Journal of Clinical Anesthesia (2015) 27, 214–220
Original Contribution
Positive perceptions on safety and satisfaction during a patient-centered timeout before peripheral nerve blockade☆,☆☆,★ Yan H. Lai MD, MPH (Assistant Professor of Anesthesiology) a,⁎, Michael R. Anderson MD (Assistant Professor of Anesthesiology)a , Alan D. Weinberg MS (Associate Professor of Population Health Science and Policy)b , Meg A. Rosenblatt MD (Professor of Anesthesiology and Orthopedics) a a
Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
b
Received 8 February 2014; revised 29 September 2014; accepted 2 October 2014
Keywords: Peripheral nerve blockade; Regional anesthesia; Block time-out; Patient safety; Patient satisfaction; Wrong side block
Abstract Objectives: To determine the psychometric outcomes of patients participating in an extensive patient-centered verification process before receiving sedation for regional anesthesia. Design: Survey. Setting: Perioperative areas of university-affiliated hospital. Patients: Two hundred eligible patients scheduled for elective orthopedic surgery undergoing peripheral nerve blockade. Interventions: Postoperative survey evaluating patient perception, experience, and satisfaction with the anesthetic timeout before regional anesthesia. Measurements: Measures using numeric rating scales were obtained on patient perceptions of safety, confidence in anesthesia provider, anxiety, and positive sentiments during participation in block timeout. These variables were analyzed using logistic regression models to correlate with reported pain and satisfaction perioperatively. Main Results: One hundred seventy-five patients (93% enrollment) completed the study. More than 90% of patients reported agreeing strongly to feeling safe, confident, relaxed, and positive about their participation in the block timeout. These sentiments are associated with less reported perioperative pain and higher overall satisfaction. Conclusions: Patient perceptions of confidence and safety in regional anesthesia providers were enhanced by a preprocedural timeout process. These positive attitudes are associated with a superior perioperative experience and patient satisfaction. © 2014 Elsevier Inc. All rights reserved.
☆
Financial source: Department of Anesthesiology, Icahn School of Medicine at Mount Sinai. Presented at the 2013 American Society of Regional Anesthesia Meeting in Boston (poster presentation). ★ Conflict of interest: None. ⁎ Correspondence: Yan H. Lai, MD, MPH, Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place Box 1010, New York, NY 10029, USA. Tel.: +1 646 344 0968. E-mail address: [email protected] (Y.H. Lai). ☆☆
http://dx.doi.org/10.1016/j.jclinane.2014.10.009 0952-8180/© 2014 Elsevier Inc. All rights reserved.
Patient perspectives on block timeout
1. Introduction In the current health care system, patient satisfaction has emerged as a valuable “non-traditional” measurement of health outcomes and delivery [1-4]. The assessment of patient satisfaction has become a significant indicator of the quality of “patient-centered” medical care [3,4]. In fact, experts have defined patient satisfaction as “the match between patient expectations and the perception of service received” [1]. In practice, the identification of patient expectations and the delivery of interventions that manages appropriate patient perceptions are both complex and multidimensional [2-4]. For instance, health care providers have believed that allowing patients to control their own postoperative pain through systemic patient control analgesia devices would lead to better satisfaction. However, patient perception of analgesic control was not a major determinant for their satisfaction with patient control analgesia devices [5]. In fact, comprehensive protocols designed by health care professionals intended for patient safety using a patient-centered model may have opposite effects of increasing perioperative anxiety and contribute to negative experiences of a seemingly unnecessary, repetitive, and burdensome practice. Hence, programs that aim to improve patient satisfaction and safety should be evaluated for their convergence with patient perceptions to optimize their efficacy. This study presents an evaluation of the match between patient perception and satisfaction regarding the timeout process during preoperative peripheral nerve blockade. It has been well established that preoperative psychological factors such as anxiety, distress, and apprehension influence patient satisfaction [6,7]. The preanesthetic interview and premedication of conscious patients are effective ways of achieving a positive perioperative experience [8,9]. However, the increased recognition of regional anesthetics performed on the wrong site, wrong side, or wrong person signals an evolving trend toward rigorous and comprehensive preprocedural protocols and checklists with a focus on conscious patients [10]. The psychological effects that these practices have on patients remain unknown. While patient-centered timeouts were designed to improve safety, they require alert patients to provide cognitive inputs for several checkpoints within an already stressful environment. In turn, a growing number of presurgical patients are subjected to various forms of repetitive confirmations by multiple providers. From the patients' perspective, it is unclear whether their active involvement impacts their satisfaction regarding the perioperative experience. The first case series of 2 wrong site blocks was published in 2004 [11]. The exact incidence of wrong site blocks remains undocumented. Wrong site regional anesthetics represent preventable errors that could have catastrophic consequences for the patient, perioperative personnel, and the health care institution. Possible complications of wrong site blocks include unnecessary exposure to local anesthetic toxicity, vascular and nerve injury, psychological trauma, and progression to wrong
215 site surgery [12]. Since 2004, the Joint Commission (formerly The Joint Commission on HealthCare Organizations) has been advocating the involvement of lucid patients in the universal protocol [13].
2. Materials and methods The Icahn School of Medicine at Mount Sinai's institutional review board approved a waiver of signed consent. All patients presenting for orthopedic surgery with a planned peripheral nerve block had a study description letter provided to them during the admitting and registration process, approximately 2 hours before the block on the day of surgery. Patients were offered the opportunity to ask questions and refuse participation in the study, should they prefer. Patients were reminded that their participation is voluntary and that they can withdraw from the study at any point. If patients had concerns, the study coordinator was called to the admitting area to address them. Fifteen minutes before the block, the coordinator verified verbal consent on all patients and collected demographic data. The anesthesiology team evaluated the patient and explained the planned anesthetic. Exclusion criteria included patients undergoing emergency surgery, those receiving anxiolytic or narcotic medications in the previous 24 hours, or if they were non– English speaking. The number of eligible patients included was based on a 3-month recruitment period. Standard American Society of Anesthesiologists (ASA) monitors were applied, and a peripheral intravenous cannula was inserted. Patient identifiers (name, birth date, and medical record number) were confirmed by the entire operative team consisting of the circulating nurse, anesthesiologists, and surgeons in accordance with standard protocol. For every procedure, all team members checked that all components of universal protocol were fulfilled with the patient. Then, all patients participated in an independent preanesthetic nerve block verification process involving both the attending anesthesiologist performing or supervising the block and an independent health care provider who was not involved in the placement of the regional anesthetic. The independent provider was the circulating nurse or any credentialed personnel working in another operating room. Together, the surgeon's mark was inspected as being on the correct extremity by both confirming with the signed surgical consent and specifically asking the nonmedicated patient. Explicitly, the attending anesthesiologist recited the institutional required block timeout script that was attached to each ultrasound machine in front of the lucid patient, stating, “We are about to do (insert side and type of block) on patient (name, DOB, MRN). The signed consent states (procedure with side). I see the surgeon's mark and the mark that I have placed at the block site. Is everyone (including the patient by name) in agreement that this is correct?” Active participation from the patient was verbally elicited and confirmed after
216 each question. Only after this was completed would premedication be administered for the regional block. An 11-item survey (Appendix 1) was administered by telephone or during the hospital visit by a single blinded investigator 24-48 hours postoperatively. Nine of the questions utilized a symmetric 6-point Likert scale for recording responses (ranging from “disagree very much” to “agree very much”). The additional items included a question that asked for a narrative response and a separate question on the appropriate level of sedation during the block. The survey was modified from the Iowa Satisfaction with Anesthesia Scale (ISAS) designed by Dexter and Candiotti [14] intended to measure patient satisfaction for minor surgical procedures performed under monitored sedation. On the questionnaire, 4 primary questions were formulated to assess patient perceptions on confidence, relaxation, safety, and positive involvement during the preblock timeout. Two additional questions were devoted to asking about pain experienced during the block as well as the entire perioperative period. The final 2 questions inquired about patient satisfaction with their anesthetic and their perioperative satisfaction. The individual responses were assigned a numeric value on a scale from − 3 to + 3 without a zero value for the 6 possible responses. The sum of responses pertaining to questions on perceptions was grouped as a primary perception variable. This variable was analyzed to compare and establish relationships with questions regarding pain and satisfaction as well as independent demographic factors. Both Pearson and Spearman's correlations were computed, and multiple regression analyses including analysis of variance were used to analyze the outcome variables. P b .05 was considered statistically significant but was not adjusted for multiple comparisons and type I error. Data were analyzed using SAS system software (SAS Institute, Inc, Cary, NC). The primary outcome is the description of patient perceptions regarding their participation in the timeout process and their correlation with self-reported pain and satisfaction. The secondary outcome was the examination of demographic factors that are associated with enhanced responses in perception, pain, or satisfaction variables.
3. Results All of the 189 eligible patients who were recruited agreed to participate in the study. Of these, 7 were lost to follow-up, 4 refused interviews postoperatively, and 3 stated that they were unable to recall any events related to the timeout. As a result, 175 patients (93% of the initial sample) completed the study questionnaires. The baseline demographics as well as block timeout characteristics are shown in Tables 1 and 2. The cohort can be described as 51% male, 82% ASA 1 and 2 patients, 70% whites, 87% English speaking, 98% completed high school education, 92% presenting for ambulatory procedures, 73% had never received a regional anesthetic,
Y.H. Lai et al. 80% had no history of depression or anxiety, and 94% never used anxiolytic or antidepressant agents. Patients who are bilingual with Spanish or other languages (13%) but are able to understand instructions in English were included. Summary of survey responses is shown in Table 3. Ninety-nine percent of patients agreed that they felt confident in their anesthesiologists during timeout, felt relaxed when asked to speak up, and felt safe when encouraged to participate in timeout. Ninety-seven percent of patients agreed that they had a positive sense of involvement during timeout. In addition, greater than 93% agreed that they were satisfied with the anesthetic as well as their perioperative experience. Finally, 88% or more did not report recalling pain during their block. No narcotics were administered as part of premedication for any block and midazolam 1-4 mg was used as the primary source of sedation after the timeout. For the question asking patients whether they agreed that it is important to have their anesthesiologist present at the timeout, 99% of patients responding with + 2 and + 3 scores.
Table 1
Patient demographic summary
Mean age (y) Gender Male Female ASA I II III Ethnicity Caucasian African American Hispanic/Latino Asian Other Primary language English English and Spanish English and other languages Education completed Grade school High school Beyond high school Declined Disposition Ambulatory Day of surgery Previous regional anesthetic Yes No Others History of depression Antidepressant use at home History of anxiety Anxiolytic use at home Narcotics use at home
50 51% 49% 33% 49% 18% 70% 13% 13% 2% 2% 87% 8% 5% 2% 12% 85% 1% 92% 8% 26% 73% 13% 15% 7% 4% 2%
Patient perspectives on block timeout Table 2
217
Peripheral nerve blockade demographics
Regional block type Interscalene Supraclavicular Infraclavicular Femoral Popliteal Ankle Procedure Shoulder Other upper extremity Knee Other lower extremity Surgical procedure duration 1 hour or less 2 hours 3 hours 4 hours or more Position at timeout and block Supine Prone Lateral Timeout location Holding area Operating room Intraoperative technique General anesthesia Monitored anesthesia care Individual explaining block Attending CA-1 CA-2 CA-3/Fellow Individual performing block CA-1 CA-2 CA-3 Fellow Preprocedure anxiety scores 0-3 4-7 8-10 Preprocedure pain scores 0-3 4-7 8-10
31% 37% 3% 12% 14% 3% 31% 40% 11% 18% 12% 53% 32% 3% 85% 14% 1% 17% 83% 47% 53% 70% 7% 2% 13% 19% 15% 46% 20% 52% 34% 14% 70% 23% 7%
Ninety-five percent of patients answered that they would choose to have the same amount of premedication if they were to have another block in the future. Five percent of the sample stated that they would prefer more sedation and no individual preferred less or no premedication for their blocks. Correlation analyses demonstrate that summation of positive responses related to perception (confidence, relaxation, safety, and sense of positive involvement) correlated with less reported pain and higher total satisfaction. In addition, of all demographic factors presented in Tables 1
and 2, higher preprocedure pain score was the only variable to achieve marginal but nonstatistically significant correlation (P = .06) with decreased patient satisfaction. No correlation exists between any other demographic factors and responses pertaining to perception, pain, or satisfaction. Linear regression analyses with multiple variables exhibit similar trends. There are positive associations between perception responses with decreased reported pain and increased satisfaction. These relationships are maintained when pain and satisfaction are taken either as individual (anesthetic and surgical) or as composite variables. Other significant associations include composite pain variables with anesthetic satisfaction and overall satisfaction. Finally, no demographic variables demonstrated any association with any survey items. Significant correlation and regression analyses are presented in Tables 4 and 5. To test for reproducibility of the modified questionnaire, 30 randomly selected patients were asked to complete the same questionnaire with the same investigator 2 weeks after the initial responses. There was an 88% correlation in the individual responses. This compares favorably to the test-retest reliability reported by Dexter and Candiotti [14] when developing the ISAS questionnaire.
4. Discussion One of the central ideologies of the perioperative surgical home model proposed by the ASA is the advocacy of a value-based, patient-centered, and cost-effective anesthesia care delivery system [15]. In the 2007 Journal of American Medical Association (JAMA) and again in the 2010 New England Journal of Medicine articles, Porter [3] and Porter and Teisberg [16] proposed that the future of health care reform is determined by our capability in creating value for patient care. In the editorial titled “Patient satisfaction and value in anesthesia care,” Neuman [17] states that “increasing awareness that the value of health care services is most appropriately determined from the perspective of the individual patient has made patient-reported outcomes, including assessments of the experience of health care, a key basis of comparison for services delivered by physicians, health plans, and hospital systems.” Hence, close associations exist between patient expectations and perceptions of the care received the overall satisfaction with a specific intervention or protocol and the creation of value for patient experiences. The preoperative period is arguably the best opportunity to evaluate the value for anesthesia care by constructing a match between patient expectations and experience. The meticulous and comprehensive understanding of patient perceptions and sentiments toward their providers, environment, and interventions may form the basis for generating positive patient satisfaction and perioperative outcomes.
218
Y.H. Lai et al.
Table 3
Patient perspectives on preanesthetic timeout: percentage of scaled responses
Feeling confident Feeling relaxed Feeling safe Positive involvement Satisfaction with anesthetic Satisfaction perioperatively No pain with block No pain perioperatively Want anesthesiologist present
Disagree very much
Disagree moderately
Disagree slightly
Agree slightly
Agree moderately
Agree very much
1% 1% 1% 0% 0% 1% 3% 0% 1%
0% 1% 0% 1% 0% 3% 3% 1% 1%
0% 0% 1% 1% 0% 2% 6% 1% 0%
4% 4% 2% 1% 1% 2% 7% 1% 0%
5% 5% 7% 3% 6% 9% 4% 3% 2%
90% 90% 90% 93% 93% 83% 77% 93% 97%
The timeout process for regional anesthesia was selected for the study due to its unique characteristics. Unlike intraoperative timeouts that are performed after anesthesia induction, block timeouts solicit the active participation of lucid patients who have full anticipation and apprehension of a subsequent invasive procedure. Logically, it would appear that this shared confirmation with their providers creates additional safety. However, lengthy protocols mandating the practitioner to rely on the conscious patient for vital information may generate emotional and psychological burden during an otherwise intense and stressful time. This could have an impact on overall patient perception of safety and their satisfaction. Our cross-sectional survey describes the positive perspectives of a surgical population participating in a standardized block timeout. The majority of patients recruited in the study were Caucasian, well educated, and mostly healthy individuals presenting for ambulatory surgery. There was a heterogeneous distribution of upper and lower extremities procedures involving a variety of peripheral nerve blocks. A large number of block timeouts were performed in the presurgical holding area, where most blocks are placed in our institution. Certain patient characteristics that were expected to correlate with differences in outcome scores did not demonstrate such an effect. These variables include age, language, education, history of anxiety, patient position during the timeout, the type of individual explaining the block, and preprocedure anxiety scores. Possible explanations include a relatively homogenous sample possibly not large enough to detect such effects or other factors that were not queried but could have contributed to differences in survey responses such as employment and health insurance status.
Table 4
Linear regression analyses a
Perception variables Perioperative pain b Perioperative satisfaction c a b c
It is not surprising to note that less self-reported pain experienced during the preoperative and throughout the surgical period is closely and consistently linked to higher satisfaction. The premise of utilizing regional anesthesia to improve patient satisfaction by decreasing perioperative pain is well established [1,2]. However, positive patient beliefs and expectations during their participation in the timeout are also strongly correlated and associated with positive satisfaction. There is a robust relationship between patient's perceptions of adherence to medical protocols by their providers with their satisfaction concerning the quality of care delivered. That study found that “a 1% increase in the doctor's adherence to medically prescribed protocol causes a 0.40% increase in the probability that a patient will be very satisfied with the quality of care they received” [18]. Hence, involving the patient in a safety protocol by the perioperative physician may play a large role impacting their satisfaction and perception of the overall quality of care. One of the strengths to this study design involved efforts to minimize the confounding effects of demand characteristics. Demand characteristics are defined as “the totality of cues and mutual expectations which inhere in a social context…which serve to influence the behavior and/or self-reported experience of the research receiver” [19]. It refers to the concept that research subjects can alter their responses to influence outcomes when they are aware of study objectives. To circumvent this bias, research hypotheses and outcome measures were carefully concealed during the consent process while maintaining an appropriate level of informed consent. By not disclosing study objectives, we successfully eliminate
Perioperative pain
Perioperative satisfaction
Block pain
Surgical satisfaction
Anesthetic satisfaction
P b .0001 Duplicate P N .05
P b .0001
P b .0001
P = .0003
P = .0003 P = .0002
P = .004
P N .05
Composite score analyses for questions on confidence, safety, relaxation, and positive involvement on the survey (questions 1-4). Analyses on 2 questions on self-reported pain during block and throughout perioperative period (questions 6-7). Perioperative satisfaction refers to the composite analyses of patient satisfaction with anesthesia care and their surgical experience (questions 5 and 8).
Patient perspectives on block timeout Table 5
219
Spearman correlation analyses Perioperative pain
Perception variables Perioperative satisfaction Block pain Anesthesia satisfaction Perioperative pain Preprocedure pain a
Perioperative satisfaction
Block pain
Anesthesia satisfaction
Pain during or after surgery
0.50 (P b .0001) 0.58 (P b .0001) 0.5 (P b .0001) 0.45 (P b .0001) 0.25 (P = .0008) 0.31 (P b .0001) Duplicate or reported 0.34 (P b .0001) Duplicate or reported 0.49 (P b .001) Duplicate or reported 0.19 (P = .01) Duplicate or reported Duplicate or reported Duplicate or reported
Perioperative satisfaction 0.34 (P b .0001) 0.44 0.49 0.07 0.16
(P b .001) (P b .001) (P = .40) (P = .03)
a Refers to preprocedure pain scores reported in peripheral nerve blockade demographics (Table 2). This is the only variable found to have significant correlation to perioperative satisfaction.
any biases to our consent process at the same day of the surgery. Patients were only asked to complete a postoperative interview regarding their perioperative experience. Specific terms and details related to perspectives during timeouts were purposely not mentioned in the consent letter. In addition, the anesthesiology team responsible for recording key demographic information was instructed not to disclose any information about research objectives. This concealment is justified and ethical because the administration of a questionnaire posed minimal risk to the patient. Another advantage to this study is the adoption of an existing and validated survey instrument that is modified to conform to the clinical context and measured outcomes of this research. In a comprehensive review of contemporary methodologies on assessing patient satisfaction, Fung and Cohen [20] identified the ISAS as 1 of the 2 most rigorous psychometric instruments available [14]. The ISAS is a simple 11-item questionnaire that is applicable for patients undergoing short invasive procedures during sedation. It has been used to document patient satisfaction after cataract surgery in an ambulatory setting [14]. Consequently, the ISAS was chosen to serve as a model for our survey instrument with the preservation of many of its core elements. It was modified to tailor some of the items to the preanesthetic timeout in the context of regional blocks. Although there is no doubt that the original validity of the ISAS is compromised by its modification, it is still the most feasible and valuable method to achieve our study objectives. One of the major limitations to this study is the lack of a validated instrument specifically used in this perioperative setting. In a review of the current literature, there are no existing validated questionnaires that examine patient perceptions relating to peripheral nerve anesthetic procedures before surgery. For the same reason, it is difficult to use any standard psychometric test due to a lack of specificity. A comparison of our survey to the original ISAS questionnaire shows that only slight modifications were made. Both surveys have the same number of questions and used the same 6-item Likert scale. For example, 3 questions from the original ISAS such as “I was satisfied with my anesthetic care,” “I felt pain during surgery,” and “I would have the same anesthetic again” were presented in their original forms. In addition, ISAS questions such as “I felt good,”
“I felt relaxed,” “I felt safe,” “I hurt,” and “I felt pain” were elaborated in the current survey with modifiers attached such as “I felt safe during the timeout process because I was encouraged to speak up.” Iowa Satisfaction with Anesthesia Scale items such as “I threw up,” “I itched,” or “I felt too cold or hot” were deemed unnecessary and were omitted. These alterations were sensible to generate a more comprehensible postoperative questionnaire for our orthopedic patients without sacrificing much of the original intention of the ISAS. A logical next step to the current study would be to establish the validity of our proposed survey for regional anesthetics. Another drawback to the study design is the lack of a control group who were not exposed to the block timeout. Although this was the original intention, it was not feasible due to the institutional policy change requiring timeout to be documented before any regional anesthetic blocks. Although having a single group limits insights into how a block timeout can impact satisfaction when patients actively participate, our results are valuable in showing that patients are highly satisfied when asked about their participation and that none of the demographic factors reported play a significant role in influencing patient perspectives. A shortcoming to this study is that an independent observer was not assigned to monitor and document the performance of every individual block timeout process. Although a block timeout is an essential component of a standard and mandatory institutional protocol, we cannot guarantee that each individual timeout was uniformly executed and completed. While obligatory use of a block timeout script that is visibly attached to each ultrasound machine may increase adherence, variability between practitioners is possible. This issue was recognized in the study design, but no change was made because it offers 2 benefits. By not having an observer, we can minimize any interactions between the patient and study personnel during the timeout. This further reduces any demand characteristics bias mentioned above. In addition, we can avoid the impact of the Hawthorne effect that an observer may have on the anesthesiologist by his or her presence [13]. The knowledge of being observed might alter the anesthesiologist's behaviors toward the timeout and his or her subsequent interactions with the patient.
220 In summary, a patient-centered block timeout protocol has become a common and essential institutional protocol with the goal of building a culture of safety in regional anesthesia. A block timeout that invites participation may provide a valuable opportunity for patients to gain insights in our continuous endeavors to ensure a high quality of safety and care. Patient participation in a comprehensive block timeout reinforces subjective sentiments of confidence, relaxation, and safety and have little, if any, adverse effects of increasing patient anxiety. Because positive subjective expectations are confirmed by patient contribution during the timeout, the block timeout can be recognized as a perioperative moment to strengthen perceptions, enhance satisfaction, establish values, and solidify our dedication to advancing the quality of anesthesia care.
Appendix 1. Survey instrument
Y.H. Lai et al.
References [1] Schug SA. Patient satisfaction—politically correct fashion of the nineties or a valuable measure of outcome? Editorial. Reg Anesth Pain Med 2001;26:193-5. [2] 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;26:196-208. [3] Porter ME. What is value in health care? N Engl J Med 2010;363:2477-81. [4] Wu AW, Snyder C, Clancy CM, Steinwachs DM. Adding the patient perspective to comparative effectiveness research. Health Aff (Millwood) 2010;29:1863-71. [5] Chumbley GM, Hall GM, Salmon P. Why do patients feel positive about patient controlled analgesia? Anaesthesia 1999;54:386-9. [6] Papanikolau MN, Voulgari A, Lykouras L, Arvantis Y, Christodoulou GN, Danou-Roussaki A, et al. Psychological factors influencing the surgical patient's consent to regional anaesthesia. Acta Anaesthesiol Scand 1994;38:607-11. [7] De Andreas J, Valia JC, Gil A, Bolinches R. Predictors of patient satisfaction with regional anesthesia. Reg Anesth Pain Med 1995;20:498-505. [8] Egbert LD, Battit GE, Turndorf H, Beecher HK. The value of the preoperative visit by an anesthetist. A study of doctor patient rapport. JAMA 1963;185:553-5. [9] Van Vlymen JM, Sa Rego MM, White PF. Benzodiazepine premedication. Can it improve outcome in patients undergoing breast biopsy procedures? Anesthesiology 1999;90:740-7. [10] Lee SL. The extended surgical time-out: does it improve quality and prevent wrong-site surgery? Perm J 2010;14:19-23. [11] Edmonds CR, Liguori GA, Stanton MA. Two cases of a wrong-site peripheral nerve block and a process to prevent this complication. Reg Anesth Pain Med 2005;30:99-103. [12] Rupp SM. Unintentional wrong-sided peripheral block. Reg Anesth Pain Med 2008;33:95-7. [13] Joint Commission on Accreditation of Healthcare Organizations. Universal protocol for preventing wrong site, wrong procedure, wrong person surgery. Available at http://www.jointcommission. org/standards_information/up.aspx. [Accessed October 1, 2013]. [14] Dexter F, Candiotti KA. Multicenter assessment of the Iowa Satisfaction with Anesthesia Scale, an instrument that measures patient satisfaction with monitored anesthesia care. Anesth Analg 2011;113:364-8. [15] Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, et al. The perioperative surgical home as a future perioperative practice model. Anesth Analg 2014;118:1126-30. [16] Porter ME, Teisberg EO. How physicians can change the future of health care. JAMA 2007;297:1103-11. [17] Neuman MD. Patient satisfaction and value in anesthesia care. Editorial. Anesthesiology 2011;114:1019-20. [18] Leonard KL. Is patient satisfaction sensitive to changes in the quality of care? An exploitation of the Hawthorne effect. J Health Econ 2008;27:444-59. [19] Orne MT, Whitehouse WG. Demand characteristics. In: Kazdin AE, editor. Encyclopaedia of Psychology. Washington, D.C.: American Psychological Association and Oxford University Press; 2000. p. 469-70. [20] Fung D, Cohen MM. Measuring patient satisfaction with anesthesia care: a review of current methodology. Anesth Analg 1998;87:1089-98.
Original Contribution
Positive perceptions on safety and satisfaction during a patient-centered timeout before peripheral nerve blockade☆,☆☆,★ Yan H. Lai MD, MPH (Assistant Professor of Anesthesiology) a,⁎, Michael R. Anderson MD (Assistant Professor of Anesthesiology)a , Alan D. Weinberg MS (Associate Professor of Population Health Science and Policy)b , Meg A. Rosenblatt MD (Professor of Anesthesiology and Orthopedics) a a
Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
b
Received 8 February 2014; revised 29 September 2014; accepted 2 October 2014
Keywords: Peripheral nerve blockade; Regional anesthesia; Block time-out; Patient safety; Patient satisfaction; Wrong side block
Abstract Objectives: To determine the psychometric outcomes of patients participating in an extensive patient-centered verification process before receiving sedation for regional anesthesia. Design: Survey. Setting: Perioperative areas of university-affiliated hospital. Patients: Two hundred eligible patients scheduled for elective orthopedic surgery undergoing peripheral nerve blockade. Interventions: Postoperative survey evaluating patient perception, experience, and satisfaction with the anesthetic timeout before regional anesthesia. Measurements: Measures using numeric rating scales were obtained on patient perceptions of safety, confidence in anesthesia provider, anxiety, and positive sentiments during participation in block timeout. These variables were analyzed using logistic regression models to correlate with reported pain and satisfaction perioperatively. Main Results: One hundred seventy-five patients (93% enrollment) completed the study. More than 90% of patients reported agreeing strongly to feeling safe, confident, relaxed, and positive about their participation in the block timeout. These sentiments are associated with less reported perioperative pain and higher overall satisfaction. Conclusions: Patient perceptions of confidence and safety in regional anesthesia providers were enhanced by a preprocedural timeout process. These positive attitudes are associated with a superior perioperative experience and patient satisfaction. © 2014 Elsevier Inc. All rights reserved.
☆
Financial source: Department of Anesthesiology, Icahn School of Medicine at Mount Sinai. Presented at the 2013 American Society of Regional Anesthesia Meeting in Boston (poster presentation). ★ Conflict of interest: None. ⁎ Correspondence: Yan H. Lai, MD, MPH, Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place Box 1010, New York, NY 10029, USA. Tel.: +1 646 344 0968. E-mail address: [email protected] (Y.H. Lai). ☆☆
http://dx.doi.org/10.1016/j.jclinane.2014.10.009 0952-8180/© 2014 Elsevier Inc. All rights reserved.
Patient perspectives on block timeout
1. Introduction In the current health care system, patient satisfaction has emerged as a valuable “non-traditional” measurement of health outcomes and delivery [1-4]. The assessment of patient satisfaction has become a significant indicator of the quality of “patient-centered” medical care [3,4]. In fact, experts have defined patient satisfaction as “the match between patient expectations and the perception of service received” [1]. In practice, the identification of patient expectations and the delivery of interventions that manages appropriate patient perceptions are both complex and multidimensional [2-4]. For instance, health care providers have believed that allowing patients to control their own postoperative pain through systemic patient control analgesia devices would lead to better satisfaction. However, patient perception of analgesic control was not a major determinant for their satisfaction with patient control analgesia devices [5]. In fact, comprehensive protocols designed by health care professionals intended for patient safety using a patient-centered model may have opposite effects of increasing perioperative anxiety and contribute to negative experiences of a seemingly unnecessary, repetitive, and burdensome practice. Hence, programs that aim to improve patient satisfaction and safety should be evaluated for their convergence with patient perceptions to optimize their efficacy. This study presents an evaluation of the match between patient perception and satisfaction regarding the timeout process during preoperative peripheral nerve blockade. It has been well established that preoperative psychological factors such as anxiety, distress, and apprehension influence patient satisfaction [6,7]. The preanesthetic interview and premedication of conscious patients are effective ways of achieving a positive perioperative experience [8,9]. However, the increased recognition of regional anesthetics performed on the wrong site, wrong side, or wrong person signals an evolving trend toward rigorous and comprehensive preprocedural protocols and checklists with a focus on conscious patients [10]. The psychological effects that these practices have on patients remain unknown. While patient-centered timeouts were designed to improve safety, they require alert patients to provide cognitive inputs for several checkpoints within an already stressful environment. In turn, a growing number of presurgical patients are subjected to various forms of repetitive confirmations by multiple providers. From the patients' perspective, it is unclear whether their active involvement impacts their satisfaction regarding the perioperative experience. The first case series of 2 wrong site blocks was published in 2004 [11]. The exact incidence of wrong site blocks remains undocumented. Wrong site regional anesthetics represent preventable errors that could have catastrophic consequences for the patient, perioperative personnel, and the health care institution. Possible complications of wrong site blocks include unnecessary exposure to local anesthetic toxicity, vascular and nerve injury, psychological trauma, and progression to wrong
215 site surgery [12]. Since 2004, the Joint Commission (formerly The Joint Commission on HealthCare Organizations) has been advocating the involvement of lucid patients in the universal protocol [13].
2. Materials and methods The Icahn School of Medicine at Mount Sinai's institutional review board approved a waiver of signed consent. All patients presenting for orthopedic surgery with a planned peripheral nerve block had a study description letter provided to them during the admitting and registration process, approximately 2 hours before the block on the day of surgery. Patients were offered the opportunity to ask questions and refuse participation in the study, should they prefer. Patients were reminded that their participation is voluntary and that they can withdraw from the study at any point. If patients had concerns, the study coordinator was called to the admitting area to address them. Fifteen minutes before the block, the coordinator verified verbal consent on all patients and collected demographic data. The anesthesiology team evaluated the patient and explained the planned anesthetic. Exclusion criteria included patients undergoing emergency surgery, those receiving anxiolytic or narcotic medications in the previous 24 hours, or if they were non– English speaking. The number of eligible patients included was based on a 3-month recruitment period. Standard American Society of Anesthesiologists (ASA) monitors were applied, and a peripheral intravenous cannula was inserted. Patient identifiers (name, birth date, and medical record number) were confirmed by the entire operative team consisting of the circulating nurse, anesthesiologists, and surgeons in accordance with standard protocol. For every procedure, all team members checked that all components of universal protocol were fulfilled with the patient. Then, all patients participated in an independent preanesthetic nerve block verification process involving both the attending anesthesiologist performing or supervising the block and an independent health care provider who was not involved in the placement of the regional anesthetic. The independent provider was the circulating nurse or any credentialed personnel working in another operating room. Together, the surgeon's mark was inspected as being on the correct extremity by both confirming with the signed surgical consent and specifically asking the nonmedicated patient. Explicitly, the attending anesthesiologist recited the institutional required block timeout script that was attached to each ultrasound machine in front of the lucid patient, stating, “We are about to do (insert side and type of block) on patient (name, DOB, MRN). The signed consent states (procedure with side). I see the surgeon's mark and the mark that I have placed at the block site. Is everyone (including the patient by name) in agreement that this is correct?” Active participation from the patient was verbally elicited and confirmed after
216 each question. Only after this was completed would premedication be administered for the regional block. An 11-item survey (Appendix 1) was administered by telephone or during the hospital visit by a single blinded investigator 24-48 hours postoperatively. Nine of the questions utilized a symmetric 6-point Likert scale for recording responses (ranging from “disagree very much” to “agree very much”). The additional items included a question that asked for a narrative response and a separate question on the appropriate level of sedation during the block. The survey was modified from the Iowa Satisfaction with Anesthesia Scale (ISAS) designed by Dexter and Candiotti [14] intended to measure patient satisfaction for minor surgical procedures performed under monitored sedation. On the questionnaire, 4 primary questions were formulated to assess patient perceptions on confidence, relaxation, safety, and positive involvement during the preblock timeout. Two additional questions were devoted to asking about pain experienced during the block as well as the entire perioperative period. The final 2 questions inquired about patient satisfaction with their anesthetic and their perioperative satisfaction. The individual responses were assigned a numeric value on a scale from − 3 to + 3 without a zero value for the 6 possible responses. The sum of responses pertaining to questions on perceptions was grouped as a primary perception variable. This variable was analyzed to compare and establish relationships with questions regarding pain and satisfaction as well as independent demographic factors. Both Pearson and Spearman's correlations were computed, and multiple regression analyses including analysis of variance were used to analyze the outcome variables. P b .05 was considered statistically significant but was not adjusted for multiple comparisons and type I error. Data were analyzed using SAS system software (SAS Institute, Inc, Cary, NC). The primary outcome is the description of patient perceptions regarding their participation in the timeout process and their correlation with self-reported pain and satisfaction. The secondary outcome was the examination of demographic factors that are associated with enhanced responses in perception, pain, or satisfaction variables.
3. Results All of the 189 eligible patients who were recruited agreed to participate in the study. Of these, 7 were lost to follow-up, 4 refused interviews postoperatively, and 3 stated that they were unable to recall any events related to the timeout. As a result, 175 patients (93% of the initial sample) completed the study questionnaires. The baseline demographics as well as block timeout characteristics are shown in Tables 1 and 2. The cohort can be described as 51% male, 82% ASA 1 and 2 patients, 70% whites, 87% English speaking, 98% completed high school education, 92% presenting for ambulatory procedures, 73% had never received a regional anesthetic,
Y.H. Lai et al. 80% had no history of depression or anxiety, and 94% never used anxiolytic or antidepressant agents. Patients who are bilingual with Spanish or other languages (13%) but are able to understand instructions in English were included. Summary of survey responses is shown in Table 3. Ninety-nine percent of patients agreed that they felt confident in their anesthesiologists during timeout, felt relaxed when asked to speak up, and felt safe when encouraged to participate in timeout. Ninety-seven percent of patients agreed that they had a positive sense of involvement during timeout. In addition, greater than 93% agreed that they were satisfied with the anesthetic as well as their perioperative experience. Finally, 88% or more did not report recalling pain during their block. No narcotics were administered as part of premedication for any block and midazolam 1-4 mg was used as the primary source of sedation after the timeout. For the question asking patients whether they agreed that it is important to have their anesthesiologist present at the timeout, 99% of patients responding with + 2 and + 3 scores.
Table 1
Patient demographic summary
Mean age (y) Gender Male Female ASA I II III Ethnicity Caucasian African American Hispanic/Latino Asian Other Primary language English English and Spanish English and other languages Education completed Grade school High school Beyond high school Declined Disposition Ambulatory Day of surgery Previous regional anesthetic Yes No Others History of depression Antidepressant use at home History of anxiety Anxiolytic use at home Narcotics use at home
50 51% 49% 33% 49% 18% 70% 13% 13% 2% 2% 87% 8% 5% 2% 12% 85% 1% 92% 8% 26% 73% 13% 15% 7% 4% 2%
Patient perspectives on block timeout Table 2
217
Peripheral nerve blockade demographics
Regional block type Interscalene Supraclavicular Infraclavicular Femoral Popliteal Ankle Procedure Shoulder Other upper extremity Knee Other lower extremity Surgical procedure duration 1 hour or less 2 hours 3 hours 4 hours or more Position at timeout and block Supine Prone Lateral Timeout location Holding area Operating room Intraoperative technique General anesthesia Monitored anesthesia care Individual explaining block Attending CA-1 CA-2 CA-3/Fellow Individual performing block CA-1 CA-2 CA-3 Fellow Preprocedure anxiety scores 0-3 4-7 8-10 Preprocedure pain scores 0-3 4-7 8-10
31% 37% 3% 12% 14% 3% 31% 40% 11% 18% 12% 53% 32% 3% 85% 14% 1% 17% 83% 47% 53% 70% 7% 2% 13% 19% 15% 46% 20% 52% 34% 14% 70% 23% 7%
Ninety-five percent of patients answered that they would choose to have the same amount of premedication if they were to have another block in the future. Five percent of the sample stated that they would prefer more sedation and no individual preferred less or no premedication for their blocks. Correlation analyses demonstrate that summation of positive responses related to perception (confidence, relaxation, safety, and sense of positive involvement) correlated with less reported pain and higher total satisfaction. In addition, of all demographic factors presented in Tables 1
and 2, higher preprocedure pain score was the only variable to achieve marginal but nonstatistically significant correlation (P = .06) with decreased patient satisfaction. No correlation exists between any other demographic factors and responses pertaining to perception, pain, or satisfaction. Linear regression analyses with multiple variables exhibit similar trends. There are positive associations between perception responses with decreased reported pain and increased satisfaction. These relationships are maintained when pain and satisfaction are taken either as individual (anesthetic and surgical) or as composite variables. Other significant associations include composite pain variables with anesthetic satisfaction and overall satisfaction. Finally, no demographic variables demonstrated any association with any survey items. Significant correlation and regression analyses are presented in Tables 4 and 5. To test for reproducibility of the modified questionnaire, 30 randomly selected patients were asked to complete the same questionnaire with the same investigator 2 weeks after the initial responses. There was an 88% correlation in the individual responses. This compares favorably to the test-retest reliability reported by Dexter and Candiotti [14] when developing the ISAS questionnaire.
4. Discussion One of the central ideologies of the perioperative surgical home model proposed by the ASA is the advocacy of a value-based, patient-centered, and cost-effective anesthesia care delivery system [15]. In the 2007 Journal of American Medical Association (JAMA) and again in the 2010 New England Journal of Medicine articles, Porter [3] and Porter and Teisberg [16] proposed that the future of health care reform is determined by our capability in creating value for patient care. In the editorial titled “Patient satisfaction and value in anesthesia care,” Neuman [17] states that “increasing awareness that the value of health care services is most appropriately determined from the perspective of the individual patient has made patient-reported outcomes, including assessments of the experience of health care, a key basis of comparison for services delivered by physicians, health plans, and hospital systems.” Hence, close associations exist between patient expectations and perceptions of the care received the overall satisfaction with a specific intervention or protocol and the creation of value for patient experiences. The preoperative period is arguably the best opportunity to evaluate the value for anesthesia care by constructing a match between patient expectations and experience. The meticulous and comprehensive understanding of patient perceptions and sentiments toward their providers, environment, and interventions may form the basis for generating positive patient satisfaction and perioperative outcomes.
218
Y.H. Lai et al.
Table 3
Patient perspectives on preanesthetic timeout: percentage of scaled responses
Feeling confident Feeling relaxed Feeling safe Positive involvement Satisfaction with anesthetic Satisfaction perioperatively No pain with block No pain perioperatively Want anesthesiologist present
Disagree very much
Disagree moderately
Disagree slightly
Agree slightly
Agree moderately
Agree very much
1% 1% 1% 0% 0% 1% 3% 0% 1%
0% 1% 0% 1% 0% 3% 3% 1% 1%
0% 0% 1% 1% 0% 2% 6% 1% 0%
4% 4% 2% 1% 1% 2% 7% 1% 0%
5% 5% 7% 3% 6% 9% 4% 3% 2%
90% 90% 90% 93% 93% 83% 77% 93% 97%
The timeout process for regional anesthesia was selected for the study due to its unique characteristics. Unlike intraoperative timeouts that are performed after anesthesia induction, block timeouts solicit the active participation of lucid patients who have full anticipation and apprehension of a subsequent invasive procedure. Logically, it would appear that this shared confirmation with their providers creates additional safety. However, lengthy protocols mandating the practitioner to rely on the conscious patient for vital information may generate emotional and psychological burden during an otherwise intense and stressful time. This could have an impact on overall patient perception of safety and their satisfaction. Our cross-sectional survey describes the positive perspectives of a surgical population participating in a standardized block timeout. The majority of patients recruited in the study were Caucasian, well educated, and mostly healthy individuals presenting for ambulatory surgery. There was a heterogeneous distribution of upper and lower extremities procedures involving a variety of peripheral nerve blocks. A large number of block timeouts were performed in the presurgical holding area, where most blocks are placed in our institution. Certain patient characteristics that were expected to correlate with differences in outcome scores did not demonstrate such an effect. These variables include age, language, education, history of anxiety, patient position during the timeout, the type of individual explaining the block, and preprocedure anxiety scores. Possible explanations include a relatively homogenous sample possibly not large enough to detect such effects or other factors that were not queried but could have contributed to differences in survey responses such as employment and health insurance status.
Table 4
Linear regression analyses a
Perception variables Perioperative pain b Perioperative satisfaction c a b c
It is not surprising to note that less self-reported pain experienced during the preoperative and throughout the surgical period is closely and consistently linked to higher satisfaction. The premise of utilizing regional anesthesia to improve patient satisfaction by decreasing perioperative pain is well established [1,2]. However, positive patient beliefs and expectations during their participation in the timeout are also strongly correlated and associated with positive satisfaction. There is a robust relationship between patient's perceptions of adherence to medical protocols by their providers with their satisfaction concerning the quality of care delivered. That study found that “a 1% increase in the doctor's adherence to medically prescribed protocol causes a 0.40% increase in the probability that a patient will be very satisfied with the quality of care they received” [18]. Hence, involving the patient in a safety protocol by the perioperative physician may play a large role impacting their satisfaction and perception of the overall quality of care. One of the strengths to this study design involved efforts to minimize the confounding effects of demand characteristics. Demand characteristics are defined as “the totality of cues and mutual expectations which inhere in a social context…which serve to influence the behavior and/or self-reported experience of the research receiver” [19]. It refers to the concept that research subjects can alter their responses to influence outcomes when they are aware of study objectives. To circumvent this bias, research hypotheses and outcome measures were carefully concealed during the consent process while maintaining an appropriate level of informed consent. By not disclosing study objectives, we successfully eliminate
Perioperative pain
Perioperative satisfaction
Block pain
Surgical satisfaction
Anesthetic satisfaction
P b .0001 Duplicate P N .05
P b .0001
P b .0001
P = .0003
P = .0003 P = .0002
P = .004
P N .05
Composite score analyses for questions on confidence, safety, relaxation, and positive involvement on the survey (questions 1-4). Analyses on 2 questions on self-reported pain during block and throughout perioperative period (questions 6-7). Perioperative satisfaction refers to the composite analyses of patient satisfaction with anesthesia care and their surgical experience (questions 5 and 8).
Patient perspectives on block timeout Table 5
219
Spearman correlation analyses Perioperative pain
Perception variables Perioperative satisfaction Block pain Anesthesia satisfaction Perioperative pain Preprocedure pain a
Perioperative satisfaction
Block pain
Anesthesia satisfaction
Pain during or after surgery
0.50 (P b .0001) 0.58 (P b .0001) 0.5 (P b .0001) 0.45 (P b .0001) 0.25 (P = .0008) 0.31 (P b .0001) Duplicate or reported 0.34 (P b .0001) Duplicate or reported 0.49 (P b .001) Duplicate or reported 0.19 (P = .01) Duplicate or reported Duplicate or reported Duplicate or reported
Perioperative satisfaction 0.34 (P b .0001) 0.44 0.49 0.07 0.16
(P b .001) (P b .001) (P = .40) (P = .03)
a Refers to preprocedure pain scores reported in peripheral nerve blockade demographics (Table 2). This is the only variable found to have significant correlation to perioperative satisfaction.
any biases to our consent process at the same day of the surgery. Patients were only asked to complete a postoperative interview regarding their perioperative experience. Specific terms and details related to perspectives during timeouts were purposely not mentioned in the consent letter. In addition, the anesthesiology team responsible for recording key demographic information was instructed not to disclose any information about research objectives. This concealment is justified and ethical because the administration of a questionnaire posed minimal risk to the patient. Another advantage to this study is the adoption of an existing and validated survey instrument that is modified to conform to the clinical context and measured outcomes of this research. In a comprehensive review of contemporary methodologies on assessing patient satisfaction, Fung and Cohen [20] identified the ISAS as 1 of the 2 most rigorous psychometric instruments available [14]. The ISAS is a simple 11-item questionnaire that is applicable for patients undergoing short invasive procedures during sedation. It has been used to document patient satisfaction after cataract surgery in an ambulatory setting [14]. Consequently, the ISAS was chosen to serve as a model for our survey instrument with the preservation of many of its core elements. It was modified to tailor some of the items to the preanesthetic timeout in the context of regional blocks. Although there is no doubt that the original validity of the ISAS is compromised by its modification, it is still the most feasible and valuable method to achieve our study objectives. One of the major limitations to this study is the lack of a validated instrument specifically used in this perioperative setting. In a review of the current literature, there are no existing validated questionnaires that examine patient perceptions relating to peripheral nerve anesthetic procedures before surgery. For the same reason, it is difficult to use any standard psychometric test due to a lack of specificity. A comparison of our survey to the original ISAS questionnaire shows that only slight modifications were made. Both surveys have the same number of questions and used the same 6-item Likert scale. For example, 3 questions from the original ISAS such as “I was satisfied with my anesthetic care,” “I felt pain during surgery,” and “I would have the same anesthetic again” were presented in their original forms. In addition, ISAS questions such as “I felt good,”
“I felt relaxed,” “I felt safe,” “I hurt,” and “I felt pain” were elaborated in the current survey with modifiers attached such as “I felt safe during the timeout process because I was encouraged to speak up.” Iowa Satisfaction with Anesthesia Scale items such as “I threw up,” “I itched,” or “I felt too cold or hot” were deemed unnecessary and were omitted. These alterations were sensible to generate a more comprehensible postoperative questionnaire for our orthopedic patients without sacrificing much of the original intention of the ISAS. A logical next step to the current study would be to establish the validity of our proposed survey for regional anesthetics. Another drawback to the study design is the lack of a control group who were not exposed to the block timeout. Although this was the original intention, it was not feasible due to the institutional policy change requiring timeout to be documented before any regional anesthetic blocks. Although having a single group limits insights into how a block timeout can impact satisfaction when patients actively participate, our results are valuable in showing that patients are highly satisfied when asked about their participation and that none of the demographic factors reported play a significant role in influencing patient perspectives. A shortcoming to this study is that an independent observer was not assigned to monitor and document the performance of every individual block timeout process. Although a block timeout is an essential component of a standard and mandatory institutional protocol, we cannot guarantee that each individual timeout was uniformly executed and completed. While obligatory use of a block timeout script that is visibly attached to each ultrasound machine may increase adherence, variability between practitioners is possible. This issue was recognized in the study design, but no change was made because it offers 2 benefits. By not having an observer, we can minimize any interactions between the patient and study personnel during the timeout. This further reduces any demand characteristics bias mentioned above. In addition, we can avoid the impact of the Hawthorne effect that an observer may have on the anesthesiologist by his or her presence [13]. The knowledge of being observed might alter the anesthesiologist's behaviors toward the timeout and his or her subsequent interactions with the patient.
220 In summary, a patient-centered block timeout protocol has become a common and essential institutional protocol with the goal of building a culture of safety in regional anesthesia. A block timeout that invites participation may provide a valuable opportunity for patients to gain insights in our continuous endeavors to ensure a high quality of safety and care. Patient participation in a comprehensive block timeout reinforces subjective sentiments of confidence, relaxation, and safety and have little, if any, adverse effects of increasing patient anxiety. Because positive subjective expectations are confirmed by patient contribution during the timeout, the block timeout can be recognized as a perioperative moment to strengthen perceptions, enhance satisfaction, establish values, and solidify our dedication to advancing the quality of anesthesia care.
Appendix 1. Survey instrument
Y.H. Lai et al.
References [1] Schug SA. Patient satisfaction—politically correct fashion of the nineties or a valuable measure of outcome? Editorial. Reg Anesth Pain Med 2001;26:193-5. [2] 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;26:196-208. [3] Porter ME. What is value in health care? N Engl J Med 2010;363:2477-81. [4] Wu AW, Snyder C, Clancy CM, Steinwachs DM. Adding the patient perspective to comparative effectiveness research. Health Aff (Millwood) 2010;29:1863-71. [5] Chumbley GM, Hall GM, Salmon P. Why do patients feel positive about patient controlled analgesia? Anaesthesia 1999;54:386-9. [6] Papanikolau MN, Voulgari A, Lykouras L, Arvantis Y, Christodoulou GN, Danou-Roussaki A, et al. Psychological factors influencing the surgical patient's consent to regional anaesthesia. Acta Anaesthesiol Scand 1994;38:607-11. [7] De Andreas J, Valia JC, Gil A, Bolinches R. Predictors of patient satisfaction with regional anesthesia. Reg Anesth Pain Med 1995;20:498-505. [8] Egbert LD, Battit GE, Turndorf H, Beecher HK. The value of the preoperative visit by an anesthetist. A study of doctor patient rapport. JAMA 1963;185:553-5. [9] Van Vlymen JM, Sa Rego MM, White PF. Benzodiazepine premedication. Can it improve outcome in patients undergoing breast biopsy procedures? Anesthesiology 1999;90:740-7. [10] Lee SL. The extended surgical time-out: does it improve quality and prevent wrong-site surgery? Perm J 2010;14:19-23. [11] Edmonds CR, Liguori GA, Stanton MA. Two cases of a wrong-site peripheral nerve block and a process to prevent this complication. Reg Anesth Pain Med 2005;30:99-103. [12] Rupp SM. Unintentional wrong-sided peripheral block. Reg Anesth Pain Med 2008;33:95-7. [13] Joint Commission on Accreditation of Healthcare Organizations. Universal protocol for preventing wrong site, wrong procedure, wrong person surgery. Available at http://www.jointcommission. org/standards_information/up.aspx. [Accessed October 1, 2013]. [14] Dexter F, Candiotti KA. Multicenter assessment of the Iowa Satisfaction with Anesthesia Scale, an instrument that measures patient satisfaction with monitored anesthesia care. Anesth Analg 2011;113:364-8. [15] Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, et al. The perioperative surgical home as a future perioperative practice model. Anesth Analg 2014;118:1126-30. [16] Porter ME, Teisberg EO. How physicians can change the future of health care. JAMA 2007;297:1103-11. [17] Neuman MD. Patient satisfaction and value in anesthesia care. Editorial. Anesthesiology 2011;114:1019-20. [18] Leonard KL. Is patient satisfaction sensitive to changes in the quality of care? An exploitation of the Hawthorne effect. J Health Econ 2008;27:444-59. [19] Orne MT, Whitehouse WG. Demand characteristics. In: Kazdin AE, editor. Encyclopaedia of Psychology. Washington, D.C.: American Psychological Association and Oxford University Press; 2000. p. 469-70. [20] Fung D, Cohen MM. Measuring patient satisfaction with anesthesia care: a review of current methodology. Anesth Analg 1998;87:1089-98.
