Improving efficiency and patient satisfaction in a tertiary teaching hospital preoperative clinic.

BACKGROUND: Clinical and organizational aspects of the preoperative visit can have a significant impact on patient satisfaction. The authors' previous work demonstrated that communication of information from the clinician to the patient was found to be the most positively rated component, whereas organizational issues, particularly waiting time, were the most negative. This study compares two yearly cycles of patient satisfaction surveys to assess the process and impact of implementation of changes. METHODS: The authors distributed a one-page questionnaire, consisting of elements evaluating satisfaction with clinical providers and with organizational aspects of the visit, to patients in their preoperative clinic during two different time periods. Fourteen different questions had five Likert scale options ranging from excellent to poor. Changes implemented included clerical, scheduling, and clinical changes. RESULTS: The overall collection rate of completed questionnaires was 79%. The scores for each question in Cycle 2 were higher for all questions, with 3 of 14 reaching statistical significance (P < 0.01). These questions related to the explanation of the Preoperative Assessment Clinic by the surgeon's office, courtesy and efficiency of the clinic staff, and satisfaction with waiting time. Average waiting time was reduced from 92 to 41 min (P < or = 0.0001). CONCLUSION: Analysis of patient flow and clinic operations led to alterations in clinic processes. Alterations included education of clinic and surgical office staff to improve customer service, and implementation of changes in provider roles. These modifications resulted in an improvement in patient satisfaction and a reduction in waiting time with minimal economic impact.

Transdermal scopolamine for prevention of intrathecal morphine-induced nausea and vomiting after cesarean delivery.

BACKGROUND: Intrathecal morphine for cesarean delivery provides excellent postoperative analgesia but is associated with significant nausea and vomiting. METHODS: We compared the antiemetic efficacy of transdermal scopolamine, IV ondansetron, and placebo during the first 24 h postoperatively. Two-hundred forty women undergoing cesarean delivery under spinal anesthesia were randomly allocated, in a double-blind study design, to receive transdermal scopolamine 1.5 mg, ondansetron 4 mg, or placebo at the time of cord clamping. RESULTS: Our study showed that the overall rates for all emesis were 59.3% in the placebo group and were reduced to 40% in the scopolamine group and 41.8% in the ondansetron group. The greatest reduction in emesis in the scopolamine group when compared with placebo was in the 6-24 h time period. CONCLUSION: Scopolamine is an effective medication for prophylactic use in parturients receiving intrathecal morphine while undergoing cesarean delivery. Its use, however, was associated with a higher incidence of side effects such as dry mouth and blurry vision.

In vitro fertilization-induced alterations in coagulation and fibrinolysis as measured by thromboelastography.

Supraphysiologic increases in estrogen produced by in vitro fertilization (IVF) promote the expression of hemostatic markers. Although quantitative studies of individual markers have been performed during IVF, their results are conflicting and do not reveal the qualitative effect of each marker on the overall coagulation and fibrinolytic processes. Thrombelastograph (TEG) coagulation analysis, by contrast, provides a global measure of coagulation and fibrinolysis and can indicate the relative contributions of clotting factors, fibrinogen, and platelets to each process. We studied the serum estrogen concentrations and TEG variables in 24 women at the beginning and conclusion of an IVF stimulation cycle. Serum estradiol (E(2)) concentrations (mean +/- SD) increased from 26.9 +/- 8.6 to 2098 +/- 913 pg/mL (P < 0.005) at baseline and oocyte retrieval, respectively. The measured TEG indices demonstrated alterations in coagulation rather than fibrinolysis. Although significant changes were noted in both the clot formation time and the coagulation index (P < 0.005), all TEG values remained within the normal range. In addition, an increased role of fibrinogen in promoting clot strength was observed. These findings may assist in the treatment of IVF patients who ultimately develop thromboembolic complications as a result of ovarian hyperstimulation. IMPLICATIONS. The dramatic changes in estrogen produced by in vitro fertilization therapies result in hemostatic marker alterations. Thrombelastograph coagulation analysis, which provides a global assessment of these changes, demonstrated significant alterations in two coagulation indices (clot formation time, coagulation index), although all variables remained within normal limits. The relative importance of fibrinogen versus platelets in determining clot strength was observed. No significant alterations in fibrinolysis were detected.