The Indian Anaesthetists’ Forum

: 2020  |  Volume : 21  |  Issue : 2  |  Page : 92--99

An educational tool to improve patient perceptions on the roles of an anesthesiologist and the importance of pre-anesthetic evaluation: A quality initiative study

Smitha Elizabeth George1, Grace Rebekah1, Anita Shirley Joselyn2,  
1 Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
2 Department of Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Correspondence Address:
Dr. Anita Shirley Joselyn
Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu


Background: There is a huge deficit in patient knowledge about roles played by an anesthesiologist and about the relevance of a proper preanesthetic evaluation. This study attempted to evaluate if quality improvement strategies could improve it during the preanesthesia clinic (PAC) visit. Materials and Methods: The Plan, Do, Study, Act cycle model of quality control projects was implemented by a prospective audit using a questionnaire, conducted in 170 patients scheduled for elective surgeries in the PAC of a tertiary care hospital, to assess knowledge levels about the relevance of PAC and roles of the anesthesiologist. Educational tools consisting of posters and information on a screen displayed in the PAC waiting area were designed. Another audit in consecutive 170 patients was conducted to assess if educational tools improved the patient's knowledge, and if factors such as patient's gender, language, educational level, and previous anesthetic exposure had any impact on knowledge levels. Results: The initial audit demonstrated a knowledge deficit about preanesthesia checkups and about the roles of the anesthesiologist. Quality improvement steps were taken, and educational tools implemented. Knowledge scores improved from 44.54 ± 17.45 to 52.12 ± 18.8 (P < 0.001, confidence interval −11.45–−3.69). Male gender, higher educational levels, and knowledge of the English language were associated with higher knowledge levels after the intervention. Conclusion: Waiting time at PAC can be utilized to educate patients about the relevance of preanesthesia checkup and about various roles of the anesthesiologist by means of posters and information on a display screen.

How to cite this article:
George SE, Rebekah G, Joselyn AS. An educational tool to improve patient perceptions on the roles of an anesthesiologist and the importance of pre-anesthetic evaluation: A quality initiative study.Indian Anaesth Forum 2020;21:92-99

How to cite this URL:
George SE, Rebekah G, Joselyn AS. An educational tool to improve patient perceptions on the roles of an anesthesiologist and the importance of pre-anesthetic evaluation: A quality initiative study. Indian Anaesth Forum [serial online] 2020 [cited 2020 Nov 25 ];21:92-99
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Full Text


Patients in developing countries have poor knowledge about the roles of the anesthesiologist and the relevance of the preanesthesia assessment.[1],[2],[3] Multiple crucial peri-operative roles played by the anesthesiologist are mostly unknown to patients,[4] the general public,[5] and even the medical community,[5] across various language groups, and educational levels.[6],[7] The knowledge that the anesthesiologist is present throughout the surgery to take care of complications and to provide peri-operative analgesia will reduce patient anxiety, improve peri-operative outcome, thus increasing the patients' confidence in the anesthesiologist and reducing the incidence of malpractice litigation.[8]

During preanesthesia checkup, withheld vital information leads to the improper assessment that increases peri-operative morbidity. Patient knowledge about the relevance of a thorough preanesthesia assessment and preoperative optimization will make it easier for the anesthesiologist to assess anesthesia fitness, help safe conduct of anesthesia, and prevent unnecessary delays and last-minute cancellations of surgery.[9],[10]

Available literature shows a huge deficit in patient knowledge about the roles of the anesthesiologist and the preanesthesia assessment.[1],[2],[3],[4],[5],[6],[11],[12] To address this lacunae, we proposed to conduct a survey and using quality improvement steps, implement educational tools in the preanesthesia clinic (PAC) waiting area, and check if this could improve knowledge levels in patients. The primary outcome was knowledge of patients about preanesthesia checkup and the role of anesthesiologist assessed from responses in the questionnaire, in the groups with and without the educational tools. We also assessed if certain factors such as gender, language, educational qualification, and previous anesthetic exposure had an impact on knowledge levels.

 Materials and Methods

After obtaining approval from the Institutional Review Board and Ethics Committee, a cross-sectional survey was conducted in 340 patients in two stages.

This was divided into phases based on the Plan, Do, Study, Act (PDSA) Cycle model, a systematic series of steps for the continual improvement of a process followed in quality control Projects,[13] demonstrated in [Figure 1].{Figure 1}

Phase 1 Identification of the problem (plan phase)


Patients often did not give relevant information in PAC, hampering preoperative optimization, which led to delay or postponement of surgeries. The available literature, including a survey done in our institution in 2004,[1] demonstrated a deficit in patient knowledge about roles played by the anesthesiologist. We designed a prospective audit to assess the knowledge of patients about preoperative assessment and the roles of the anesthesiologist.

Phase 2 Collection of data (do phase)

We conducted a survey in 170 patients for 1 week to assess their knowledge about the roles of the anesthesiologist and the preanesthesia assessment. In the 2 weeks of the survey, patients who came to PAC, who fulfilled the inclusion criteria and gave informed consent were included in the study.

During the working hours of the PAC, all eligible patients were approached by a staff member of the quality control unit of our institution, who distributed questionnaires in the appropriate languages to patients who agreed to participate in the study. Questionnaires were collected back before they met the anesthesiologist. The person handing out the questionnaires and collecting them back from patients was a nonmedical person who was unaware of the right responses to the questions. Questionnaires were available in four languages, namely English, Tamil, Hindi, and Bengali. Illiterate people were allowed to participate in the survey if accompanied by a relative who could help them read and record their responses.

Inclusion criteria

All adult patients posted for elective surgeries visiting PAC for preanesthetic evaluation, who were able to fill up the questionnaires in any of the four chosen languages, were eligible to participate in the survey.

Exclusion criteria

The patients were excluded if the questionnaire was not in a language understood by the patient, or if patient comprehension or cooperation was poor due to a medical condition.

The questionnaire consisted of questions to assess the demographic profile of the patients, and 25 questions to assess patient knowledge pertaining to two main domains: the preanesthesia checkup and peri-operative roles of the anesthesiologist. These questions had choices, of which the patient had to tick the most appropriate answer according to him/her. Scoring was done, and each question answered correctly was given 1 mark while incorrect answers were awarded 0 marks. Knowledge score was separately calculated for questions about preanesthesia checkup and questions about the anesthesiologist. The individual patients' total score for the questionnaire was calculated out of 25 and converted to percentage.

Phase 3: Data analysis and design of changes (study phase)

Based on data analysis, steps were planned to address the problem. Information to be conveyed was translated from English into the three commonly spoken regional languages and incorporated into educational tools along with self-explanatory pictures that convey appropriate information.

Phase 4: Implementation of changes (act phase)

In this phase, changes were implemented to improve knowledge levels in patients by the end of their PAC visit. Educational tools were initiated in PAC in the form of colorful posters and PowerPoint slides displayed in the overhead display screen explaining important aspects of preanesthesia evaluation and the roles of the anaesthesiologist in 4 different languages. Posters placed in strategic locations were available for reading; the entire time patients spent in the PAC waiting area. The overhead display area continuously displayed information with easy to understand pictures and slides with two languages at a time, displayed over 7 min, to ensure patients would have an opportunity to see it multiple times during their waiting period in the PAC (average of 45 min). The staff from the quality control unit who distributed the questionnaires encouraged the patients to go through the educational information in the PAC waiting area before they filled up the questionnaire.

Phase 5: Evaluation of the effects of implemented changes (secondary Plan, Do, Act phase)

We conducted yet another survey to evaluate the effect of the educational tools introduced in PAC. Data collection was performed in the target population after they had adequate opportunity to read the information presented in the educational tools. A questionnaire survey was conducted again over 1 week in a manner similar to the 1st week with these educational tools in place. We analyzed the responses and compared the knowledge scores of patients assessed by the questionnaire, separately for the groups with and without educational tools.

For the analysis, “Group 1” was used to refer to the group of patients assessed before the educational program was introduced, and “Group 2” was used to refer to the group of patients assessed after introducing the educational tools.

Sample size calculation

The initial audit or pilot study showed an overall patient knowledge score of 44% in Group 1. We calculated the sample size for Group 2 based on this study.

Assuming a 12% increase in knowledge with an alpha error of 5% and power of 80% for a two-sided test, we calculated a sample size of 134. However, so that a comparable number would be there in both groups, we studied 170 consecutive patients after the introduction of educational tools.

Statistical methods

Data were entered using EpiData 3.0 software (data v 3.1, Odense, Denmark). Statistical analysis was performed using the Statistical Package for the Social Sciences(v21.0, IBM, Bangalore). Descriptive statistics using mean ± standard deviation were reported for continuous variables, frequency, and percentage for categorical variables. Comparison of means scores was made using two independent sample t-test. One-way analysis of variance (ANOVA) was used for more than two categories, and Bonferroni multiple comparison was made after checking for normality. Comparison of knowledge scores about preanesthesia check-up and about roles of the anesthesiologist for two groups was assessed using two-independent sample t-test. Association between multiple factors and the knowledge/perception regarding preanesthesia check-up and role of anaesthesiologists was reported using Chi-square/Fisher's exact test. Two proportions test was used to compare the proportions between the groups. P < 0.05 was considered statistically significant.


Around 500 patients were seen per week in PAC, of which 300 met the inclusion criteria in the 1st week. Although 200 questionnaires were distributed to patients who consented to take part in the survey, only 170 patients returned completed questionnaires that were used for analysis in the 1st week of the survey. Out of this, one patient was excluded in the analysis as he belonged to a language group different from the four languages considered. Thus, 169 questionnaires were analyzed in the 1st week, i.e., Group 1 patients. In the 2nd week, after educational tools were introduced, consecutive 170 completed questionnaires were collected and analyzed over the next week of the survey like the 1st week.

Demographic details

The age, gender distribution, educational profile, and language profile are given in [Table 1]. The demographic profile in terms of age, gender, educational levels, and the number of PAC visits were comparable in both Group 1 and Group 2.{Table 1}

Knowledge scores were seen to be higher in the group with educational tools. This was statistically significant. Mean knowledge scores in percentages, for subsections of the questionnaire, and the total score for 25 questions, are given in [Table 2].{Table 2}

Various demographic factors were analyzed to check if it made a significant difference in the knowledge levels. In Group 2 (the group with educational tools), higher knowledge score was found in men (49.67 ± 22) compared to women (42.61 ± 18) (confidence interval [CI] 0.61–13.68, P = 0.032, Independent sample t-test). In Group 1, there was no significant difference in knowledge between men and women.

One-way ANOVA, multiple comparisons using the Bonferroni test showed that education and language had an impact on knowledge levels. In both groups, higher scores were in patients who had graduated from college. Knowledge scores in college graduates were higher (48.21 ± 20.78) compared to primary school graduates (37.21 ± 17.21) in Group 1 (P = 0.009, CI 42.42–54.00), and it was 58.07 ± 22.71 in college graduates compared to 38.93 ± 16 for primary school graduates in Group 2 (P <0.001, CI 52.26–63.89).

Language also impacted knowledge levels. In Group 2, knowledge scores were higher in patients who could read and write English (60.44 ± 22.19) when compared with patients using Tamil (45.86 ± 22.38), Hindi (37.76 ± 18.65), and Bengali (38.47 ± 13.95) (P <0.001, 95% CI 54.39–66.51). Previous surgery/anesthesia was found to have no impact on knowledge levels.

The question on where they had heard or understood about anesthesia and the role of the anesthesiologist before was answered as follows.

Most patients (20%) had got this information through their personal experience with anesthesia and surgery. The next most common source of information was the surgeon (19%), followed by the experience of friends and relatives (10%), and then, the media (9% from newspapers, 9% from the Internet, 9% from movies and books). More than 20% of patients admitted they had never heard of the relevance of PAC check-up or about the roles of an anesthesiologist, before this survey.

The number of patients who gave the right responses to queries about the preanesthesia checkup (details would be necessary for the anesthesiologist to check fitness for surgery) are given in [Table 3].{Table 3}

Among these responses, improvement in knowledge levels for a few questions in Group 2 was statistically significant. The overall awareness that history of substance abuse should be reported to the anesthesiologist was only 26.9%, of which, a significant number (58/170), i.e., 63.7% were in Group 2 (P = 0.006).

The number of patients who recorded the right responses about the roles of an anesthesiologist is given in [Table 4].{Table 4}

When asked about the roles of the anesthesiologist, most people knew about checking fitness for anesthesia and giving anesthesia for surgery. Less people knew about other roles, for example, that the anesthesiologist checks blood loss and starts blood if needed. A statistically significant number in Group 2 realized that the anesthesiologist is involved in giving fasting orders and orders about taking medicines on the day of surgery (P = 0.04), as well as waking up patient (P = 0.001) and taking care of intensive care unit patients (P = 0.002).

The questionnaire had multiple choice questions about preanesthesia check-up and about the roles played by the anesthesiologist. When asked who checks vital signs, resuscitates patients if needed, and ensures patient safety throughout the time of surgery, 111 patients chose the anesthesiologist as their response, of which majority, i.e., 67 belonged to Group 2, which had the educational tools (P <0.009). Similarly, for the question who ensures the patient does not have pain peri-operatively, 106 gave anesthesiologist as their answer, of which 65 belonged to Group 2 (P <0.006). The correct answer that all three factors, i.e., uncontrolled and unoptimized medical conditions, active respiratory infection, and elderly age can be risk factors in anesthesia, was given by 65 people in Group 2, compared to only 46 in Group 1 (P = 0.002). All these responses were found statistically significant using Chi-square/Fischer's exact test.


The survey results showed that the implementation of educational tools using quality improvement strategies demonstrated a significant increase in patient knowledge levels about preanesthesia checkup and about the roles of the anesthesiologist. Male gender, higher educational levels, and knowledge of the English language were found to be associated with higher knowledge levels after the educational program in PAC.

The increase in knowledge in our study is in line with previous studies,[14],[15],[16],[17] that have shown preoperative educational tools to be useful in achieving different aims like the reduction of patient anxiety, increasing satisfaction with anesthesia, etc., Similar to the ASA campaign in 2008 that aimed to improve the public understanding of the role of anaesthesiologists,[18] our study attempted to help patients understand what we do in our practice. The Australian Incident Monitoring Study database of 6271 reports by Kluger et al.[19] demonstrated incorrect preoperative assessment in 478, and inadequate preoperative preparation in 248, which caused six-fold increase in peri-operative mortality. This emphasizes the need for thorough preoperative assessment and proper optimization, which will be possible only if patients are also aware of its relevance.

For an anesthesiologist, the only opportunity for effective patient interaction is during the preoperative assessment visit; as the second encounter with a premedicated patient ready to undergo surgery, is not conducive to education. With a daily patient turnover of 100 patients or more, the average waiting for time patients spent in PAC outside the doctor's room in our institution was around 45 min and only 15 min with the anesthesiologist as per an audit by James and Thampi.[20] Patients would be unable to assimilate too much information during the limited preoperative check-up time spent with the anaesthesiologist.

The PDSA cycle model of quality improvement project helped us in this study to identify factors affecting patient knowledge, namely, poor literacy levels and lack of proper knowledge sources for patients, constraints of time for the anaesthesiologists to spend with each patient educating them, less opportunities for anesthesiologist to interact with patients, and language barriers to communication in hospitals like ours with multilingual patients; as illustrated in [Figure 2]. To address this, we implemented improvements like educational tools designed, keeping in mind the requirement of the target population. Posters and PowerPoint presentations were made with appropriate information in English and the most commonly spoken three regional languages, incorporating self-explanatory pictures that were placed in strategic positions in the PAC waiting area.{Figure 2}

The better knowledge scores found in men in comparison to women in Group 2, may be because men had less inhibitions (due to cultural factors) in moving from their seats to read the displayed posters in detail. As expected and reported,[3] patients with a better literacy level had a better knowledge score and even more so after education, as their ability to comprehend and assimilate information would have been more. In keeping with findings in previous studies, patients who had a previous surgery or anesthetic did not have increased knowledge levels about PAC or about the roles of the anesthesiologist,[21],[22] which probably indicates constraints of time and language and lack of opportunities for the anaesthesiologist to interact with patients in hospitals with huge patient loads.

Although the increase in knowledge levels in our study was much less than expected, there has been a change for the better, and we hope that this heralds an era of better awareness among patients. For hospitals, especially the ones lacking a fixed area for PAC, we suggest that educational posters can be placed in the surgery outpatient areas where potential patients are likely to see it before they approach the anaesthesiologist for preoperative assessment. If patients get this information from the time they approach the surgeon, repeatedly viewing the information in posters might help to reinforce and increase knowledge levels in patients effectively.


Educational tools like posters require patients to have basic literary skills and the motivation to read it completely.[22] A video/audio presentation, or an interactive session with the anesthesiologist where doubts could be clarified, would have been more effective. Due to a shortage of personnel and time constraints, we could not afford to have these sessions.The actual meaning may have been partly lost in translation to the three regional languages, affecting the responses. This could be why patients who could understand English did better in the posteducation analysis.


Educational tools such as posters and information displayed on overhead screens in the PAC waiting area and surgical outpatient area can be a useful tool in improving patient knowledge about the relevance of the preanesthesia check-up and roles played by the anesthesiologist, especially when quality improvement strategies are used to implement it. We would like to recommend this to more hospitals as a simple and easily reproducible educational tool with multiple benefits. Better knowledge levels about the preanesthesia checkup and roles played by the anesthesiologist will make patients confident to face anesthesia, and translate to improved safety standards and enhanced quality of anesthesia services.

On completion of this study, we implemented further quality improvement changes in PAC. These include giving patient information sheets about anesthesia in multiple languages at the time of registration in PAC, continued display of the educational tools used in this study, and introduction of physician assistants to do initial preoperative screening so that the anesthesiologist has more time to communicate with patients, clarifying doubts and reassuring them.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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