Patient's experiences and satisfaction with preanesthesia services: A prospective audit.

BACKGROUND: Patient satisfaction with the medical services is an important indicator of quality of healthcare but is seldom given importance in our country. It is difficult to measure patient satisfaction, especially in pre- and perioperative period.
MATERIALS AND METHODS: We conducted this audit by means of a questionnaire designed to assess preanesthetic clinic services in a large government hospital. A total of 200 patients were randomly selected to respond to a multiple item questionnaire. STATISTICAL ANALYSIS: A database was created and analyzed using Microsoft Excel.
RESULTS: 95% patients filled the proforma. Most of the patients (60%) were not aware of the purpose of visit to preanesthetic clinic. Majority of them were attended in time by the doctors but most of them (60%) received fitness after 2 to 3 visits. Majority was not explained about the preanesthesia instructions. Most of them were not satisfied by amenities in hospital. Several studies have shown that a thorough preoperative examination can be as effective as an anxiolytic premedication and can increase quality of care. In our study, location of preanesthetic clinic and unable to get fitness in first visit (because of lack of coordination between doctors of various specialties) were the major hindrances.
CONCLUSION: Measures should be taken to improve the functioning of preanesthesia clinic and patient satisfaction.

Introduction

Practice of anesthesia today is no longer limited to operation and it incorporates all various aspects of perioperative medical care of the patients. The goal of preanesthesia evaluation is to obtain relevant information regarding the patient's current and past medical history and formulate anesthetic plan based on risk assessment.[12] Preanesthesia clinics (PACs) have been developed in an attempt to streamline the preoperative experience by coordinating surgical, anesthesia, nursing, and laboratory care. Despite these benefits to the hospital system, the patient experience and satisfaction with such clinics has not been adequately studied in India. Patient satisfaction is a unique clinical endpoint and is an indicator of the quality of healthcare provided.[34] Moreover, due to increased need for ambulatory surgery and short hospital stays, an efficient working PAC is required. This audit was conducted in a leading government hospital in Delhi to determine the level of satisfaction of patients, identify problems, and suggest measures to improve the services.

Materials and Methods

A total of 200 patients were given a multiple-item questionnaire, designed to assess the level of satisfaction, problems faced, and suggestions to improve [Appendix]. The questionnaire was handed over just before they completed their first visit and they were explained the study requirements. They were assured of the confidentiality and anonymity of the questionnaire. Their future visits were tracked till patients were declared fit for surgery. Children less than 15 years were excluded from the study. For illiterate patients, proforma was filled up with the help of their parents/relatives. A database was created and analyzed using Microsoft Excel.

Appendix

Results

Of 200 patients, only 190 filled the proforma. Of these, 110 were females and 80 were males. 65% patients were literate and 40% had come from outside Delhi. 12% of them were older than 60 years. 90% of patients found difficulty in finding the PAC with the major reasons cited as, it being far from the main outpatient department (OPD) (80%) and inadequate sign posts indicating the location of PAC (70%). 20% could reach the PAC only after the registration time was over [Figure 1].

Figure 1

Difficulty faced by patients in reaching preanesthesia clinics

Only 40% patients knew about the purpose of visit to PAC and of these only 40% patients knew that PAC visit was important to rule out major diseases that may affect anesthesia. Majority thought that some kind of testing with anesthetic drugs will be done in PAC or they will be administered short anesthesia. Only 20% patients were aware of the fact that PAC fitness was necessary before getting operated and their surgery can be delayed if they are not found fit.

Twenty percent patients had come fasting and 5% had stopped drinking/smoking 2 to 3 days prior to coming to PAC. 75% of the patients did no preparation prior to visiting PAC. Surgeons had given no advice to majority of patients (60%). 20% were advised to take reports of all investigations before going to PAC and 10% were referred to subspecialty clinic before visiting PAC.

Most of patients (80%) were attended in time by the doctors and 20% (ASA III/IV) were referred to senior Anesthetists. The average waiting time for most of the patients was <20 minutes. A few patients (15%) had to wait for longer time before being examined [Figure 2]. Majority (80%) were not explained the preanesthesia instruction in detail by the anesthesiologist.

Figure 2

Average waiting time in preanesthesia clinics

Most of the patients did not receive fitness for surgery on their first visit. On an average, patients had to visit 2 to 3 times (60%) before getting fitness [Figure 3]. In 70% patients, fresh blood tests were ordered, 25% were sent for Physician referral to optimize medical condition and 5% were referred to senior Anesthetist; 20% were sent back to bring previous reports and investigations [Figure 4].

Figure 3

Average number of visits before getting fitness for surgery

Figure 4

Causes of revisit to preanesthesia clinics

Majority of patients (80%) were of the opinion that the PAC was overcrowded. 80% of the patients were not satisfied with privacy in the PAC (80%), arrangements in the waiting area (82%), and arrangements of safe drinking water and toilets for the patients (91%). Only 15% of patients were comfortable with the fact that patients related to staff of the hospital were given priority.

Discussion

Traditionally, the focus of medical care has been restricted to diagnosis and treatment of disease and not on patient experience during the course of treatment. Medical outcome in terms of morbidity and mortality is considered as the main indicator of quality.[3] However, these outcomes poorly assess various issues of importance to the patient. Patient satisfaction involves physical, emotional, mental, social, and cultural factors. It is determined by the quality of care provided and the patient's expectations of the care.[4] Patient involvement in decision making by means of an audit has emerged as an effective tool for quality assurance in health services.

Main aim of this audit was to assess patient satisfaction with the preoperative anesthesia care, identify the problem areas which can be improved in relatively short time in order to improve patient satisfaction with respect to PAC services in a cost-effective manner. In this study, the major problems identified were administrative in nature which can be reduced by good planning and utilization of resources.

Location of the PAC was a major concern in our study. It was an important factor leading to dissatisfaction in patients. Ideally, PAC should be near the surgical OPD, but in our hospital, PAC is located away from the main OPD. Moreover, many (60%) of the patients are illiterate and appropriate sign boards indicating the location of the PAC are not there. The details of the anesthesiologist sitting inside (his qualification and seniority status) were also not displayed. As a result, patients had difficulty in locating the PAC and many patients could reach only after the registration had closed. The PAC should be located in the main OPD, near the surgical OPD, to reduce transit time and for better coordination between specialties. Proper color codes/signage in the corridors for illiterate patients/relatives at all the important places in the OPD should be provided.[56]

Poor information was another major concern. Anesthesia is specialized branch and people come in contact with an anesthesiologist only after being referred by a surgeon. Most of the surgeons do not make patients understand the prerequisites and purpose of PAC. So, the level of understanding among the patients about the field is limited. This is the main reason why most of the patients had no clue about the purpose of visit to PAC and they were rather apprehensive that they will be administered some kind of anesthesia in PAC.

On an average, the patients had to visit more than once to obtain fitness for anesthesia.

In a PAC, a thorough history and checking of records is followed by a focused preanesthesia physical examination to assess the airway, lungs, heart, and documentation of vital signs. After this, suitable medical tests are advised. Anesthetist may also order physician referral or senior Anesthetist referral to optimize medical condition, especially if the patient is ASA grade III/IV. Patients do not follow instruction given in PAC and often lose records. So, it is difficult for patients to receive fitness on their first visit. Only patients who are found medically fit and have all records are made fit in first visit. This problem can be overcome by better patient education about the purpose of preanesthesia evaluation, instructing them to carry all the relevant past medical records and necessary investigations. Clear instructions should be given to patients for the prerequisites to be fulfilled before next visit, in case a revisit is required.

It has been estimated that 60 to 75% of preoperative tests ordered are medically unnecessary[16] and they only add to the cost and delay the procedure and add to patients inconvenience and discomfort. The ASA Task Force recommends that preoperative tests may be ordered, required, or performed on a selective basis for purposes of guiding or optimizing perioperative management. The indications for such testing should be documented and based on information obtained from medical records, patient interview, physical examination, and type and invasiveness of the planned procedure.[7] The medical tests are important but they should be ordered only if required. Consensus guidelines among anesthetist on the indications for preoperative testing should be established and conveyed to the surgeons also. This will avoid the unnecessary visit by the patient as surgeons can advice the relevant test and patients will visit the clinic with required laboratory tests. This will also reduce the cost on unnecessary tests and discomfort to the patient.

Overcrowding was another problem defined, despite the fact that most of the patients were examined in less than 20 minutes of their arrival. This may be due to uneven flow pattern of the patients referred by surgical specialties for PAC. Patients generally come by 10 am, whereas the official time starts at 9 am. There are times when doctors are sitting idle in PAC while at other times, it is overcrowded with patients crowding around the doctor. Peak rush is generally in the middle period. This problem can be addressed by increasing the number of consultation rooms, developing a screening questionnaire to be used by interns/junior doctors to hasten the process of evaluation, keeping separate timings for follow-up and new patients, and advising patients about the probable time of his turn at the time of registration to help chalk out his schedule. PAC, like any other OPD, should have a comfortable environment with adequate privacy, waiting area, and other basic facilities like safe drinking water and toilets for patients.[5] These areas were found grossly lacking and need attention.

Patient feedback to assess quality of medical care is as important for PAC as for any other OPD. Every effort should be taken to increase overall patient satisfaction by increasing the quality of medical care. Areas which can provide maximal increase in patient satisfaction with minimal expenditure should be accorded high priority.

Standards of service of all dimensions could be improved by better communication with the patients. All measures should be taken to reduce the number of visits of patients to PAC before being declared fit for anesthesia.

There is a need for improvements in the management of PAC services to ensure optimum utilization of resources and increasing satisfaction of patients. We have tried to outline measures to improve the functioning of PAC and patient satisfaction. We should not be contended merely with availability and accessibility of health services but rather their acceptability and acceptance.

Appendix

Primary data questionnaire

Kindly fill the below given information. The information provided by you will be kept confidential.