Effect of Intraoperative Anesthetic Events on Postoperative Patient Satisfaction

QjJ Effect of Intraoperative Anesthetic Events on Postoperative Patient Satisfaction DAVID

L.

BROWN, M.D., MARY

AND KENNETH

E. WARNER, M.D., DARRELL R. SCHROEDER, M.S.,

P. OFFORD, M.S.

• Objective: To assess overall perioperative and anesthetic care-specific patient satisfaction. • Design: We mailed questionnaires postoperatively to three groups of surgical patients (those who underwent anesthesia without complications, those who experienced airway management difficulties, and those who had cardiovascular perturbations) and analyzed the responses. • Material and Methods: All patients 18 to 75 years of age who underwent hospital-based surgical procedures in our acute-care hospitals during the interval from January to September 1993 were eligible for this investigation. We asked a total of315 patients-lOS in each of the three study groups-about their satisfaction with perioperative care. Specific positive or negative comments that the patients returned in their questionnaires were tabulated into the following subcategories: physician, nurse, technique, time, and institution concerns.

• Results: Of the 315 questionnaires sent to patients, 239 (75.9%) were returned. No difference in overall patient satisfaction (defined as very satisfied or a combination of very satisfied and satisfied) was noted among the groups. No patients identified themselves as dissatisfied or very dissatisfied with their overall care, although a small percentage expressed dissatisfaction because of time delays. The specific patient comments suggested that the positive interactions with physicians and nurses outweighed the concerns about time delays. • Conclusion: This study showed that intraoperative anesthetic events did not affect patient satisfaction. Interactions with physicians and nurses dominated the decision about patient satisfaction, and time delays were the most frequently cited negative comment. (Mayo Clin Proc 1997; 72:20-25)

Understanding patient satisfaction is important in attempting to improve anesthetic care' and minimize malpractice litigation.' Most research into patient satisfaction with anesthetic care has focused on postoperative recognition of adverse perioperative anesthetic side effects, such as nausea and vomiting after operat ion;' or on increased satisfaction with alleviation of pain postoperatively." By design, the intraoperative period is typically a time when patients are unaware and thus unable to remember events. Some of these intraoperative events may result in consequences that extend into the postoperative period and ultimately influence patient satisfaction.' Nevertheless, the effect of experiences during the intraoperative period on patient satisfaction remains an area that is unexplored.

In this investigation, our objective was to assess the overall perioperative and anesthetic care-specific satisfaction of three groups of patients : (I) those who underwent anesthesia with no intraoperative, anesthesia-related adverse experiences, (2) those who experienced airway management problems, and (3) those who had intraoperative cardiovascular events.

PATIENTS AND METHODS Study Subjects.-AII patients, 18 to 75 years of age inclusive, who underwent hospital-based surgical procedures in either of the acute-care hospitals at Mayo Clinic Rochester (Saint Marys Hospital or Rochester Methodist Hospital) during the interval from January to September 1993 were eligible for inclusion in this investigation. We used the Department of Anesthesiology prospectively tabulated intraoperative quality-assessment database in order to identify a total of 105 patients in each of three groups who fulfilled study criteria. The patient groupings for the specific intraoperative observations (side effects) were as fol-

From the Department of Anesthesiology (D.L.B., M.E.W.) and Section of Biostat istics (D.R.S. , K.P.O.), Mayo Clinic Rochester, Rochester , Minnesota . Address reprint requests to Dr. D. L. Brown , Department of Anesthesiology, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905 . Mayo Clin Proc 1997; 72:20-25

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© 1997 Mayo Foundation/or Medical Education and Resear ch

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Mayo Clin Proc, January 1997, Vol 72

lows: group A-patients with no adverse intraoperative anesthesia-related side effects (N = 105); group B-patients with airway management difficulties (N = 105), which included aspiration, laryngospasm, difficult tracheal intubation, and dental injury; and group C-patients with cardiovascular perturbations (N = 105), including hypertension, hypotension, arrhythmias, and myocardial ischemia. Dejinitions.-Specific definitions were used to identify patients who experienced intraoperative anesthesia-related events. Patients classified in group B had the following events: aspiration = regurgitation of gastric contents into the trachea; laryngospasm = inability to maintain a masked airway because of closure of the vocal cords; difficult tracheal intubation = tracheal intubation that unexpectedly necessitated use of nonstandard mechanical aids; and dental injury = unplanned dislodgment or injury to teeth or other dental appliance. Patients in group C were characterized by the following cardiovascular events: hypertension = systolic blood pressure of 180 mm Hg or more for longer than 10 minutes during maintenance of anesthesia; hypotension = systolic blood pressure of 75 mm Hg or less for longer than 10 minutes during maintenance of anesthesia; arrhythmia =any new non-sinus rhythm during maintenance of anesthesia (for example, atrial flutter, atrial fibrillation, atrioventricular junctional rhythm, or ventricular rhythm), including heart rates of more than 120 or less than 50 beats/ min (less than 40 beats/min with long-term B-blocker therapy); and myocardial ischemia = new electrocardiographic, pulmonary artery occlusion pressure, or transesophageal echocardiography wall motion changes consistent with ischemia. Conditions defining group Band C membership have been previously identified as potentially harmful by other investigators.v' Thus, for each patient, the following exclusion criteria were observed: outside the 18- to 75-year age range or multiple negative anesthetic events, unless the multiple events were in the subset of airway or cardiovascular observations noted for groups Band C. Study Design.-We estimated on the basis of our 1992 intraoperative quality-assessment database that during a 1year interval we had approximately 50,000, 260, and 3,600 patients in groups A, B, and C, respectively. Designing the study to include equal numbers of patients in groups A, B, and C for each month was limited by the number of patients in group B; therefore, random samples were selected for groups A and C. Patient satisfaction was assessed by distribution of a questionnaire that inquired about overall care, scheduling, anesthetic care, and surgical results (Table 1). These questionnaires were regularly mailed in the middle of the month after the surgical procedure. No telephone follow-up or

ANESTHETIC EVENTS AND PATIENT SATISFACTION

21

additional mailings were used to contact patients who failed to respond to the initial mailing. In addition to tabulation of overall patient satisfaction within each of the groups, specific positive or negative comments recorded by patients on the returned questionnaires were tabulated. These comments were grouped on the basis of whether patients described themselves as very satisfied or satisfied versus those who identified themselves as dissatisfied or very dissatisfied with their overall care. Within each group, the positive and negative comments were tabulated as being related to a physician, nurse, or technique or associated with a timing or institutional issue. Data Analysis.-Analysis of these data included the customary display and summarization of patient characteristics and comparability of the three study groups, in addition to the primary study outcomes related to patient satisfaction (reflected in the questionnaire; Table 1). These data were compared by using X2 and analysis of variance or rank sum tests, as appropriate. The data were summarized as mean values ± SD for each group. Pairwise comparisons of group means were done with use of the rank sum test. In all cases, two-sided tests were used, and P values of 0.05 or less were considered statistically significant. RESULTS Of a total of 315 questionnaires sent to patients (105 to each of the three aforementioned study groups), 239 (75.9%) were returned. In the 76 cases in which questionnaires were not returned, 62 were unanswered, 2 were returned as unclaimed letters, 3 patients refused to participate, and 9 patients died before the survey was received. The percentage of patients who returned the questionnaire did not differ across the three groups (Table 2). The demographic, anesthetic, and hospital admission characteristics of the patients who returned the questionnaire are tabulated in Table 3. Patients in group B (median age, 60 years; range, 18 to 74) were younger than those in group A (median age, 65 years; range, 22 to 75) and group C (median age, 66 years; range, 31 to 76). Significantly more first-time surgical patients were noted in group B than in group A. Furthermore, group B had significantly more first-time Mayo Clinic patients than did groups A and C. Anesthesia types differed across the study groups, whereas admission status (outpatient versus inpatient) did not. The distribution of intraoperative events in patients in groups Band C is outlined in Table 4. No significant difference among the groups was noted in overall patient satisfaction when satisfaction was defined as very satisfied or a combination of very satisfied and satisfied (Fig. 1), The specific positive and negative comments tabulated from those identified as very satisfied or satisfied are listed by group and subcategory in Table 5. No patients

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ANESTHETIC EVENTS AND PATIENT SATISFACTION

Table I.-Questionnaire Distributed Postoperatively to Study Patients Overall care 1. Overall, how satisfied were you with the care and service you received at the Mayo Clinic or affiliated hospitals? Scheduling 2. How satisfied were you with the length of time it took to get an appointment at the Mayo Clinic that led to this operation? 3. How satisfied were you with the length of time from when the decision to have the operation was made until the operation was performed? Anesthetic care 4. How satisfied were you with the way your questions about anesthesia were answered before your operation?* 5. Overall, how satisfied were you with the way the anesthesiologist put you at ease and made you feel comfortable?t 6. How satisfied were you with the way your questions about anesthesia were answered after your operation? 7. How satisfied were you with the management of your postoperative pain? Results 8. Overall, how satisfied were you with the results of your operation? 9. If you needed health-care services in the future, would you return to the Mayo Clinic? 10. If a family member or friend needed an operation similar to the one you had, would you recommend the Mayo Clinic?

*Responses limited to patients who responded "yes" to the following question: Before your operation, were you seen by an anesthesiologist to discuss your anesthetic care? tResponses limited to patients who responded "yes" to the following question: Were you seen by an anesthesiologist after your operation?

described themselves as dissatisfied or very dissatisfied with their overall care. DISCUSSION The data from this study show that overall patient satisfaction postoperatively, measured by a standardized mailed questionnaire, is unaffected by intraoperative anesthetic events. In each of the three study groups, patient satisfaction (categorized as very satisfied or satisfied) was more than 98%. Similarly, no patients in any of the groups considered

themselves dissatisfied or very dissatisfied with their overall care. Despite random selection of the patients on the basis of development of anesthesia-related events, certain differences may affect results when the three groups are compared. Group B patients were significantly younger than the other two groups of patients (Table 3), a finding likely explained by the type of adverse events that defined the criteria for inclusion in group B (airway events). Patients in group B more frequently underwent general anesthesia

Table 2.-Summary of Patient Responses to Postoperative Questionnaire

Overall

Group A* (no complications)

Group B* (airway event)

Group C* (cardiovascular event)

Factor

No.

%

No.

%

No.

%

No.

%

Questionnaires sent Answered questionnaires returned Refusal to participate Unclaimed letters Death of patient Unanswered questionnaires

315 239 3 2 9 62

100.0 75.9 1.0 0.6 2.9 19.7

105 76 0 1 1 27

100.0 72.4

105 83 0 1 2 19

100.0 79.0

105 80 3 0 6 16

100.0 76.2 2.9

1.0 1.0 25.7

1.0 1.9 18.1

5.7 15.2

*See text for description of group membership criteria.

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Mayo Clin Proc, January 1997, Vol 72

ANESTHETIC EVENTS AND PATIENT SATISFACTION

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Table 3.-Summary of Characteristics of Patients Who Responded to the Questionnaire and of Procedural Data Group A* (N =76) (no complications) Characteristic

No.t

Age (yrH 18-29 30-39 40-49 50-59 60-69 70-79

4 8 5 6 31 22

Sex Male Female

33 43

First operation§ Yes No

3 72

76

%

Group B* (N =83) (airway event) No.t

5 11 7 8 41 29

5 8 14 13 33 10

43 57

39 44

4 96

14 68

19 15 14 5 10 37

32 12 5 7 9 17

55 20 25

78 5 0

25 75

15 68

76

75

Years a Mayo patientf First time 1-5 6-10 11-15 15-20 >20

10 4 7 27

Anesthesia type~ General Regional Monitored care

42 15 19

Admission status# Outpatient Inpatient

19 57

11

76

No.t

83

83

73 14

%

Group C* (N = 80) (cardiovascular event)

82

80 6 10 17 16 40 12

0 4 10 14 29 23

47 53

45 35

17 83

7 72

39 15 6 9

14 10

11

11

21

27

94 6

59 15 6

76

83

18 82

13 67

5 12 18 36 29 80 56 44 79

82

83

%

9 91 80 18 12 14 9 14 34

11

7

80

74 19 8

80 16 84

*See text for description of group membership criteria. [Number of patients responding to the specific question. :j:Group B was significantly younger than groups A and C (P =0.007 and P =0.002, respectively; rank sum test). §Group B had a significantly higher percentage of first operation than did group A (P =0.010; Fisher's exact test). #Group B had a significantly higher percentage of first-time Mayo patients than did groups A and C (P =0.008 and P = 0.003, respectively; Fisher's exact test). ~Group B had a significantly higher percentage with general anesthesia than did groups A and C (P = 0.001 in both cases; Fisher's exact test). Group C had a significantly higher percentage with general anesthesia than did group A (P =0.019; Fisher's exact test). #No significant difference between groups (P = 0.35; X2 test).

than did those in the other groups; airway events are usually associated with general anesthesia. Regional anesthesia was used more often in groups A and C than in group B, and more monitored anesthesia care was provided for group A patients than for those in group B or C. None of these differences in anesthesia type affected overall patient satisfaction. Similarly, inpatient or outpatient admission status did not affect overall patient satisfaction.

In addition, we found that being a first-time Mayo surgical patient was associated with an increased likelihood of experiencing an airway event (Table 3). One explanation for this finding may relate to the long history at the Mayo Clinic of providing all prior anesthetic records for anesthesiologist review before any subsequent surgical procedure. Included in these records is a detailed outline of the ease or difficulty of prior tracheal intubation. We believe that, in patients who

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Mayo Clin Proc, January 1997, Vol 72

ANESTHETIC EVENTS AND PATIENT SATISFACTION

Table 4.-Intraoperative Events Experienced by Study Patients in Groups Band C Who Responded to the Questionnaire Patients No.

%

Group B (N = 83) (airway events)* Aspiration Laryngospasm Difficult intubation Change in dental status

1 11 70 4

1 13 84 5

Group C (N = 80) (cardiovascular events)* Hypertension Hypotension Arrhythmia Myocardial ischemia

12 57 17 0

15 71 21

Study group

*Patients had multiple events. See text for description of group membership criteria.

undergo more than one surgical procedure at the Mayo Clinic, this system of anesthetic record review produces fewer unexpected airway management difficulties.

Quality is an essential component of contemporary medical practice, and patient satisfaction is an important element of quality. The overwhelmingly positive patient response in the three study groups indicates that surgical and anesthetic care has been well received by our patients. Even among those patients who identified themselves as very satisfied, however, comments were submitted as suggestions for further improvement. When these patient comments were stratified by event group and then by the subcategories of physician, nurse, technique, time, and institution, some differences developed. As shown in Table 5, the positive comments about physicians and nurses outnumbered the negative comments by approximately 10:1 and 15:I, respectively. From these same patients, the positive and negative comments about techniques and the institution were more evenly balanced; in contrast, comments about time concerns were preponderantly negative (5:1). These data suggest that the positive interactions with physicians and nurses outweighed the negative concerns about time and allowed patient satisfaction to prevail. One might speculate that, if time issues were modified to minimize patient delays, patient

100

----0~

en

80 60

c:

CD

ta

a..

40 20

0 Group: ABC ABC ABC ABC ABC ABC ABC ABC ABC ABC 7 10 4 8 9 5 6 1 2 3 Question:

. ~

Very satisfied Dissatisfied

II Satisfied

•

Very dissatisfied

•

Neither

Fig. 1. Distribution of patient responses to a mailed postoperative questionnaire, stratified by study group (A = no complications; B = airway events; and C = cardiovascular events) and by individual questions posed (see Table 1).

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Mayo Clin Proc, January 1997, Vol 72

ANESTHETIC EVENTS AND PATIENT SATISFACTION

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Table 5.-Classification of Comments From Patients Who Indicated They Were Either Satisfied or Very Satisfied With Their Overall Care Study group* A

No. of patients 76

Content of comment was related to the following']

Nature of comment

Physician

Nurse

Technique

Time

Institution

Positive Negative

17 1

10 0

6 7

0 11

10 14

19

No comment

B

83

Positive Negative

24 2

13 2

2 6

4 4

15 10

23

C

80

Positive Negative

17 4

6 0

3 6

0 7

14 7

22

65

31

30

26

70

64

Total

239

*See text for description of group membership criteria. [Entries are number of patients. Classifications are not exclusive because a patient could submit positive and negative comments related to multiple items. satisfaction might be increased. We believe that the oftenheld assumption that technical excellence is the sine qua non hallmark of quality in medical care should be reconsidered. Although technical expertise is easily measured by tabulating medical care events and outcomes, patient-perceived quality likely involves elements that are more difficult to measure, such as patient satisfaction with physician and nurse interactions.

CONCLUSION In this study, we have shown that intraoperative anesthetic experiences do not decrease patient satisfaction. Patient comments suggest that interactions with physicians and nurses dominate their ratings of satisfaction. Furthermore, time delays were the most frequently cited negative comment, even among patients who identified themselves as satisfied or very satisfied with care. We believe that efforts should be invested to minimize these delays and to optimize patient satisfaction.

REFERENCES 1. Moerman N, van Dam FS, Oosting J. Recollections of general anaesthesia: a survey of anaesthesiological practice. Acta Anaesthesiol Scand 1992; 36:767-771 2. Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, et al. Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA 1994; 272:1583-1587 3. Cohen MM, Duncan PG, DeBoer DP, Tweed WA. The postoperative interview: assessing risk factors for nausea and vomiting. Anesth Analg 1994; 78:7-16 4. Brown DL, Mackey DC. Management of postoperative pain: influence of anesthetic and analgesic choice. Mayo Clin Proc 1993; 68:768-777 5. Cohen MM, Duncan PG, Pope WD, Biehl D, Tweed WA, MacWilliam L, et al. The Canadian four-centre study of anaesthetic outcomes. II. Can outcomes be used to assess the quality of anaesthesia care? Can J Anaesth 1992; 39:430-439 6. Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anaesth 1994; 41:372-383 7. Urban MK, Gordon MA, Harris SN, O'Connor T, Barash PG. Intraoperative hemodynamic changes are not good indicators of myocardial ischemia. Anesth Analg 1993; 76:942-949

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