Concepts for the Development of Anesthesia-Related Patient Decision Aids

Anesthesiologists and Community Engagement: A Scoping Review of the Literature

Millions of individuals require anesthesia services each year. Although anesthesia-associated mortality rates have declined, anesthetic-related morbidity remains high, particularly among vulnerable populations. Disparities in perioperative screening, optimization, surveillance, and follow-up contribute to worse outcomes in these populations. Community-engaged collaborations may be the essential ingredient needed for anesthesiologists to improve disparities in anesthetic outcomes and prioritize the needs of patients and communities. This scoping review seeks to examine the available literature on community engagement among anesthesiologists to identify gaps and seek opportunities for future work. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). OVID MEDLINE, Scopus, and Web of Science Core Collection were searched to identify sources that used or recognized community-engaged strategies and involved the work of anesthesiologists. Sources were selected based on inclusion criteria and consistent data were extracted from each paper for compilation in a data chart. The initial search generated 1230 articles of which 16 met criteria for inclusion in the review. An updated search of the literature and reference scan of included sources resulted in 7 additional articles being included. The sources were grouped according to overarching themes and methods used and ultimately categorized according to the spectrum of public participation developed by the International Association for Public Participation (IAP2). This spectrum includes 5 levels: inform, consult, involve, collaborate, and empower. This review identified 5 sources at the inform level, 8 studies in consult, 0 in involve, 7 in collaborate, and 3 in empower. Results indicate that most initiatives representing deeper levels of community engagement, at the collaborate or empower level, occur internationally. Efforts that occur in the United States tend to emphasize engagement of individual patients rather than communities. There is a need to pursue deeper, more meaningful community-engaged efforts within the field of anesthesiology at a local and national level.

Autonomous patient consent for anaesthesia without preoperative consultation: a qualitative feasibility study including low-risk procedures

Background

Informed consent for anaesthesia is mandatory and requires provision of information and subsequent consent during consultation between anaesthesiologist and patient. Although information can be provided in an electronic format, it is unknown whether this a valid substitute for a consultation. We explored whether provision of digital information is equivalent to oral consultation and whether it enables patients to give electronic informed consent (e-consent) for anaesthesia.

Methods

Qualitative feasibility study using semi-structured interviews in 20 low-risk adults scheduled for minor surgery under general anaesthesia or procedural sedation at a university hospital. Data were analysed using a thematic content analysis approach. During the interviews, patients followed an application that provides information and subsequent e-consenting.

Results

The mean age was 50 yr and patients had good digital skills. Fifteen patients (75%) had previous experience of anaesthesia. The digital application provided enough information for all patients, but eight (40%) preferred consultation with an anaesthesiologist, mainly for personal contact. Patients had different information needs, with previous experiences leading to lower information needs. Nineteen patients had sufficient information to consent autonomously. Most patients considered separate anaesthesia consent superfluous to the surgical consent.

Conclusion

The digital application provided sufficient information and patients valued the information offered and the advantage of processing information at their own pace. This information made patients feel empowered to autonomously consent to anaesthesia without consultation. Remarkably, consent for anaesthesia was considered unimportant, because patients felt they had 'no choice' if they wanted to undergo surgery.

Enhanced recovery after surgery: Current status and future progress

Enhanced Recovery After Surgery (ERAS) pathways were first introduced almost a quarter of a century ago and represent a paradigm shift in perioperative care that reduced postoperative complications and hospital length of stay, improved postoperative quality of life, and reduced overall healthcare costs. Gradual recognition of the generalizability of the interventions and transferable improvements in postoperative outcomes, led them to become standard of care for several surgical procedures. In this article, we critically review the current status of ERAS pathways, address related controversies, and propose measures for future progress.

Putting patients first: ambulatory surgery facilitates patient-centered care

PURPOSE OF REVIEW

Ambulatory surgery is associated with improved patient experience while reducing overall costs without compromising patient safety. Patient-centered care is crucial for further expansion and success of ambulatory surgery because it is associated with superior patient experience and improved patient satisfaction. This article discusses the approach to improving patient-centered care and patient-reported outcomes (PROs).

RECENT FINDINGS

It is necessary to recognize that each patient is different and may have different needs and preferences. Patient education and shared decision-making are critical components of patient-centered care. Shared decision-making emphasizes patient engagement in an effort to improve PROs. Implementation of enhanced recovery after surgery principles in ambulatory surgery is necessary to improve PROs.

SUMMARY

Delivery of patient-centered care will require modification of the current approach to perioperative care. It is imperative to measure PROs by implementing a comprehensive continuous quality improvement program.

Awareness and its associated factors towards anesthesia and anesthetists' among elective surgical patients in Debre Tabor Comprehensive Specialized Hospital, North Central Ethiopia 2021: Cross-sectional study

Background

Patient awareness level of anesthesia and anesthetist is not well known in the study area which makes patients blind about the risk and benefits of anesthesia and the role of anesthetists'. This study aimed to assess elective surgical patients' awareness and its associated factors of anesthesia and anesthetists’ in Debre tabor comprehensive specialized Hospital, north-central Ethiopia, 2021.

Method

Institutional based cross-sectional study was conducted on 367 patients who underwent for elective general surgery in Debre Tabor Comprehensive Specialized Hospital from December 15, 2020, up to May 15, 2021. Data were collected with a structured questionnaire of 13 items after translating the English version to the local language (Amharic). Descriptive statistics were expressed in percentage and presented with tables. Bivariable and multivariable logistic analysis were done to identify factors associated with the awareness level of patients on anesthesia and anesthetists. Statistical significance level was set at P < 0.05 with 95 % CI.

Results

In this study, 25.1 % [95 % CI= (20.7–29.6)] of patients were adequately aware of anesthesia and anesthetist. Multivariable logistic analyses showed that male patients [AOR = 1.90; 95 % CI= (1.03–3.52)], level of education of secondary school [AOR = 3.20; 95 % CI= (1.07–9.61)] and collage and above [AOR = 4.75; 95 % CI= (1.73–13.06)], patients from Urban [AOR = 6.34; 95 % CI= (3.01–13.39)], and patients with previous anesthesia exposure [AOR = 3.43; 95 % CI= (1.76–6.69)] were more aware of anesthesia and anesthetist than their counterparts.

Conclusion

The awareness level of patients about anesthesia and anesthetists in this study was poor. Sex, residency, educational level, and previous anesthesia exposure were factors associated with patients’ awareness level of anesthesia and anesthetists.

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Awareness of patients about anesthesia improves clinical service.

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Awareness of patients about anesthesia was poor in DCSH.

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Sex, residency, and previous anesthesia exposure are associated with awareness.

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Awareness creation strategies are required to improve awareness levels.

Patient Involvement in Anesthesia Decision-making: A Qualitative Study of Knee Arthroplasty

BACKGROUND

Calls to better involve patients in decisions about anesthesia-e.g., through shared decision-making-are intensifying. However, several features of anesthesia consultation make it unclear how patients should participate in decisions. Evaluating the feasibility and desirability of carrying out shared decision-making in anesthesia requires better understanding of preoperative conversations. The objective of this qualitative study was to characterize how preoperative consultations for primary knee arthroplasty arrived at decisions about primary anesthesia.

METHODS

This focused ethnography was performed at a U.S. academic medical center. The authors audio-recorded consultations of 36 primary knee arthroplasty patients with eight anesthesiologists. Patients and anesthesiologists also participated in semi-structured interviews. Consultation and interview transcripts were coded in an iterative process to develop an explanation of how anesthesiologists and patients made decisions about primary anesthesia.

RESULTS

The authors found variation across accounts of anesthesiologists and patients as to whether the consultation was a collaborative decision-making scenario or simply meant to inform patients. Consultations displayed a number of decision-making patterns, from the anesthesiologist not disclosing options to the anesthesiologist strictly adhering to a position of equipoise; however, most consultations fell between these poles, with the anesthesiologist presenting options, recommending one, and persuading hesitant patients to accept it. Anesthesiologists made patients feel more comfortable with their proposed approach through extensive comparisons to more familiar experiences.

CONCLUSIONS

Anesthesia consultations are multifaceted encounters that serve several functions. In some cases, the involvement of patients in determining the anesthetic approach might not be the most important of these functions. Broad consideration should be given to both the applicability and feasibility of shared decision-making in anesthesia consultation. The potential benefits of interventions designed to enhance patient involvement in decision-making should be weighed against their potential to pull anesthesiologists' attention away from important humanistic aspects of communication such as decreasing patients' anxiety.

EDITOR’S PERSPECTIVE

Enhanced recovery pathways for ambulatory surgery

PURPOSE OF REVIEW

Implementation of enhanced recovery pathways have allowed migration of complex surgical procedures from inpatient setting to the outpatient setting. These programs improve patient safety and patient-reported outcomes. The present article discusses the principles of enhanced recovery pathways in adults undergoing ambulatory surgery with an aim of improving patient safety and postoperative outcomes.

RECENT FINDINGS

Procedure and patient selection is one of the key elements that influences perioperative outcomes after ambulatory surgery. Other elements include optimization of comorbid conditions, patient and family education, minimal preoperative fasting and adequate hydration during the fasting period, use of fast-track anesthesia technique, lung-protective mechanical ventilation, maintenance of fluid balance, and multimodal pain, nausea, and vomiting prophylaxis.

SUMMARY

Implementation of enhanced recovery pathways requires a multidisciplinary approach in which the anesthesiologist should take a lead in collaborating with surgeons and perioperative nurses. Measuring compliance with enhanced recovery pathways through an audit program is essential to evaluate success and need for protocol modification. The metrics to assess the impact of enhanced recovery pathways include complication rates, patient reported outcomes, duration of postoperative stay in the surgical facility, unplanned hospital admission rate, and 7-day and 30-day readmission rates.

Recommendations for Preoperative Assessment and Shared Decision-Making in Cardiac Surgery

Purpose of review

Recommendations about shared decision-making and guidelines on preoperative evaluation of patients undergoing non-cardiac surgery are abundant, but respective recommendations for cardiac surgery are sparse. We provide an overview of available evidence.

Recent findings

While there currently is no consensus statement on the preoperative anesthetic evaluation and shared decision-making for the adult patient undergoing cardiac surgery, evidence pertaining to specific organ systems is available.

Summary

We provide a comprehensive review of available evidence pertaining to preoperative assessment and shared decision-making for patients undergoing cardiac surgery and recommend a thorough preoperative workup in this vulnerable population.