectivamente, en el pre, intra y pos-anestésico. Les gustaría haber estado con su niño/adolescente en la llegada a la SRPA, 78,9%. Fueron relacionadas preocupaciones en el período pre, intra y pos-anestésico con el sexo y la edad del paciente - no haber tenido ninguna preocupación - mayoría de los entrevistados - y con la escolaridad del entrevistado - cuanto más completa, menor fue el número y la variedad de las preocupaciones relatadas. Las anotaciones atribuidas al Servicio de Anestesiología tuvieron mayor frecuencia entre 7 y 10 (97,4%).
CONCLUSIONES: Se considera que el Servicio de Anestesiología desarrolla un buen trabajo, a pesar de fallos en la comunicación, que son de fácil solución y dependen más de la voluntad del Servicio que de su conocimiento científico.
Publications on anesthetic quality and patients' satisfaction have increased in the last decades. Some authors have found higher satisfaction in patients able to express their concerns during evaluation and also when the physician has further explained the procedure. A more clarifying contact with the anesthesiologist is an important factor to determine parental levels of satisfaction 1-3.
In terms of pediatric and adolescent anesthesia, parents or tutors are part of the "audience to be targeted". There are studies showing that preoperative preparation with the participation of parents decreases children's anxiety 4-8. Transmitting anxiety to children and adolescents leads to negative implications for a long period, causing sleep and appetite disorders, among others 7.
In addition to better information, some authors have reported that most parents or tutors would like to participate on some decisions about their children's anesthesia 9. It would then be important to know the opinion of these parents or tutors about how preanesthetic evaluations are being conducted to, as from these evaluations, be able to propose changes to optimize those patients' management.
So, this study aimed at evaluating anesthetic management of children and adolescents at the Hospital das Clínicas, Faculdade de Medicina, Botucatu, by interviewing their parents or tutors.
This survey was carried out after the Clinical Research Ethics Committee, Faculdade de Medicina, Botucatu, UNESP approval and the written consent of parents or tutors. From April to December 2003, 230 parents or tutors of children and adolescents submitted to anesthesia in the Operating Center were interviewed during post-anesthetic evaluation. Pre and post-anesthetic evaluations are part of the routine of our Anesthesiology Department.
Survey consisted of a questionnaire with four items:
1. Identification of children and adolescents with birth date, age, gender, race and type of surgery. Identification of parents or tutors with age, gender, race, civil status, origin, occupation and level of education.
2. Questions related to preanesthetic evaluation (PAE): has the person conducting PAE introduced him/herself (anesthesiologist, if not introduced or if there were any memory about this item), were preoperative fasting, preanesthetic medication, concurrents diseases, drugs used and previous anesthesias adequately explained? We have also asked about parents or tutors preanesthetic concerns, which should be classified in descending order of importance.
3. Questions related to the anesthetic period - whether they had been informed about the type of anesthesia to be used and which were the concerns during anesthesia, which should be classified in descending order of importance.
4. Questions about post-anesthetic recovery (PAR), whether parents or tutors had been informed about the importance and objectives of PAR, whether they had been informed about child/adolescent arrival to PACU and about the estimated time they would remain there. Whether they had been informed about children's health while in the PACU and were explained about the need to maintain venous access when discharged to the ward, and whether they would have liked to be present when the child arrived to the PACU. We have also asked about who had given such information (anesthesiologist, surgeon, PACU administrative employee, nurse) and if there were post-anesthetic complications (nausea, vomiting, pain, prolonged sleepiness, sore throat, others).
At the end of the questionnaire, parents or tutors would grade the Anesthesiology Department from 0 to 10.
Data were descriptively and comparatively evaluated. Some data were crossed to check their relationships. This way, pre, intra and post-anesthetic concerns were related to child's gender and age and to respondents' education.
Parents or tutors of 230 children and adolescents aged one month to 17 years and submitted to surgeries in the period April-December 2003 have answered questions 1 to 3. Only 218 parents or tutors answered question 4, since 12 patients were directly referred to the Intensive Care Unit (ICU). Patients were divided in 5 groups according to age bracket (Table I).
There were 74 (32.2%) females and 156 (67.8%) males, of whom 181 (78.7%) where Caucasian, 11 (4.8%) were Afro-American and 38 were mestizos (16.5%).
There were 214 (93%) patients submitted to routine procedures and 16 (7%) submitted to emergency procedures. Respondents were fathers, mothers, uncles, grandparents, bothers and cousins. Questionnaire was answered by 189 (82.2%) mothers, 15 (6.5%) fathers and 26 (10.9%) tutors. Respondents age has varied from 13 to 66 years being most between 20 and 39 years, in a total of 114 respondents (75.6%). There were 168 (73.1%) Caucasian, 45 (19.5%) mestizos and 17 (7.4%) Afro-American respondents. Of these, 148 (64.3%) were married, 38 (16.5%) were concubines, 26 (11.3%) were single, 11 (4.8%) were separated and 7 (3%) were divorced.
The survey has shown that 100% of parents or tutors were from the state of São Paulo, being most from Botucatu and neighbor cities. As to occupation, 140 (60.9%) reported having no occupation, including unemployed, housewives and retired. As to education, respondents were divided in 7 groups for evaluation purposes: 1 = incomplete elementary school 127 (55.2%); 2 = complete elementary school, 37 (16.1%); 3 = incomplete second degree, 14 (6.1%); 4 = complete second degree, 27 (11.7%); 5 = incomplete third degree, 3 (1.3%); 6 = complete third degree, 14 (6.9%); 7 = illiterate, 8 (3.5%).
The anesthesiologist has identified him/herself in 89% of evaluations and has not in 9%. This fact was not remembered by 2% of respondents.
About topics explained or not during PAE, the importance of preoperative fasting was explained to 85 (37%) respondents and fasting period was explained to 178 (77.4%). The need for preanesthetic medication was reported to 82 (35.7%). Questions about concurrents diseases were answered to: 190 (82.6%) respondents about upper airway infections, 189 (82.2%) about anemia, 209 (90.9%) about allergy and 205 (89.1%) about other diseases (heart diseases, asthma, diabetes). Routine use of drugs was asked to 196 (85.2%) respondents and previous anesthesias to 182 (79.1%) (Table II).
There were 243 preanesthetic concerns of parents or tutors in a total of 26 different answers (Table III). About information on the type of anesthesia to be used in the child, 121 (52.6%) were not informed, while 109 (47.4%) have stated having been informed about the type of anesthesia (Table IV).
Concerns reported by parents or tutors during PAE involved intra and post-anesthetic anxieties. There were 23 different concerns from a total of 241 answers (Table V).
From all respondents, 45 (20.6%) have not asked information about their children - whether they were already in the PACU - since some administrative employees have spontaneously informed them. Most respondents (148, 67.9%) have reported asking for such information, but 25 (11.5%) have stated not receiving or asking for any type of information, just knowing about children's situation when they arrived in the ward (Table VI).
As to identification of the person in charge of information when children were already in the PACU, 142 (65.1%) respondents have answered that the person has introduced him/herself, while 76 (34.9%) have answered that the person has not introduced him/herself (Table VII).
From 218 respondents, 49 have received PACU information from anesthesiologists. Surgeons were identified as the only responsible or as one of the responsibles for information by 39 respondents. Most respondents (86) have referred being informed by a "PACU employee". The nurse was the sole person or one of the persons in charge of information according to 25 respondents (Table VIII).
When asked whether these professionals had explained the importance and objective of PACU, only 102 (46.8%) have answered positively. As to being informed that the child would remain for a while in the PACU, 135 (61.9%) have answered yes. In terms of PACU stay, only 92 (42.2%) respondents were contacted and informed. As to patient's health status when already in the PACU, 159 (72.9%) have been informed. The need for venous access maintenance was the less explained item; only 48 (22%) respondents were informed.
When asked if they would have liked to be present at child's arrival to PACU, 172 (78.9%) have answered yes.
Post-anesthetic signs and symptoms were nausea (14, 6.1%), vomiting (23, 10%), pain (61, 26.5%), prolonged sleepiness (100, 43.5%) and sore throat (10, 4.3%) (Table IX).
A different question would ask respondents to grade the Anesthesiology Department from 0 to 10. Most frequent answers were between 7 and 10 (221 = 97.4%) (Figure 1).
Pre, intra and post-anesthetic concerns related to patients' gender and age and to respondents' education are shown in table X.
Relatives answering the questionnaire have reported 77 concerns related to 74 female patients and 166 concerns related to 156 male patients. Some people have reported more than one concern.
For both genders, most respondents have reported no concern. In descending order of importance, the other three more frequent concerns for female children were not awakening after anesthesia, fear of general anesthesia and feeling ill. For males, the second most frequent concern was previous health status.
When concerns were correlated to children's age, it has been observed that most respondents have reported no concern, followed by fear of children not awakening after anesthesia, regardless of age bracket (Table XI).
When concerns were correlated to respondents' education, it was observed that, regardless of the level of education, most have referred not having any concern. Not awakening after anesthesia was the second most frequent concern throughout all education levels.
In addition, it has been observed that less educated people had a higher number and variety of concerns. This variety decreases as the level of education grows.
Most frequent concerns of parents and tutors were similar, regardless of gender. Most had no concern, followed by not awakening after anesthesia and surgical problems.
For all age brackets, predominant answers were no concern, followed by not awakening after anesthesia and surgical problems.
Most frequent answer, regardless of respondents' education was also no concern, followed by surgical problems and not awakening after anesthesia.
This study aimed at evaluating parents or tutors view about the management provided to them and their children or adolescents by the Anesthesiology Department, Hospital das Clínicas, Faculdade de Medicina, Botucatu, UNESP.
Because it is a Teaching Hospital, which should be a stage for teaching both graduation students and resident physicians, the concern with this view is that it could be a tool to evaluate teaching in this Department.
Very often, medical professionals are concerned with technical-scientific teaching neglecting human aspects of physician-patient relationships, which could contribute for patients and parents/tutors to be happy with the service.
Authors, such as Kopp et al. 10 have stressed the evidence of the importance of communication in anesthesia. Anesthesiologists participate in activities involving complex medical-legal, ethical and personal transactions. They receive and convey information affecting their participation in actions of other medical professionals.
The American Society of Anesthesiologists has assigned a Committee to act to improve public education and Anesthesiology reports, acknowledging the importance of communication which promotes professional integrity, as well as patients' safety and satisfaction. So, the attention to professional communications structure and function is as important as learning anesthetic agents pharmacokinetics and pharmacodynamics. These concerns come from the fact that the field of action of Anesthesiology has been widened.
Hepner et al. 11 have reinforced this aspect, listing what is part of anesthesiologists actions: induction of unconsciousness, care with homeostasis and pre, intra and postoperative pain control. The understanding of physiology, pharmacology and anatomy helps neuraxial and peripheral blocks with new fields of action. Preoperative evaluation for anesthetic planning, drug adjustments, answering patients' questions and anxieties, the expansion of pain treatment areas and perioperative care has provided an opportunity to prolong the contact with awaken patients. So, it has never been so important to effectively communicate. These same authors also remind that there is concern in teaching techniques and sciences, but when the emphasis is in general patients care, there are few reports related to the medical area. They also question whether the new generation of anesthesiologists is being trained to be good perioperative physicians and professionals with good communication skills.
Predominant profile of the subject of this survey was the mother, aged 20 to 39 years, housewife, Caucasian, married, currently living in Botucatu or neighbor cities, with incomplete elementary education. Most respondents have answered that those in charge of preoperative evaluation have identified themselves as the anesthesiologist. There has been no identification in 11% of cases. It should be stressed that this topic is extremely significant.
Lopes et al. 12, in a survey about the knowledge of patients about who would anesthetize them, have observed that slightly more than half knew that anesthesiologists are physicians with specialization, and approximately 20% could not even answer to the question: "who is the anesthesiologist?". As to anesthesiologists' role, half the patients have related them to pain relief and loss of consciousness; drug administration or vital signs monitoring was the answers of a minority; and 20% were unaware of the anesthesiologist's role.
Physical comfort, adequate information, professional involvement, emotional support and respect are factors valued by patients and interfering with their understanding of the anesthetic procedure 13.
According to patients, quality of anesthesia also means that attention given to anxiety, expectations and psychological aspects in the preoperative period should be the same, or even higher, than that given to drug choice, monitor or lab exams abnormalities in the perioperative period 3. In this survey, attention given to interpersonal aspects of the anesthetic-surgical procedure has provided higher levels of satisfaction with the Anesthesiology Department.
So, it is of paramount importance that anesthesiologists dedicate time to explain what they can and may do to patients. Klock et al. 14 are emphatic in saying that anesthesiologists' actions during the preoperative evaluation are the most important.
Jeske et al. 15 have shown that if anesthesiologists offer patients a business card, this will increase the probability of patients remembering their names, but not their satisfaction with anesthesia. However, this could reassure their role as perioperative physicians and allow patients and other physicians to know that they are really honest and involved with the broadening of their role. If they are really relying in good communications, patients will feel comfortable when having to use card information to get in contact with them to have their potential questions answered 11.
So, the distribution to relatives of a leaflet with information about anesthesia, PACU or postoperative pain control 7, or even the development of educational programs to prepare parents for anesthetic induction or PACU visits 16, were effective to decrease anxiety and, at the same time, increase parental satisfaction with anesthetic care.
Remaining questions are highly significant for children and adolescents anesthesia. These are topics which have to be clarified because in general, when this is not done, there are conflict situations or increased morbidity-mortality in this age bracket. Among these issues, there is timing and importance of preoperative fasting, which is always a stressing factor for both parents and children.
Our survey has observed that only 85 (37%) respondents were explained about the importance of preoperative fasting and of fasting period. There is no information or misinformation about this topic. It is not uncommon to find children with too long or too short fasting period, with surgery postponing when parents cannot determine which food to give to children and in which time period. Understanding should start with an understandable explanation about increased morbidity if there is aspiration pneumonia and that fasting period is related to children's age and type of food 17.
Our study has observed that explanation about preoperative fasting period was given to 77.4% of respondents and that the importance of this measure was only explained to 37%.
On the other hand, questions related to concurrents diseases were more satisfactorily explained to more than 80% of cases. This might be because there is more concern with diseases, which are objective facts, than with whether a prolonged fasting period would make children cry and become more anxious.
In analyzing the anesthetic period, it is alarming to observe that in 52.6% of cases, relatives were not informed about the type of anesthesia to be used to their children. In the era of written consent, which in Brazil is still not a routine, we do not have the habit of informing about anesthetic technique risks and alternatives and of asking about relatives and/or patients' preferences.
Written and informed consent offering people the opportunity to know, within their level of understanding, the procedures to be performed has been widely discussed, because it seems to increase their satisfaction with regard to medical treatment.
Leaflets explaining the anesthetic process children will go through, associated to oral information, may help achieving written consent after information and improve parental satisfaction 8.
Stiles et al. 18 have observed higher patients' satisfaction if they could further express their anxieties during preoperative evaluation and if the physician would further explain the procedures.
Other authors have shown that parents would like to more actively participate in decisions involving their children's anesthesia and that when this happens, they feel happier with anesthetic care 9.
Patients' satisfaction may reflect many facets of their care, such as compassion, efficiently meeting their needs, their participation in decisions concerning them, and adequate information and communications. Patients' satisfaction - and patients are customers - is being considered the endpoint of care and the indicator of quality of anesthetic management 19. Adequate communication with children's tutors is of paramount importance. If children are able to understand, they should participate in the explanation. Coté 17 has a good example of this issue. He tells that he starts talking to the child, identifying himself, explaining who is the anesthesiologist, what is Anesthesiology, what type of sleep will be induced by anesthesia and that at the end he/she will awaken and return to his/her parents. He also reports that children have the same anxieties as adults, however very often they are unable to express them. After being informed about anesthesia they know that they will not feel anything, will not remember anything and will awaken after the surgery. These attitudes aim at decreasing parents and children's anxiety.
Several studies have shown that more than 60% of children undergoing surgery may present some negative behavior up to two weeks after 20-22, such as enuresis, difficult feeding, apathy and sleep disorders. In addition, preoperative anxiety activates responses to stress, releasing serum cortisol and adrenaline, and interfering with cell killer activity 22,23. There are evidences of two-way communications between neuroendocrine and immune systems, increasing susceptibility to infections and neoplastic diseases 24.
When asked about pre, intra and postoperative concerns, most respondents reported no concern, followed by fear of children not awakening after surgery. Another frequent concern before surgery was fear of general anesthesia and during surgery was the possibility of surgical problems.
When these data were crossed with children's gender and age, and parental education, there has been no difference in most frequent concerns for both genders, and no concern had the highest incidence.
When pre, intra and postoperative concerns were correlated to children's age, there has been a higher number of concerns related to children above one year of age.
Medical literature reports higher incidence of complications in children below one year of age, especially due to systems' immaturity 25. However, this is not known by parents. What they see, and which probably increases their anxiety and concern, is that children cry and become anxious when being taken away from parents. Children up to six month of age may be gently separated from parents or relatives. After 7-8 months, and also in the pre-school age, this separation is more traumatic 21-26.
When correlating concerns to education in all studied periods, it has been observed that less educated tutors had more concerns as compared to more educated ones. It could be assumed that the more educated group, exactly for being more informed, have more concrete concerns and are more confident on the professional dealing with their child.
As to PACU evaluation, it has been observed that most respondents were not informed about its importance and length of stay. However, 70% of respondents were informed that the child was already in the PACU, in addition to his/her health status.
The anesthesiologist has identified him/herself as responsible for information supplied during PACU stay in very few cases (22%). Another important data was that in 67.9% of cases the respondent had to go after information about the child. If good preoperative communication is important, it is extremely important that it continues in the postoperative period.
Sikich et al. 27 have carried out a study with parents about expectations and preferences during children's anesthetic recovery. Interestingly, they have observed that they were not comfortable when children had a too short recovery time because the hospital environment would bring them further comfort.
The postoperative period is a source of parental stress, especially with regard to what children may eat or drink and when 28, although the vast majority is concerned with pain, nausea and vomiting. This issue should be explained and, in case of outpatient procedure, parents should have access to a contact phone number to notify possible complications at home.
The Anesthesiology Department was scored 10 by 68.6% of respondents. Notwithstanding the lack of major explanations for tutors, both related to pre and intra and postoperative periods, evaluation was satisfactory. Most respondents have scored above 7 (97.4%). It is possible that when answering postoperative questions, parental anguishes had already decreased.
One may consider that in spite of the satisfactory evaluation of the Anesthesiology Department, by parents and tutors of children and adolescents referred to HC, Faculdade de Medicina, Botucatu, there were communication failures between those in charge of preanesthetic evaluations and tutors of children and adolescents. Problems are easy to solve and depend more on the willingness of the department than on scientific knowledge. They do not incur additional costs, complex monitoring devices, but rather simply a deeper involvement with relatives and children.
In addition, this information should be conveyed to graduating students and residents who should also observe them, because example is the best way of learning.
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Dra. Norma Sueli Pinheiro Módolo
Address: Depto de Anestesiologia da FMB UNESP
Distrito de Rubião Junior, s/nº
ZIP: 18618-970 City: Botucatu, Brazil
Submitted for publication October 6 2004
Accepted for publication March 17, 2005
* Received from CET/SBA da UNESP - Universidade Estadual Paulista, Faculdade de Medicina de Botucatu (FMB) - SP