Comments a recent paper About patient satisfaction after nerve blocks
Using IRORA (International Registration of Regional Anesthesia) the primary objective of the authors of this paper was to report the results of a newly developed patient satisfaction questionnaire and to determine predictors associated with unwillingness to have PNB repeated in the case of future surgery.
The inclusion criteria was patients that were anesthetised with PNB as the sole anesthetic technique, or PNB combined with general anesthesia or neuraxial blockade. If patients received PNB after discharge from the postanesthesia care unit or for nonsurgical pain were excluded.The questionnaire developed used elements of previous validated questionnaires (Leiden questionnaire, for example) and three domains of importance were identified and addressed: 1. provision of information (2 questions), 2. pain and discomfort (5 questions), 3. interaction with the anesthesiologist (3 questions). The responses for information and interaction were based on a 5-point Likert-scale (1 - completely dissatisfied to 5 - completely satisfied) and for pain-related questions a 4-point scale raging from 1 (none) to 4 (severe - very preoccupied by the symptom) was used. A final question og willingnes or unwillingness to have a repeated peripheral nerve block (PNB) in case of a future surgery (categorical yes/no) was added, resulting in an 11-item multidimensional questionnaire of patient satisfaction.A copy of the questionnaire was provided to the patients after the surgery and were contacted 2 days after (by telephone or in the ward). All responses were included in the analysis.
The primary outcome was willingness to have a repeated PNB in a future similar surgery and trough this univariate relationship, the authors created a logistic regression model to predict the willingness to have another PNB. The final model included all variables with P values < 0,05 and those with odds ratios with potencial clinical significance (even if the P value was > 0,05).Data were collected from 1st July 2011 to 31st March 2013, in a total of 9,969 procedures there were 6142 responders (61,6% response rate). Of those, 94,6% (5,809 patients) accepted a repeated PNB in a future similar surgery. More than 90% of the responders were satisfied or completely satisfied with the information provide about the PNB and with the interaction anesthesiologist-patient.
Commonly, patients would express physical complaint of moderate and (lesser extent) severe degree, especially pain after surgery and after PNB regression. Patients that refered high pain scores, complaints of motor weakness and reported lower score in the information and interaction were less willing for have a second PNB. Other clinical predictors for lower rates of willingness for repeated PNB were younger age, feamale sex, after-hours surgery, preoperative antineuropathic medications, neck sur- gery, PNB complications, failed PNB, and severe pain in the postanesthesia care unit. Being unresponsive during the performance of regional technique was predictive of increased willingness to undergo repeat PNB.
This questionnaire can have some drawbacks because it’s not a formally validated tool, whether or not the survey nonresponders would have answered the questions differently than the responders and, in some rare occasions, the physician involved in the anesthetic care was involved in the administration of the questionnaire.
The authors concluded that there were high levels of patient satisfaction with more than 90% of patients being satisfied or completely satisfied with information provided and the anesthesiologist-patient interaction. The responses to questions comprising pain and discomfort were variable, indicating the need for clinicians to attend to issues such as pain during PNB insertion and recession, and the intensity of the motor and sensory block in the perioperative period. Clinical predictors of dissatisfaction after PNB may permit better patient selection. Predictors of dissatisfaction also provide possibilities for prospectively tested, targeted interventions as part of quality improvement programs. The majority of survey respondents (94.6%) were willing to undergo repeat PNB in case of future surgery.
Interest on patient’s satisfation has been increasing inside medical community as an important indicator of quality of care. Each medicine area has it’s specific characteristics. Measuring patients satisfaction is difficult, complex and subjective, once it depends on patients’ expectations. Recently was published a self-reported multidimentional questionnaires (tools used to access patients’ satisfaction) combining several dimensions and improving the sensitivity when compared to unidimensional questionnaires. A properly constructed questionnaire can produce better quality of data, with more variability, greater validity and reliability in measuring the level of patient satisfaction (Caljouw 2008).
Personnaly, I think that our primary consern should be the patients. So, any research considering patient satisfation can only give us valuable data and tools for improvement.The main question now is wich tools are valuable and how can they be identified and addressed the best, objective and correct way. With no under or over rating.That is why questionnaires can be valuable and considered for research after tested and approved, like the Leiden questionnaire (Caljouw 2008) and others (Jlala 2010, Mui 2013).Based on this paper and others (Maurice-Szamburski 2013, Flierler 2013) patients appreciate to receive information about the anesthetic procedure and a healthy, real interaction with the anesthesiologist.
Patients wish to be involved when it come to decide the anesthetic technique they are going to receive and their satisfaction is proportional to the information they receive (Flierler 2013, Straessle 2011). Bottom line, Anaesthesiologists need to step out the operating room and get involved in more close and “intimate” way with the patient that is going to be submited to any form of anesthaesia.
The best way that information gets to the patient (flyer, videos, consultation) and the best way to establish an interaction are yet to be determined.
Caljouw M et al. Patient’s satisfaction with perioperative care: development, validation, and application of a questionnaire. Br J Anaesth. 2008; 100: 637–44 Jlala H et al. Patient satisfaction with perioperative care among patients having orthopedic surgery in a university hospital. Local and Regional Anesthesia 2010:3 49–55 Maurice-Szamburski A et al. Development and Validation of a Perioperative Satisfaction Questionnaire in Regional Anesthesia. Anesthesiology. 2013; 118: 78-87 Flierler W et al. Implementation of shared decision making in anaesthesia and its influence on patient satisfaction. Anaesthesia. 2013; 68: 713–722Straessle R et al. Is a pre-anaesthetic information form really useful? Acta Anaesthesiol Scand. 2011; 55: 517–523
Becoming an expert...
Clara Lobo, Specialist Anaesthetist
Centro Hospitalar Trás-Os-Montes e Alto Douro, Vila Real, Portugal.
Anesthesiologist since 2003, soon felt the appeal for Regional Anaesthesia and Ultrasound guided blocks.
President of the portuguese Regional Anaesthesia Society (Clube de Anestesia Regional - CAR/ESRA Portugal), portuguese representative at the ESRA Council and member of the EDRA faculty, since 2013.
Holds the title of Chronic Pain Management Competency atributed by the national portuguese medical society (Ordem dos Médicos), since 2008.
Faculty of regional anaesthesia and anatomy national and international workshops, lecturer at several national and international meetings and congresses of several Anesthesiology Societies.
Teaches human anatomy to medicine students at the Instituto de Ciências Biomédicas Abel Salazar, at Porto University, since 2008.
Author of a book chapter with international edition (The Anesthesia Guide, McGrawHill, 2013) and papers published in national and international literature.
Editor and co-author of a portuguese manual of sonoanatomy applied to peripheral nerve blocks, the theoretical base of a course of ultrasound-guided regional anesthesia organized by CAR/ESRA Portugal.
She loves to read thrillers, travel and listen to music.
Interview with the expert
1- You are playing the leading role in the boom of the regional anesthesia in your country, Portugal. What is coming in regional anesthesia to seduce the next generations of portuguese anaesthetists?
As President of CAR/ESRA Portugal I feel the responsability for promoting regional anaesthesia (RA) practice with the highest standards of care. The best way to accomplish that goal is to provide high quality of regional anaesthesia teaching through courses, workshops, meetings, etc… Recently, RA got an enormous impulse and spreading wih ultrasound, that contributed for an objectivity and precision that was still lacking with nervestimulation. The countless advantages of these techniques and patient satisfaction are the main seducers of the next generation of anaesthetists. I would like to say also that the fear that this high level of popularity with RA nowadays could be followed by a decrease in it’s performance, like a fashion tendency, is fading from my mind as the medical community gets more aware of the full potential of RA.
2-Learning curves and time consume are two mean factors to perform a nerve block... Do anesthetists perform enough/too much peripheral nerve blockades?
I think that you can’t speak of enough/too much peripheral nerve blockades. You should pratice a lot, in order to increase your success rate (improving the learning curve) and decrease your performance time. I feel that residents have a strong will to perform RA, but the less experient specialist with RA techniques limit that pratice and compromises the two factors mentioned before (success and time). Anaesthesiologists and anesthesiology residents should always try to evolve and that implies a lot of personal and professional investment. Maybe the best way to start is to built your RA experience and develop your skills with basic blocks. After you feel confortable with that, you can increase the complexity of the blocks and so on.
3- Patients completely satisfied, but... what about the surgical team? Are surgeons and nurses happy with these techniques?
Change always implies extra work. And, usually, people are resistant to change. It’s quite natural that surgeons and nurses resist to the application of those RA techniques. Specially if the anesthesiologist that is performing them is at the begining of it’s RA pratice (more time and low success). So, they are not happy at the begining. But, once they start to realize the advantages they “surrender” and accept them gladly. That patients are more confortable and can have an early PACU discharge and have less pain complaints and opioid systemic lateral effects will conquer the other caregivers. You have to be perseverant and little stubborn before you get the best results.
CLARA LOBO MD
Centro Hospitalar Trás-Os-Montes e Alto Douro,
Vila Real, Portugal