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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.59 no.2 Campinas Mar./Apr. 2009
Patient perception of the utility of the Preanesthetic Clinics in a caribbean developing country*
Percepción de los pacientes respecto de la utilidad del Ambulatorio de Evaluación Preanestésica en un país caribeño en desarrollo
Seetharaman HariharanI; Deryk ChenII; Nicholas JuraiIII; Amanda PartapIII; Rakesh RamnathIII; Dinesh SinghIII
FCCM - University of the West Indies
IIAnesthesiologist. FRCA - Lecturer
OBJECTIVES: Perception of the patients regarding the utility of the Preanesthetic
Clinics and flow time in clinics has not been widely studied in the developing
world. The present study aims to study this aspect.
METHODS: A self-administered 15-item questionnaire survey was conducted among patients attending the Preanesthetic Clinics at a tertiary care teaching hospital in Trinidad. The questionnaire was also distributed to the patients attending the General Surgical Clinic for comparison. Another questionnaire was distributed among the staff of the Preanesthetic Clinic. Patient demographics including age, gender, and educational status and American Society of Anesthesiologists physical status were noted. Other data recorded were patient flow time and details of attending staff.
RESULTS: Of the 220 patients who attended the Preanesthetic Clinics, 92.7% participated in the study. The reliability of the questionnaire was supported by Cronbach's alpha coefficient (0.67). The median time for referral from the surgical clinic to Preanesthetic Clinic was 50 days, median waiting time in the clinic was 2.7 hours, and the median waiting time for surgery after acceptance in the clinic was 13 days. The patients' opinions regarding the benefits of the clinic, length of the waiting time was independent of their age and educational status. Patients felt that attending the Preanesthetic Clinic was beneficial and not costly to them, although the waiting times were found to be longer.
CONCLUSIONS: Patients perceive that attending the Preanesthetic Clinic has been useful before the surgical procedure and the care they received in the clinic was satisfactory
Key Words: EVALUATION, Pre-anesthetic: outpatient.
Y OBJETIVOS: La percepción de los pacientes respecto de la utilidad
del Ambulatorio de Evaluación Preanestésica como también
el flujo de pacientes, no fueron extensamente estudiados en el mundo en desarrollo.
El objetivo de este estudio fue analizar ese aspecto.
MÉTODOS: Se realizó una investigación aplicando un cuestionario entre los pacientes atendidos en el Ambulatorio de Evaluación Preanestésica de un hospital subcontratado de enseñanza en Trinidad. Como comparación, ese cuestionario también se distribuyó a los pacientes atendidos en el Ambulatorio de Cirugía General. Los parámetros demográficos, incluyendo edad, sexo, nivel escolar y estado físico ASA se registraron. Otros datos registrados incluían el flujo de pacientes y los detalles respecto del equipo médico.
RESULTADOS: De los 220 pacientes atendidos en el Ambulatorio de Evaluación Pré-anestésica, un 92,7% participaron del estudio. La validez del cuestionario fue apoyada por el coeficiente alfa de Cronbach (0,67). El tiempo promedio para la derivación al ambulatorio de cirugía para la Clínica Preanestésica fue de 50 días; el tiempo promedio de espera en la clínica fue de 2,7 horas y el de espera por la cirugía después de la aceptación por parte del ambulatorio fue de 12 días. Las opiniones de los pacientes respecto de los beneficios de la clínica y tiempo de espera no tuvieron ningún influjo por la edad ni por el nivel cultural. Según los pacientes, la atención en el Ambulatorio de Evaluación Preanestésica fue benéfica, pero los tiempos de espera fueron considerados extensos.
CONCLUSIONES: Según los pacientes, la consulta en el Ambulatorio de Evaluación Preanestésica antes del procedimiento quirúrgico fue útil y la atención fue considerada satisfactoria.
Patients scheduled for elective surgery are usually referred from various surgical specialties to the anesthesiologists for evaluation before the surgical procedure. The patients are either visited in the ward if they are hospitalized, or referred to Preanesthetic Clinics (PAC) on an outpatient basis 1. The primary responsibility of the preanesthetic consultation is to prepare the patient both physically and psychologically for anesthesia and to ensure that the patient is in the most favourable condition to undergo the surgery. This entails completion of a health questionnaire in some centers, obtaining pertinent medical history, assessment of the vital signs, obtaining necessary laboratory tests and other investigations, and discussing the types of anesthesia and the risks involved with the patient 2.
Depending on the nature of the surgical operation and the physical status of the patient, the anesthesiologist makes the decision regarding and the so-called 'fitness' for anesthesia 3. The visit to the clinic plays an important role in educating the patient about the anesthesia, and let the patient participate in the decision-making process 4.
Many systemic diseases that may seriously affect the patient during the perioperative period can have an impact on the efficiency of the operating room resource utilization 5. The visit to the clinic provides sufficient time to identify these illnesses, optimize the organ systems before the surgery, thereby minimizing the morbidity and mortality associated with surgery and anesthesia 6. In addition to this, it serves to reduce patient anxiety level and provides a chance for the anesthesiologists to build rapport with the patient before the surgery.
Although the concept of an anesthesia outpatient clinic was originally proposed 47 years ago 7, only in recent times many centers around the world have started establishing them. In the English speaking Caribbean, the earliest clinic was established a decade ago at the Eric Williams Medical Sciences Complex (EWMSC) in Trinidad and Tobago. There have been earlier reports regarding the benefits of a preanesthetic clinic such as the reduction of the proportion of last-minute cancellations of surgery, financial viability and cost-benefits 8-12. However, the patients' perception of attending a preanesthetic clinic has not been widely studied. Only recently, a study has reported the validation of a "Patient Experiences with the Preoperative Assessment Clinic (PEPAC)" questionnaire from Europe 13. To our knowledge, there has been no report regarding the patient experiences from many other countries especially a developing country.
With this background, the present study attempted to evaluate the patient perception regarding the facilities of the preanesthetic outpatient clinic and to assess the process of care including patient flow times.
Study setting - Trinidad and Tobago is a twin island nation in the English-speaking Caribbean with a population of 1.3 million. Although, it has a Gross Domestic Product (GDP) of 13,170 per capita (PPP International $) and is one of the most affluent islands in the Caribbean, it is still considered a developing country (World Health Organization, 2005). Despite the increase of petrodollars due to oil booms in Trinidad and Tobago, the Total Expenditure on Health (THE) as a percentage of the GDP has decreased from 4.2% in 1998 to 3.9% in 2003 falling as low as 3.6% and the net out-of-pocket spending on health has increased from 86.4% in 1998 to 88.6% in 2003 (World Health Organization, 2005). The Eric Williams Medical Sciences Complex is the only one of the three public hospitals which has preanesthetic outpatient clinics. Two clinics are functioning in this hospital, one each for adult and pediatric patients, operating once weekly.
Approval was obtained from the Ethics Committee of the University of the West Indies and the Hospital Authorities of the North Central Regional Health Authority to conduct the study. All patients who entered the Preanesthetic Clinic (PAC) at the Eric Williams Medical Sciences Complex, Trinidad during the 15 weeks of the study were enrolled except patients who were unwilling to be interviewed. The study per se did not require any intervention in patient management and informed consent was obtained explaining the nature of questionnaire. Patient confidentiality was maintained by codifying data entry.
Data Collection - A 15-item questionnaire (Appendix 1) was distributed to the patients attending the adult PAC and the parents of the patients attending the pediatric PAC. Respondents were asked to fill the questionnaire after consultation process has been completed. The questions were explained individually to every respondent to ensure uniform response. The responses were based on a 5-point Likert scale from "Strongly Disagree" to "Strongly Agree". The same questionnaire was also distributed among patients attending the General Surgery Clinic for comparison.
The time taken for the patients to be assessed in the PAC after referral from the parent surgical unit was noted as T1. The length of time each patient spent within the PAC was noted as T2. The time taken for surgery to be undertaken after assessment in the PAC was noted as T3. Patients' records were used to collect data such as American Society of Anesthesiologists (ASA) physical status, comorbid illnesses and fitness for anesthesia. Patients were followed up until their surgery.
The number of medical staff attending the PAC and their hierarchical position were noted. A different questionnaire (Appendix 2) was distributed among the staff of the PAC to elicit their opinion regarding the process of patient care.
Data were entered into Statistical Package for Social Sciences (SPSS)-version 12 (Chicago IL, USA) for analysis. The statistical significance was fixed at the level of p<0.05. Reliability of the questionnaire items were tested using Cronbach's alpha. Chi-square tests were used for comparing the opinions between patients grouped by gender, educational status, etc.
Of 220 patients who attended the Preanesthetic Clinic during the study period, 204 participated in the study (92.7% response rate). Thirty percent of the respondents were parents of children attending the Pediatric Preanesthetic Clinic.
Of all patients who attended the Preanesthetic Clinic, 33% belonged to American Society of Anesthesiologists (ASA) physical status (PS) I and 55% to ASA PS II and 12% belonged to ASA PS III.
Among the respondents 58.3% were males; 49% were first time visitors, 16.2% visited the clinic second time, 17.8 % 3-5 times and 18% had visited more than five times.
Thirteen House Officers and 1 intern provided patient care at the PAC, and no Consultants and Registrars attended the clinic during the study period. Of the House Officers, 9 had more than 5 years and 4 had less than 5 years experience in anesthesia.
The median time for referral to PAC (T1) was 50 days, median waiting time in the clinic (T2) was 2.7 hours (interquartile range 1.2-3.4 h), and the median waiting time for surgery after acceptance in the clinic (T3) was 13 days. Of note, none of the patients were referred to any specialty clinic during the study period.
Chi-square tests done to analyse if the patients' opinion regarding the waiting times was influenced by their age and educational status showed no statistically significant differences. Similarly there was no statistically significant relationship between the patients' educational status and their opinion regarding the benefits of the clinic and if it was costly to attend the clinic. However, more than men, women opined that the PAC had a friendly atmosphere. (χ²: 14.8; df:1, p < 0.05). The patients' opinion that the clinic reduces their fear for surgery was also independent of age.
Table I shows the various responses for each question from patients attending the Preanesthetic Clinics.
The questionnaire was distributed and responses were elicited from 200 patients attending the General Surgical Clinic to have a reasonable comparison. Figure 1 represents the various total scores obtained from the questionnaires in PAC and the General Surgical Clinic. The mean value obtained from the PAC was found to be 36 compared to 37 for the General Surgical Clinic. These values are calculated as the sum of the scores from the individual questions of the questionnaires divided by the number of questionnaires collected from each clinic.
Fourteen medical personnel and three nurses responded to the questionnaire distributed to the staff. The nurses are involved in only administrative functions and eliciting vital signs and are not responsible for assessing the patient fitness for anesthesia. Sixty two percent of the staff was satisfied with the human resources present and 57% indicated that the material resources were sufficient. Eighty two percent of the staff agreed to the view that the PAC prevents cancellation of surgery and 90% agreed that it increases the confidence level in patients.
The major finding of the present study is the satisfaction expressed by patients attending a Preanesthetic Clinic. This may be important because preanesthetic outpatient clinic is a relatively recent phenomenon; such a facility may exist only in major University hospitals, although with different organizational structures 14. In many hospitals, patients are seen in the waiting area of the operating room before surgery and the need for a separate clinic might be considered logistically difficult. Positive patient opinion regarding the clinics may help in sustaining the clinic by satisfying the hospital administrators regarding the need of such a clinic.
In addition, a survey of this nature could help medical managers in the quality improvement of the clinic from the customers' perspective. Preoperative preparation requires various perspectives and strategies for process improvement that may require tools previously unfamiliar to many medical managers 15.
An earlier study showed that in Trinidad many patients did not adequately know the role of anesthesiologists 16. In such a situation, it is important to note that majority of the patients felt that the clinic was beneficial, its facilities were adequate, and attending the clinic was convenient and affordable. The patients' opinion was independent of their educational status. Notwithstanding a few patients who found it inconvenient to attend the clinic, a majority of the patients agreed that it was worthwhile attending it. It was also heartening to note that many patients felt that the doctors and nurses were professional and amiable. Moreover, three-quarters of the patients found that the care they received from the doctors and nurses was satisfactory. A recent report found that patients attending the PAC in the United Kingdom had the most positive experience with the nurses 17.
Another finding of the study was that the patients' opinions regarding PAC and General Surgical Clinic were similar. Most patients in both clinics found that it was beneficial to them with a very friendly atmosphere as well as the care received from the nurses, clerks and doctors were satisfactory. A substantial proportion of patients found that visits to both clinics reduced their fear of surgery.
The major areas of dissatisfaction are the delay in getting an appointment, and the long time spent in the clinic. Earlier studies have reported similar findings and long waiting times have been one of the most common difficulties associated with the organization of the Preanesthetic Clinic 18,19. This could be improved in our situation by telephone appointments as well as having the clinic more frequently than once-weekly. A previous study has used simulation techniques to reduce the prolonged waiting times in preanesthetic clinics 20.
On an average, patients had to wait two weeks from the time of evaluation at the preanesthetic clinic to the time of performance of surgery. Only 56% of the patients who attended the PAC actually had the surgical procedure within the study period. The value of attending preanesthetic clinics in avoiding cancellations have been well established, although there have been some dissident views 9,10,21-23. In our situation, there are many reasons attributable to this delay, the most common being inadequate operating room personnel, although this was not studied in detail because it was not the primary objective of the study.
In the present study, all patients seen in the PAC were accepted for anesthesia which may have different implications. Either the PAC was fulfilling its job of limiting the last minute cancellations or it is possible that the junior doctors could have failed to recognize the coexisting illnesses. Patients with worse physical status are usually referred to various specialty clinics, which also did not happen during the study period. This is compounded by the fact that during the study period, there were no consultants or registrars present in the clinic for patient evaluation. Although this may show that there is room for improvement in the process of care, there are many preanesthetic clinics which are exclusively run by nurses 24.
There are some limitations to this study. The major one is the short duration of study. We could not compare it with another PAC since the studied clinic is the only one of its kind in the English- speaking Caribbean. Like any other questionnaire survey, there could have been some bias with respect to responses. To avoid this, the study team explained the questions individually to every respondent to ensure uniform response. However, this could have possibly introduced a 'social desirability' bias. Patient and professional feedback is known to be important factors in improving the quality of preanesthetic outpatient clinics 17. The present study undoubtedly contributed to this aspect.
In summary, the PAC was found to be satisfactory with respect to patient care and seemed to be fulfilling its duty, although there is room for improvement in the process of care.
We wish to thank Dr Lorna Merritt-Charles, Reishad Ghany, Edward Hai-Ting, Neera Ramnarine and Rajesh Ramsamooj for their kind help during the study.
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Correspondence to: Submitted em 11
de outubro de 2008 *
Received from the University of the West Indies, St. Augustine, Trinidad,
Dra. Seetharaman Hariharan
Eric Williams Medical Sciences Complex,
Mount Hope, Trinidad, West Indies
Accepted para publicação em 3 de dezembro de 2008
Submitted em 11
de outubro de 2008
* Received from the University of the West Indies, St. Augustine, Trinidad, West Indies