Perioperative patient outcome in anaesthesia

Schiff, Jan-Henrik (2013) Perioperative patient outcome in anaesthesia. PhD thesis, James Cook University.

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Patient satisfaction with anaesthesia is an important but complex measure. However, there are only a few appropriate psychometrically designed instruments that contain items on all important factors. Psychometric instruments providing information about satisfaction in children are completely missing. Thus, a need for sound psychometrical instruments to assess satisfaction with anaesthesia care in the German adult and paediatric patient population exists.

Anaesthesia is a high risk medical profession and it is important to evaluate severe incident, events and complications (IEC) including deaths that occur. Details about the anaesthetic risks are an important part of the anaesthetic consult. There is no standardised worldwide registry system and a lack of thorough reported data on critical IEC or deaths, hence, debate over the incidence of anaesthesia-related mortality in the different countries continues and rates for anaesthesia-related severe IEC in Germany need to be evaluated.

The aims of my studies were to develop measures for perianaesthetic satisfaction in adult and paediatric patients, as well as to determine the rate of severe IEC attributable to anaesthesia in Germany.

Specific aims of the studies presented in this thesis:


• To develop perianaesthetic questionnaires for adult and paediatric patients that adhere to a strict psychometric design

• To compare satisfaction with anaesthesia between participating hospitals, in paediatric patients with/without disabilities and existing questionnaires

• To analyse the anaesthesia pre-operative evaluation clinic (APEC) and the ward with regard to time (costs), information gain and patient satisfaction

IEC (incidents, events and complications)

• To evaluate the general quality of the collected (core) data (set) (CDS), the frequency of coding errors in American Society of Anaesthesiologists Physical Status (ASA PS) 1 and 2 Patients and to identify filtering methods that could be used in future studies

• To elucidate the underlying mechanisms of the severe IEC

• To assess the frequency of severe IEC in healthy patients in the whole dataset and the anaesthetic contributions


The thesis comprises the results of eight dedicated studies. One regional, one national, and one paediatric questionnaire were developed based on a sound psychometric design to assess patient satisfaction with anaesthesia. This included patients' involvement, cognitive and pilot testing, validation for validity and reliability, and the adjustment for confounding variables. The basis of this thesis is the multicentre development of the Heidelberg Perianaesthetic Questionnaire (HPQ). Five of the studies presented are directly linked to or are using the findings and experiences made in this study.

The questionnaires were used to test the performance of an APEC, to benchmark hospitals, as well as to test satisfaction between different patient groups. IEC were assessed in the CDS, which is in use as a national surveillance system. A first study identified rather healthy patients displaying severe IEC. The frequency of coding errors in the dataset between 2002 and 2004 was determined by matching the cases to more detailed reports received by mail from the participating anaesthetic departments, and the nature of IEC were analysed. Filtering methods to analyse a large set of data with more than 4 million anaesthetic records were employed. In this second study, the incidence of severe IECs in healthy patients was determined. Cases where the underlying (IEC) codes suggested direct anaesthetic involvement were identified and analysed through normative discussion groups.

Overall results and conclusions of the studies presented in this thesis

My psychometric questionnaires were used to evaluate satisfied and dissatisfied groups and to benchmark satisfaction with anaesthesia care at different hospitals. The main areas where satisfaction may be improved include patient information, preparation for anaesthesia, as well as discomfort and its treatment. Satisfaction with anaesthesia was lower in the groups of children with disabilities as compared to non-disabled. Negative comments related to the anaesthetists' behaviour, the anaesthetic consultation, and anxiety.

Another study that co-and cross-validated a translated French questionnaire found that instruments should best be constructed and validated within the same socio-cultural background. Assessment of the anaesthetic consult found favourable results in terms of time spent for the consult with the patient and amount of information passed on to the patients for the APEC compared to the ward.

The studies using the CDS provide detailed data on the topic of severe IEC including death. Coding errors were encountered with a frequency of nearly 50%. Most reported events (IEC) were related to patient, surgical or procedural risks, 15% were noticeable or conspicuous events. The rate of major morbidity/mortality was about 3 per 100,000, the anaesthetic contribution was about 1 per 100,000 case sin healthy patients.

Overall relevance of the studies presented in this thesis

My studies presented here constitute a sound psychometric approach to the development of instruments for the measurement of patients' satisfaction with anaesthesia and the first worldwide for paediatric patients. The questionnaires presented are valid and reliable tools and thus hold the key to essential feedback data from patients for the identification of specific areas where improvement in patient care can be achieved. The relevance of the developed tools presented in this thesis is highlighted by the fact that all questionnaires have already found entry to routine clinical use at various hospitals worldwide.

My studies also provided sound evidence that an APEC substantially improves the cost efficiency and the delivery of comprehensive information to the patients during the anaesthetic consult. In the light of cost containment discussions with time restraints in patient care, this is an important finding.

The studies using the CDS provide the first reliable data on the frequency of severe anaesthesia-related IEC and death for Germany, holding the key for national monitoring and international comparison of rates. While they indicate low rates of anaesthesia-related IEC, measures to improve the quality of the CDS data need to be adopted, facts that have been presented at various national and international conferences.

Item ID: 42191
Item Type: Thesis (PhD)
Keywords: anaesthesia; anaesthesiology; anesthesia; anesthesiology; complications; Germany; Heidelberg Perianaesthetic Questionnaire; HPQ; IEC; incidents, events and complications; paediatric anaesthesia; patient satisfaction; pediatric anesthesia; perianaesthesia nursing; perianesthesia nursing; psychometric testing; psychometric tests; questionnaires
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This is a thesis by publication. Published articles included in chapters 2, 3, 5, 6 and 7 and appendix viii have been redacted from the thesis due to copyright restrictions. The full thesis may either be requested via document delivery at your local library or viewed in the Eddie Koiki Mabo Library at JCU, Townsville.

Publications arising from this thesis are available from the Related URLs field. The publications are:

Chapter 2: Schiff, J.H., Fornaschon, A.S., Frankenhauser, S., Schiff, M., Snyder-Ramos, S.A., Martin, E., Knapp, S., Bauer, M., Böttiger, B.W., and Motsch, J. (2008) The Heidelberg Peri-anaesthetic Questionnaire - development of a new refined psychometric questionnaire. Anaesthesia, 63 (10). pp. 1096-1104.

Chapter 3: Schiff, J.-H., Hüppe, M., Möllemann, A., Pützhofen, G., Martin, J., Schleppers, A., Bothner, U., Krausch, N., and Eberhart, L.H.J. (2008) Evaluierter Fragebogen Anästhesie: entwicklung eines fragebogens zur erfassung der spezifisch vom patienten empfundenen anästhesiequalität. Anäesthesiologie und Intensivmedizin, 49. S25-S32.

Chapter 5: Schiff, J.H., Frankenhauser, S., Pritsch, M., Fornaschon, S.A., Snyder-Ramos, S.A., Heal, C., Schmidt, K., Martin, E., Böttiger, B.W., and Motsch, J. (2010) The Anesthesia Preoperative Evaluation Clinic (APEC): a prospective randomized controlled trial assessing impact on consultation time, direct costs, patient education and satisfaction with anesthesia care. Minerva Anestesiologica, 76 (7). pp. 491-499.

Chapter 6: Schiff, J-H., Russ, N., Ihringer, K., Heal, C., Martin, E., and Walther, A. (2011) Paediatric Perianesthesia Questionnaire: development and data from eight hospitals across Germany. British Journal of Anaesthesia, 106 (1). pp. 88-95.

Chapter 7: Schiff, Jan-H., Russ, Nicolai, Ihringer, Katja, Heal, Clare, Martin, Eike, and Walther, Andreas (2012) Pediatric patients with disabilities - assessment of satisfaction with anesthesia. Pediatric Anesthesia, 22 (11). pp. 1117-1123.

Chapter 8: Schiff, Jan-Henrik, Welker, A., Fohr, B., Henn-Beilharz, A., Bothner, U., Van Aken, H., Schleppers, A., Baldering, H.J., and Heinrichs, W. (2014) Major incidents and complications in otherwise healthy patients undergoing elective procedures: results based on 1.37 million anaesthetic procedures. British Journal of Anaesthesia, 113 (1). pp. 109-121.

Appendix VIII: Ihringer, K., Russ, N., Walther, A., and Schiff, J.-H. (2013) Anästhesiologische Besonderheiten der Trisomie 21 (Down-Syndrom). Anaesthesist, 62 (5). pp. 407-419.

Date Deposited: 20 Jan 2016 00:24
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1103 Clinical Sciences > 110301 Anaesthesiology @ 100%
SEO Codes: 92 HEALTH > 9202 Health and Support Services > 920204 Evaluation of Health Outcomes @ 50%
92 HEALTH > 9202 Health and Support Services > 920207 Health Policy Evaluation @ 50%
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