Fritz E. Gempeler*, María Victoria Avellaneda S.**

* Profesor Asociado, Facultad de Medicina, Pontificia Universidad Javeriana - Anestesiólogo Hospital Universitario de San Ignacio. gempeler@javeriana.edu.co.

** Profesora, Facultad de Medicina, Pontificia Universidad Javeriana, Anestesióloga Hospital Universitario de San Ignacio. Máster en Estudio y Tratamiento del dolor. Universidad Rey Juan Carlos.

Recibido: marzo 2 de 2010. Enviado para modificaciones: marzo 10 de 2010. Aceptado: marzo 15 de 2010.

The expression “patient satisfaction” was introduced into the clinical practice in the 90’s and since then we have acknowledged its huge subjectivity and how difficult it is to measure. Presently, patient satisfaction is a major indicator of medical care quality that contributes to evaluate the structure, the process and the outcomes of health care services (1-14).

Several psychological theories suggest that patient satisfaction is in the end a combination between the patient’s expectations and the perception of the service received; it is a multidimensional concept that embraces sociodemographic, cognitive and emotional components. Every patient has a baseline comparator against which he/she will pass judgment on the new experience. When the difference between the actual situation and the patient’s expectations exceeds the ability of the patient to take in that change, the level of satisfaction changes. Hence, the patient’s satisfaction depends on the consistency between what the patient expects and what really happens (1,8,14).

Some of the patient-related components are: socio-demographic factors, age, gender, level of education, marital status, occupation, race, etc. The health care provider factors include verbal and non-verbal interactions, professional skills, etc.; and the process-related factors include access, convenience, supplementary services, bureaucracy, costs, environment and organization of health care services (15).

Determining the relationship among these various factors has been rather difficult from the statistical point of view; actually, it is not yet clear which are more important when trying to take an objective measurement (15).

One-dimensional tools have been used to measure patient satisfaction (Numerical scale, visual analogue scale and Likert-type categorical scales), that in general give overall information about the health care provided, unless they are specifically targeted to a particular factor. The multidimensional surveys are difficult to develop but provide more specific and reliable information because of the large number of variables evaluated. At a large scale, questionnaires such as QoR (Quality of Recovery Score) and the extended QoR–40 version have been used in countries like Australia (8,14,15).

Health care satisfaction is usually very high. Many studies have reported levels of satisfaction above 85 % and patient’s satisfaction in terms of anesthesia is not very different. However, there are few studies available, mostly not randomized and using one-dimensional instruments that are biased and inaccurate (1,7,8).

The general conclusion has been that patients are satisfied not just with the anesthesia per se, but with the final outcome of the surgical procedure, including many other variables that are quite unrelated to the anesthetic experience; i.e., access to health care, convenience, the institutional structure, interpersonal relations, the skills of the health care professionals and the patient’s expectations and preferences. (1,7,8).

Surveys administered to over 10 thousand patients in the UK, asking about satisfaction and anesthesia have documented that the factors most usually related to dissatisfaction are intraoperative awakening, severe, uncontrolled pain, nausea and vomiting, thirst, cold, tremors and dizziness, in addition to complications at the PACU (1,11,13).

In terms of the variables that result un patient satisfaction with anesthesia, these include: the use of regional anesthesia due to a better control of postoperative pain, adequate treatment by the anesthesiologist, older age, male gender and the presence of co-existing medical conditions (ASA III patients) (1,15).

With regards to recovery time, until recently we believed that most regional techniques led to shorter PACU stays and reduced institutional costs (3); however, with the introduction of short-acting and fast elimination anesthetics this concept has changed. The impact of the anesthetic technique on the recovery process and perioperative complications is fundamental in determining the health care costs for the patient satisfaction (3).

The perfect combination is a low-cost, safe and effective anesthetic technique that ensures a short PACU stay and high patient satisfaction (3).

Keeping in mind the specific objectives of assessing patient satisfaction following the administration of general, regional or combined anesthesia (regional neuroaxial and general) at the San Ignacio University Hospital and determining the length of stay at the PACU in accordance with the anesthetic technique, a prospective, observational study was designed, with no direct intervention in the clinical management of patients.

In order to facilitate the data collection and to get a more homogeneous sample of patients, only patients scheduled for surgery at the San Ignacio University Hospital between 7 a.m. and 2 p.m. as of June 2006 were included, until the calculated sample of 550 patients was completed. The patient distribution was as follows: 200 general anesthesia, 200 regional neuroaxial anesthesia (epidural or spinal anesthesia), 100 regional peripheral anesthesia in the upper or lower limb and 50 combined anesthesia procedures (regional neuroaxial plus general anesthesia).

The sample was calculated to achieve a 10 % difference in the level of satisfaction with the various anesthetic techniques, with an 80 % power.

The inclusion criteria were as follows: the use of regional, general or combined anesthesia in patients over 18 years of age, ASA I – IV. The exclusion criteria included: patients requiring ICU admission after surgery; patients unable to communicate verbally or mentally disabled to respond to the questionnaire; receiving more than one anesthesia during the hospital stay and emergency surgical patients.

Once the patient was selected from the surgical list, the basic data were recorded: identification, type of surgery and data collection format. The anesthesiologist in charge of the case, the OR staff, neither the PACU personnel were aware of the fact that the patient was included in the observation protocol. The OR admission, preanesthesia management and PACU management were all as usual. The surveyors had no intervention whatsoever.

Once the patient met the PACU discharge criteria (length of stay at the PACU), trained staff administered the survey and completed the necessary information based on the pre-anesthesia evaluation, the anesthesia records and the PACU records. The survey was developed using the verbal analogue scale, and questions addressing the issues that could impact patient satisfaction. We avoided using any of the validated surveys because they were in a foreign language and asked questions that were irrelevant to our environment or too complicated.

Then, each patient’s data were recorded into an Excel database using SPSS statistics version 17 for processing. The statistical analysis calculated central trend and dispersion measurements for continuous variables and the relative frequencies for qualitative variables were estimated. The intent was to assess whether there was any relationship between patient’s satisfaction and certain variables. Contingency tables were applied to obtain Pearson’s χ2, Odds ratio, confidence interval and p-value for the dychotomic variables, and Cramer’s V for the polytomous variables. Logistic regression was applied for the ordinal variables to get the Odds ratio, confidence interval and p-value.

The overall satisfaction (defined as score >5 in the verbal analogue scale from 0 to 10) was 99.1 % and dissatisfaction with the anesthetic procedure (defined as a score ≤5 in the verbal analogue scale from 0 to 10) was 0.9 % (5 patients), see Table 5.

In general and in each group, depending on the type of anesthesia, over 90 % of the patients rated satisfaction at ≥8 in the verbal analogue scale. As shown in Table 6, no significant differences were observed.

None of the patients receiving regional peripheral anesthesia or combined anesthesia reported scores ≤5.

Of the 5 patients who were dissatisfied with the anesthetic procedure, one was a high school graduate and four were university students. None of the patients who only competed elementary school or who had no education what so ever, expressed dissatisfaction.

The causes for dissatisfaction of the 5 patients are shown in table 7.

Among the dissatisfied patients the causes of their response were quite similar as those reported in the literature: pain, cold, throat ache, nausea and vomiting during the time they spent at the PACU (table 7).

Although out of the 550 patients, only 5 expressed dissatisfaction with the anesthesia, while 11 patients wouldn’t want to have the same anesthetic procedure in the future. It is surprising that although not significant, 3 % of the patients who underwent regional peripheral anesthesia wouldn’t chose the same technique for future interventions, basically because of the discomfort caused by its administration (table 8).

The evaluation of patient satisfaction following anesthetic procedures is an important parameter for quality control and on-going improvement of hospital care.

There are multiple instruments to assess the surgical patient satisfaction, ranging from onedimensional tools such as the verbal analogue scale to elaborated and extensive surveys. We chose the verbal analogue scale to measure satisfaction because it is easy to use and can be administered to a large number of patients in the future.

The complete data collection instrument used in the study was a non-validated, face-to-face survey model that allowed for the collection of multiple variables, open answers and measurement of satisfaction using the analogue verbal scale. According to the protocol, the survey was administered at the time of discharge from the PACU and hence it assessed the feelings or the patient satisfaction with regards to an event at the time of discharge, rather than the side effects or complications during the anesthesia and time spent at the PACU. It is important to be clear about this concept to be able to adequately interpret the results.

The satisfaction measured using the verbal analogue scale from 0 to 10 in the 550 patients was 9.23 in average (SD = 1.09) and was similar regardless of the type of anesthesia administered. The lowest rating however was for the combined anesthesia group with 8.98 % (SD = 1.13), but the differences were not clinically or statistically significant. With regards to previous studies assessing satisfaction with anesthesia care this study ratifies the worldwide trend of rating satisfaction high as has been shown by Myles et al (1). He reports a level of satisfaction of 96.8 %, while Hellwagner et al measured levels of patient exceeding 90 %. The review article by Fung et al (8) refers to patient satisfaction levels ranging from 80 to 100 %.

The level of satisfaction according to the type of anesthetic technique shows no clinically or statistically significant differences (tables 5 and 6), contrary to what is reported in the world literature with higher patient satisfaction following regional anesthesia. Our observations of patients evaluated at the San Ignacio University Hospital showed similar levels of satisfaction with regional anesthesia both neuroaxial and peripheral, versus general and combined anesthesia.

It should be kept in mind that over 90 % of the patients surveyed reported satisfaction values above 8 in the analogue verbal scale, indicating an adequate level of satisfaction in general. No significant differences were seen among the different anesthesia techniques; however, the ratings were higher for the regional peripheral anesthesia patients. This slight difference between regional peripheral anesthesia and regional anesthesia may be influenced by the higher level of sedation received by patients with regional peripheral anesthesia that allows for an adequate administration of the different types of nerve blocks.

This explains why none of the patients receiving regional peripheral anesthesia reported satisfaction ratings below 6.

Only 5 patients reported values ≤5. We considered these ratings unsatisfactory. 3 of these patients received general anesthesia and their main complaint was postoperative pain and feeling cold during recovery. If the results were unsatisfactory in only 5 patients, then 99.1 % were satisfactory. However, as we discussed in the Introduction, patient satisfaction refers in most cases to the overall care (anesthesia, surgery, administrative processes, boarding, etc.) and it is very difficult to separate each factor, unless individual surveys are administered addressing each particular factor.

The answer to the question “If you were to undergo a similar procedure in the future, ¿would you choose the same anesthetic technique you received today?" Is quite relevant to us because it expresses the feelings of the patient about the anesthetic experience. The study showed that 11 patients would rather not receive the same type of anesthesia. Though the differences are not significant, most of the patients (3 %) who did not want the same anesthesia belonged to the regional peripheral anesthesia group and complained about pain and discomfort during tapping.

The causes for dissatisfaction as well as the main complaints reported by the patient are consistent with the literature; i.e. feeling cold during the recovery, painful administration of the anesthetic agent –even for general anesthesia– (probably as a result of vein puncture, propofol or rocuronium), postoperative nausea and vomiting and throat ache. None of the complaints reported by Myles PS (1), intraoperative awakening and thirst, were reported in this study. Although the incidence of postoperative nausea and vomiting reported in the world literature ranges from 1 % to 15 %, depending on the anesthetic technique and the agent used, only 6 (1.09 %) patients complaint about these events in our study. Since the results were recorded through a survey administered at the time of discharge from the RR, this limits the reports of certain side effects if the patient felt they were not significant; i.e. nausea and vomiting. The results just show what was relevant for the patient at the time of discharge from the PACU.

It is interesting to note that as the more relevant side effects of anesthesia –nausea and vomiting– decrease, and pain is more adequately controlled, other events that were considered of minor importance, now become relevant for the patient. For instance, cold and chills during recovery; these were significantly higher in the general anesthesia group.

As shown in the results of the dissatisfied patients, these were 35 to 55 years old, 4 were males and all of them were high school or college graduates and were classified as ASA I & II.

None of these variables, or any prior experiences with anesthesia or pre-surgical anxiety influenced the level of dissatisfaction. These results can be explained in terms of the small number of dissatisfied patients.

The factors associated with satisfaction are: old age, male gender and the presence of coexisting medical conditions (ASA III patients) (1); however, in our study patient satisfaction was hand-in-hand with fine treatment by the anesthesiologists and adequate pain control at the PACU. No statistically or clinically significant relationship was found with any of the study variables. According to the results, 43 % of the patients reported fine treatment by the anesthesiologists and 65.2 % of the patients reported adequate pain control. These percentages are based on the patients response to the question “What is / are the reason (s) for satisfaction / dissatisfaction?” and a list of factors was provided. 43 % of the patients said fine treatment by the anesthesiologists influenced the level of satisfaction and 65.2 % said adequate pain control. This doesn’t mean to say that 57 % received inadequate treatment. This answer basically responds to the type of survey and the way the questions were asked. 65.2 % of the patients reported adequate pain control but this doesn’t mean that 34.8 % were inadequate.

In terms of recovery times, it is well known that most regional techniques lead to shorter lengths of stay at the PACU because the patients meet the discharge criteria faster. This was the case in our study with the shorter PACU lengths of stay were experienced by the patients in the regional peripheral anesthesia group. The time difference to meet the discharge criteria with regional peripheral anesthesia versus general and regional neuroaxial anesthesia was approximately 30 minutes, while versus combined anesthesia the difference was 40 minutes. This time difference in the length of PACU stay has considerable impact on the PACU turnover rates and on the costs of care.

If we compare the our patients length of stay at the PACU versus the information in the literature, our data are consistent with other studies such as Hadzic et al (4) that compared recovery times of hand surgery patients receiving regional peripheral block versus general anesthesia. The results showed 100 +/- 44 minutes to discharge patients receiving regional anesthesia and 203 +/- 91 minutes for patients under general anesthesia. Similarly our recovery times are shorter than those reported by Song at al (3), where patients who underwent herniorrhaphy with peripheral nerve block and sedation experienced recovery times of up to 133 minutes as compared to 80.4 minutes for patients under regional anesthesia in our study.

We believe that shorter recovery times at the PACU meeting the discharge criteria are due to the administration of safe and efficient anesthetic techniques using short-lasting drugs at the appropriate dosages for the particular procedure and to the adherence to strict PACU management protocols with a full time attending anesthesiologist. This promotes a smooth transition of patients from phase 1 to phase 2, beds turnover and expeditious administrative processes for discharge of patients.

Additionally, this study contributes important information about the types of anesthesia administered and their impact in terms of recovery times and side effects. These date are extremely useful for the continuous improvement of the department of anesthesiology.

The advantages of our study are: a precise sample of our everyday reality as a health care service provider and as an anesthesiology department; provides useful information to constantly improve our service and to assess the institutional processes. The limitations are that we failed to use a validated rating scale questionnaire –the reasons have already been discussed– but this does not lessen the importance of the outcomes.

Currently, intravenous anesthesia, low solubility inhaled anesthetic agents and regional anesthesia techniques are being used more often to facilitate a faster turnaround at the PACU and excellent patient satisfaction.

In general, the patients receiving anesthesia at the San Ignacio University Hospital are satisfied with the anesthetic technique administered. In addition to a high scientific quality, these results are due to the fine treatment given by the anesthesiologists and adequate postoperative pain control. There were no significant differences in terms of the different anesthetic techniques but the PACU length of time was shorter with the regional peripheral anesthetic techniques.

This study reflects the quality of our everyday work and encourages us to constantly work harder to provide a high quality service from the scientific, technical and human point of view, adhering to the highest standards in anesthesia to ensure safety and patient satisfaction.

We want to thank Nelcy Miranda for her assistance with the statistical analysis of the data.

1. Myles PS, Williams DL, Hendrata M, Anderson H, Weeks AM. Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10,811 patients. Br J Anaesth. 2000;84(1):6-10.

2. Zvara DA, Nelson JM, Brooker RF, Mathes DD, Petrozza PH, Anderson MT, et al. The importance of the postoperative anesthetic visit: do repeated visits improve patient satisfaction or physician recognition? Anesth Analg. 1996;83(4):793-7.

3. Song D, Greilich NB, White PF, Watcha MF, Tongier WK. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg. 2000;91(4):876-81.

4. Hadzic A, Arliss J, Kerimoglu B, Karaca PE, Yufa M, Claudio RE, et al. A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries. Anesthesiology. 2004;101(1):127-32.

5. Morgan PJ, Halpem S, Lam- McCulloch J. Comparison of maternal satisfaction between epidural and spinal anesthesia for elective Cesarean section. Can J Anesth. 2000; 47(10):956-61.

6. Hellwagner K, Holzer A, Gustorff B, Schroegendorfer K, Greher M, Weindlmayr-Goettel M, et al. Recollection of dreams after short general anaesthesia: influence on patient anxiety and satisfaction. Eur J Anesthesiol. 2003;20(4):282-8.

7. Le May S, Hardy JF, Taillefer MC, Dupuis G. Patient satisfaction with anesthesia services. Can J Anesth. 2001;48(2):153-61.

8. Fung D, Cohen MM. Measuring patient satisfaction with anesthesia care: a review of current methodology. Anesth Analg. 1998;87(5):1089-98.

9. Hepner DL, Bader AM, Hurwitz S, Gustafson M, Tsen LC. Patient satisfaction with preoperative assessment in a preoperative assessment testing clinic. Anesth Analg. 2004;98(4):1099-105.

10. Heidegger T, Husemann Y, Nuebling M, Morf D, Sieber T, Huth A, et al. Patient satisfaction with anaesthesia care: development of a psychometric questionnaire and benchmarking among six hospitals in Switzerland and Austria. Br J Anaesth. 2002;89(6):863-72.

11. Bauer M, Bohrer H, Aichele G, Bach A, Martin E. Measuring patient satisfaction with anaesthesia: perioperative questionnaire versus standardized face-to-face interview. Acta Anaesthesiol Scand. 2001;45(1):65-72.

12. Luntz SP, Janitz E, Motsch J, Bach A, Martin E, Bottiger BW. Cost-effectiveness and high patient satisfaction in the elderly: sevoflurane versus propofol anaesthesia. Eur J Anaesthesiol. 2004;21(2):115- 22.

13. Coyle TT, Hlefrick JF, González ML, Andresen RV, Perrott DH. Office-based ambulatory anesthesia: Factors that influence patient satisfaction or dissatisfaction with deep sedation/general anesthesia. J Oral Maxillofac Surg. 2005;63:163-172.

14. Schug SA. Patient satisfaction--politically correct fashion of the nineties or a valuable measure of outcome? Reg Anesth Pain Med. 2001;26(3):193-5.

15. Wu CL, Naqibuddin M, Fleisher LA. Measurement of patient satisfaction as an outcome of regional anesthesia and analgesia: a systematic review. Reg Anesth Pain Med. 2001;26(3):196-208.