Information gain in patients using a multimedia website with tailored information on anaesthesia.

BACKGROUND: The preoperative visit is an appropriate time to educate the patient on anaesthesia. The aim of this study was to determine if a website, as an information source for anaesthesia before the visit to the preoperative assessment clinic (PAC), increases patients' knowledge on anaesthesia. METHODS: A multimedia website was developed containing specific information about anaesthesia relevant to the patient. A questionnaire was developed to measure knowledge gain. Patients were divided into three groups: (i) those who read the existing brochure; (ii) those who looked at the new website; and (iii) a cluster of non-brochure and non-website users: those who did not read the brochure or website but had completed the questionnaire. An anaesthesiologist also informed all three groups during the preoperative visit at the PAC. RESULTS: Patients visiting the website had a higher educational level than others. A significant increase in knowledge was observed after using the website information compared with the other two groups (P<0.001). The group with higher education levels had higher knowledge gains, and the website independently contributed to the knowledge gain. CONCLUSIONS: A patient-tailored multimedia website is an effective way to support the information provided by the anaesthesiologist in order to inform patients about their upcoming anaesthetic procedure. The use of such a website gives a significant increase in knowledge compared with only spoken information, or spoken information combined with a brochure.

Comparing the organisational structure of the preoperative assessment clinic at eight university hospitals.

The preoperative assessment clinic (PAC) has been implemented in most major hospitals. However, there is no uniformity in the way PACs are organised. We compared the organisational structure of the PACs from all eight university hospitals in The Netherlands, looking at the following variables: number of patients visiting the PAC, staffing of the PAC, opening hours, scheduling, and additional preoperative diagnostic testing. The number of patients seen yearly varies from 7.000 to 13.500. In all clinics, the preoperative assessment was performed by anaesthetists and residents. In five PACs, preoperative assessment was also performed by physician assistants or nurse practitioners. Opening hours varied. Consultations are by appointment, 'walk-in', or a combination of these two. In four clinics additional testing is performed at the PAC itself. This study shows that the organisational structure of the PAC at similar university hospitals varies greatly; this can have important implications when designing a benchmarking process.

Setting priorities for improving the preoperative assessment clinic: the patients' and the professionals' perspective.

BACKGROUND: The quality of the preoperative assessment clinic (PAC) is determined by many factors. Patients' experiences are important indicators, but often overlooked. We prepare to set priorities to improve the PAC by obtaining detailed patients' feedback on the quality of the PAC, and establishing the value patients and professionals attach to different care aspects, using the Patient Experiences with the Preoperative Assessment Clinic questionnaire. METHODS: The PAC's standard of service was determined for five care aspects (dimensions), using patients' feedback. The importance of a dimension to patients was determined by calculating the effects of the dimensions on patients' overall appraisal. In addition, professionals were asked to rate the importance of the different care aspects. RESULTS: Patients had the most positive experiences with the nurse, and the least positive experiences with waiting. However, waiting was least important to patients. When combining the PAC's standard of service with the value given to the dimensions by patients and professionals separately, we found in both instances that waiting was in greatest need of improvement. This was followed by reception, the anaesthetist, remaining experiences, and finally the nurse. CONCLUSIONS: Quality improvement of the PAC can be achieved by obtaining patients' feedback on the quality, determine a PAC's standard of service, recognize service areas that require improvement, and identify actions appropriate to bring about improvement. The value patients and professionals attach to different aspects of care can then be used to prioritize improvements.

Patient flow in the preoperative assessment clinic.

BACKGROUND AND OBJECTIVE: Previous research has shown that a preoperative assessment clinic enhances hospital cost-efficiency. However, the differences in organization of the patient flow have not been analysed. In this descriptive study, we evaluated the consequences of the organization of the patient flow of a preoperative assessment clinic on its performance, by analysing two Dutch university hospitals, which are organized essentially differently. METHODS: In the final analysis, the study included 880 patients who visited either academic centre. The performance of the two preoperative assessment clinics was evaluated by measuring patient flow time, various procedure times and the total waiting time. Patients' age, ASA physical status and any preoperative tests requested by the physician were also recorded. RESULTS: There was a significant difference in patient flow time between the two preoperative assessment clinics. More time was needed for the preoperative assessment when patients' ASA class was higher. The patient flow time was longer when electrocardiogram and venepuncture were performed at the general outpatient laboratory than when they were performed at the preoperative assessment clinic due to longer waiting times. More tests were requested when they were performed at the preoperative assessment clinic. CONCLUSIONS: This study shows that the organization of patient flow is an important aspect of the logistic processes of the preoperative assessment clinic. It might influence patient flow times as well as the number of preoperative tests requested. Together with other aspects of logistic performance, patient satisfaction and quality of medical assessment, patient flow logistics can be used to assess the quality of a preoperative assessment clinic.

Simulation to analyse planning difficulties at the preoperative assessment clinic.

BACKGROUND: Little research has been performed on designing appointment systems for the preoperative assessment clinic (PAC). We aimed to investigate how two organizational planning difficulties, (i) long access times and (ii) long waiting times, could be analysed systematically. METHODS: Two simulation models were used to test different scenarios to reduce access time and waiting times. First, we determined the number of appointments needed to reduce the access time from 5 weeks to 10 working days for 95% of all patients. Subsequently, we determined how long the consultation time should be, taking patients' American Society Anesthesiologists (ASA) physical status into account, to reduce the maximum waiting time to 10 min for 95% of all patients. RESULTS: Although we found the actual capacity, that is, consultations per day, to be enough to meet demand, a backlog existed, as the access time for the PAC was 5 weeks. A temporary extra capacity is needed to eliminate this backlog. When the reserved consultation time is 18 min for patients with ASA class I or II and 30 min for patients with ASA class III or IV, the maximum waiting times decrease to 10 min for 95% of all patients. CONCLUSIONS: This study shows that a simulation model is a helpful tool to determine the capacity needed to achieve and to maintain a proposed service level for access times and waiting times. In addition, waiting times at the PAC can be reduced by making the reserved consultation time dependent on patients' ASA physical status.

Patient Experiences with the Preoperative Assessment Clinic (PEPAC): validation of an instrument to measure patient experiences.

BACKGROUND: Presently, no comprehensive and validated questionnaire to measure patient experiences of the preoperative assessment clinic (PAC) is available. We developed and validated the Patient Experiences with the Preoperative Assessment Clinic (PEPAC) questionnaire, which can be used for quantitative measurements of patient experiences of the PAC. METHODS: We adapted the National Health Service outpatient questionnaire, incorporating questions specific for anaesthesiology. To make the PEPAC appropriate for quantitative measurements, dimensions and single items suitable for statistical analysis were constructed. Each dimension consists of multiple items measuring the same aspect of care. Reliability was established by computing Cronbach's alpha coefficients. Construct validity was assessed by correlating the dimensions with the patient's overall appraisal (Pearson's r). These dimensions should explain a substantial level of variance of the patients' overall appraisal; therefore, regression analysis was performed. RESULTS: After a pilot phase, the questionnaire was sent to 700 consecutive patients (response 74%). Five scales measuring five dimensions of patient experiences were constructed. Cronbach's alpha ranged from 0.56 to 0.84, supporting reliability of the PEPAC. Correlations between the dimensions and patients' overall appraisal ranged from 0.22 to 0.56. Collectively, the five scales explained 51% of patients' overall appraisal. CONCLUSIONS: The PEPAC is a comprehensive, reliable, and validated questionnaire to measure patient experiences with the PAC. It might be a useful tool to identify the service areas of the PAC that require improvement and to determine which actions can bring about improvement.

Complete nucleotide sequence of chikungunya virus and evidence for an internal polyadenylation site.

In this study, the complete genomic sequence of chikungunya virus (CHIK; S27 African prototype) was determined and the presence of an internal polyadenylation [I-poly(A)] site was confirmed within the 3' non-translated region (NTR) of this strain. The complete genome was 11805 nucleotides in length, excluding the 5' cap nucleotide, an I-poly(A) tract and the 3' poly(A) tail. It comprised two long open reading frames that encoded the non-structural (2474 amino acids) and structural polyproteins (1244 amino acids). The genetic location of the non-structural and structural proteins was predicted by comparing the deduced amino acid sequences with the known cleavage sites of other alphaviruses, located at the C-terminal region of their virus-encoded proteins. In addition, predicted secondary structures were identified within the 5' NTR and repeated sequence elements (RSEs) within the 3' NTR. Amino acid sequence homologies, phylogenetic analysis of non-structural and structural proteins and characteristic RSEs revealed that although CHIK is closely related to o'nyong-nyong virus, it is in fact a distinct virus. The existence of I-poly(A) fragments with different lengths (e.g. 19, 36, 43, 91, 94 and 106 adenine nucleotides) at identical initiation positions for each clone strongly suggests that the polymerase of the alphaviruses has a capacity to create poly(A) by a template-dependant mechanism such as 'polymerase slippage', as has been reported for vesicular stomatitis virus.