By Modi, Neil Shaw, Steve; Allman, Keith; Simcock, Peter
KEYWORDS Anaesthesia / Anxiety / Cataract / Handholder / Pain / Satisfaction To assess factors influencing perception of pain, anxiety and overall satisfaction during local anaesthetic cataract surgery an audit was carried out at the West of England Eye Unit. Patients receiving sub-Tenons after previous peribulbar anaesthesia had significantly higher pain scores. Patient satisfaction was significantly higher when a handholder was present in theatre. Finally, no difference was found in the three variables whether anaesthesia was administered by an anaesthetic practitioner or an anaesthetist.
Introduction
Nursing feedback from the West of England Eye Unit expressed concern that some patients were not satisfied with their ‘cataract experience’. An audit was performed to investigate if this was a frequent occurrence or a rare event. Data regarding patients’ pain, anxiety and satisfaction with local anaesthetic cataract surgery was collected and compared to standards from the literature.
Local anaesthesia is currently the preferred method of anaesthesia for cataract surgery in the UK (Royal College of Anaesthetists & College of Ophthalmologists 2001). A pain free operation remains the gold standard for surgery. Absence of pain however, does not always equate to patient comfort. Anxiety or sensation of pressure may increase the requirement for sedation (Nielsen & Allerod 1998). Patients’ pain, anxiety and overall satisfaction following local anaesthetic cataract surgery has been extensively reviewed (Briggs, Beck & Esakowitz 1997, Katz et al 2000, Friedman et al 2001, Zafirakis et al 2001, Bellan, Gooi & Rehsia Mathew et al 2003, Sauder & Jonas Fung et al 2005, Muttu et al 2005).
These reviews have not, however, considered the effect of handholders in theatre on patients’ pain, anxiety and satisfaction. This was assessed here to address management efforts to cut back numbers of theatre staff. The use of anaesthetic practitioners in our unit is not universal in ophthalmic theatres, and the management of patients’ pain in particular, as well as their anxiety and satisfaction is important in validating this practice. Again this has not been assessed in the literature.
Patients and methods
For 10 weeks from April 2006 we consecutively collected patients having routine day case local anaesthetic cataract surgery at the Royal Devon and Exeter NHS Trust. The patients demographic details, anaesthetist and surgeon name and grade, local anaesthetic technique, handholder presence, duration of surgery and details of any previous cataract surgery were noted.
Anaesthesia was performed by anaesthetic nurse practitioners (sub- Tenons only), senior house officers, specialist registrars and consultants. In total, 26 anaesthetists were involved in this audit. sub-Tenons anaesthesia and peribulbar anaesthesia were used with topical proxymetacaine applied prior to both techniques.
Surgery was performed by clinical assistants, senior house officers, specialist registrars, fellows and consultants. In total, 15 surgeons were involved in the audit. Small-incision phacoemulsification cataract surgery was performed on all patients.
Following surgery ophthalmic-trained nurses asked patients to place a mark on a 90mm visual analogue scale (1-10) representing their experience of pain, anxiety and their satisfaction, giving a continuous variable.
Non-parametric Mann-Whitney and KruskalWallis tests were used for comparing the pain, anxiety and satisfaction scores of different groups. Spearman’s correlation was also used for looking at the relationship with duration. Note that pain, anxiety and satisfaction scores were all clearly not normally distributed (hence the use of non-parametric methods).
Results
Two hundred and sixty eight patients were audited (101 male, 167 female). Results were compared to the findings of the Misericordia Cataract Comfort study 3 as the ‘standard comparator’. This standard found mean pain, anxiety and satisfaction to be 13.5,14.9 and 87.9 respectively when converted to a comparable scale to facilitate comparison with our results. The other factors were reviewed descriptively and where possible assessed with multivariate statistical analysis.
Overall pain, anxiety and satisfaction
Overall pain, anxiety and satisfaction with local anaesthetic cataract surgery for all patients in our audit (Table 1) were compared to the ‘standard’. Mean values were used as they were the only numerical values presented in the ‘standard’: 28.3% felt more pain, 55.3% felt more anxiety, and 40.4% felt less satisfied overall than the standard.
Table 1 Summary statistics for outcome scores: pain, anxiety and satisfaction (based on n=268 patients)
Table 2 Percentages of non-sedated patients having either sub- Tenons or Peribulbar local anaesthetic who experienced more pain, anxiety and less satisfaction than standard
Table 3 The three outcomes for non-sedated patients having sub- Tenons local anaesthesia
Table 4 The three outcomes for non-sedated patients having Peribulbar local anaesthesia
Table 5 Percentages of patients who had more pain, anxiety and less satisfaction than the standard, for patients both with and without handholders in the anaesthetic room
Table 6 Percentages of patients who had more pain, anxiety and less satisfaction than the standard, for patients both with and without handholders in theatre
The mean values of the three outcomes were within one standard deviation of the standard. We concluded that overall pain, anxiety and satisfaction with local anaesthetic cataract surgery for all patients in this audit were comparable to the standard.
Local anaesthetic technique
One hundred and fifty three patients received sub-Tenons and 109 received peribulbar anaesthetic. Six patients received peribulbar and needed a top-up of sub-Tenons anaesthetic intraoperatively.
Only non-sedated patients (n=145) were analysed (as sedation often causes amnesia) (Table 2); 114 received subTenons and 31 received peribulbar anaesthetic. Tables 3 and 4 give the summary statistics for the three outcomes when using sub-Tenons and peribulbar local anaesthesia respectively.
The mean values for both types of anaesthetic were within one standard deviation of our chosen standard. We conclude that there was no significant difference between the three outcomes for our patients, and the standards. Of our patients, we found no evidence of any significant differences between those who had Peribulbar (n=31) and those who had sub-Tenons (n=114) anaesthesia for pain (p=0.76), anxiety (p=0.75) or satisfaction (p=0.42).
Previous cataract surgery
We found no evidence of difference in pain, anxiety or satisfaction in patients having their first (n=151) or second (n=104) cataract operation (p>0.1). In patients having their second cataract operation, we noted our patients experienced significantly more pain if they received sub-Tenons after previous peribulbar technique (n=20, p=0.007). In patients having peribulbar after previous sub-Tenons technique (n=15, p>0.1) no significant difference in pain, anxiety or satisfaction was seen.
Figure 1 Mean of the three outcomes with handholder present and not present
Table 7 The three outcomes for patients with a handholder present in theatre
Table 8 The three outcomes for patients with no handholder present in theatre
Handholder
Table 5 compares the data from this audit to the standard when a handholder was present (n=55) in the anaesthetic room with no handholder being present (n=189).
No significant difference in pain (p=0.39) or anxiety (p=0.076) was noted with or without a handholder in the anaesthetic room. Satisfaction scores were lower when a handholder was present (mean=79.9, median=79.9) compared to when there was no handholder (mean=84.8, median=89), but with a borderline p value of 0.046.
Table 6 compares whether a handholder was present (n=215) in theatre with no handholder being present (n=48) with respect to the standard.
The mean standard values for the three outcomes were within one standard deviation of our audit data. We concluded that there was no significant difference between the three outcomes with or without handholder present, and the standard.
It can be seen descriptively from Figure 1 and Tables 7 and 8 that patients felt less pain, anxiety and were more satisfied with a handholder present in theatre compared to no handholder. We found no significant evidence of a difference in pain or anxiety whether (Figure 7) or not (Figure 8) a handholder was present in theatre. Our data did show that satisfaction scores were significantly higher (p
Grade of individual anaesthetist and surgeon
This study involved four grades of anaesthetist (anaesthetic practitioner n=51, consultant n=136, senior house officer n=59 and specialist registrar n=21). We found no significant difference in any of the three outcomes between the different anaesthetist grades (p>0.1). The study encompassed five grades of surgeon (clinical assistant n=23, consultant n=109, senior house officer n=10, specialist registrar n=87 and fellow n=38). No evidence of any differences in anxiety or satisfaction (p>0.25) was noted but there was some evidence of differences in average pain scores between grades of surgeon. Average pain scores were lowest for consultants and highest for SHOs with the other three grades between. Magnified view of a cataract in a human eye, seen on examination with a slit lamp using diffuse illumination
No valid comparisons could be made between individual surgeons or anaesthetists as the small numbers for each individual would give invalid results.
Discussion
The purpose of audit is to assess the efficacy of current clinical practice and to contribute to improving that practice. Our aim was to consider our patients’ experience of cataract surgery in terms of pain, anxiety and their overall satisfaction, and determine whether the measures we have in place are effective. We drew our conclusions by comparison of our results with standards from chosen from the Misericordia Health Centre Cataract Comfort Study (Bellan, Gooi & Rehsia 2002). The Cataract Comfort Study was selected because it was similar to ours, and looked at the same three outcomes.
This audit was of a large size compared to many papers in the literature (Briggs, Beck & Esakowitz 1997, Neilsen & Allerod 1998, Zafirakis et al 2001, Bellan, Gooi & Rehsia 2002, Mathew et al 2003, Sauder & Jonas 2003, Srinivasan et al 2004, Cagini et al 2006). The Royal Devon and Exeter Hospital was representative of a broad range of settings as 15 surgeons and 26 anaesthetists were involved, performing over 2,000 cataract operations per year. We consecutively accepted all patients having routine local anaesthetic, day-case cataract surgery over a three month period. This study was an audit and not a controlled clinical trial. It therefore has limitations as a single centre study without patient randomisation with the possibility of selection bias. There were no specific inclusion or exclusion criteria, which leads to great variability between patients. Staff were not blinded to the surgery or which method of anaesthesia was used. No single member of staff was responsible for collecting the data and many anaesthetists and surgeons were involved. Finally, sedation causes amnesia which might lead to reduced reporting of pain (Nielsen & Allerod 1998). We have reduced this to some extent by removing patients who had sedation when comparing the two local anaesthetic techniques.
The audit data indicated that pain, anxiety and satisfaction with local anaesthetic day case cataract surgery at the Royal Devon and Exeter is comparable (within one standard deviation) to that found in the Misericordia Cataract Comfort Study (Bellan, Gooi & Rehsia 2002).
The large standard deviation of our results is unavoidable because of bias, subjectivity, lack of good methodology to test the small degrees of pain associated with cataract surgery, along with amnesia caused by intravenous sedation (Nielsen & Allerod 1998). Many studies did not report standard deviations, and those which did were of similar magnitude (Srinivasan et al 2004).
When comparing the two local anaesthetic techniques, excluding sedated patients because of amnesia, we found no significant difference. Nielsen and Allerod (1998) noted significantly more pain on administration of retro-bulbar anaesthesia, but less perioperative discomfort. They concluded that patients preferred subTenons anaesthesia. Briggs, Beck & Esakowitz (1997) also considered pain scores for the two techniques, finding significantly lower scores on administration of sub-Tenons anaesthetic compared to peribulbar. The main difference of these from our own studies was that they considered pain scores on administration of the anaesthetic and during the operation, whereas we considered our three outcomes at the end of the operation in recovery. There is good evidence that anxiety levels vary, being highest when the patient first arrives at the department to being lowest after the operation (Bellan, Gooi & Rehsia 2002, Habib, Mandour & Balmer 2004). Perception of pain from a procedure may vary also, perhaps diminishing with time as the patient’s anxiety reduces. This might reduce our pick-up rate for patients’ perception of pain, by rendering the difference between the two groups less and thus nonsignificant.
Pain, anxiety and satisfaction were not related to whether the patients were having their first or second cataract operation. Interestingly, we did find that patients who had sub-Tenons after previous peribulbar technique felt significantly more pain. There was no difference when we looked at the three outcomes for patients who had peribulbar after previous sub-Tenons anaesthesia. Although the numbers for both groups were small, the difference was highly significant and as a recommendation from this audit, we will advocate the use of a peribulbar technique if a patient has previously had this technique on the fellow eye.
Budget cuts to ophthalmic theatres have made it increasingly difficult to justify the expense of staff such as handholders. In ophthalmic theatres however, handholders are not just as a means of comfort for patients but also an important tool for communication between surgeon and patient. In the anaesthetic room handholding did not appear beneficial but patients with a handholder in theatre, however, felt less pain and anxiety and were significantly more satisfied than those without a handholder.
In the anaesthetic room 22.5% of patients had a handholder, whereas in theatre 82.7% of patients had a handholder. It is not usual however for handholders to be present in the anaesthetic room, unless a patient specifically requests this or if they are particularly anxious. This is an obvious selection bias and the patients in the two groups are not comparable. This may explain why patients with handholders in the anaesthetic room appeared more anxious and less satisfied (although did not reach statistical significance). There was no such selection bias for patients having handholders in theatre, as all patients received a handholder except when staff numbers would not permit this.
We found no difference in any of the three outcomes depending on the grade of anaesthetist. This includes the anaesthetic nurse practitioner trained in sub-Tenons anaesthesia. This finding offers the possibility of expanding their role in cataract surgery, as a more cost-effective alternative to employing an anaesthetist.
Consultants were found to have the lowest patient pain scores whereas SHOs had the highest. The other three grades were similar to each other. Mathew, Webb & Hill (2002) also found a greater level of discomfort of around 11%, when comparing a trainee with an experienced surgeon (although not statistically significant). This again is difficult to explain as the anaesthesia was the same for the various grades of surgeon.
Presentations
This paper was presented at the South West Ophthalmic Society meeting in Bristol 2006.
No significant difference in pain or anxiety was noted with or without a handholder in the anaesthetic room
We found no significant difference between two anaesthetic techniques with regard to pain, anxiety and satisfaction
Summary and implemented changes
* Pain, anxiety and satisfaction with local anaesthetic day-case cataract surgery at the Royal Devon and Exeter is comparable to a published standard.
* We found no significant difference between two anaesthetic techniques with regard to pain, anxiety and satisfaction.
* More pain is experienced if patients received sub-Tenons after previous peribulbar technique. In future, peribulbar anaesthetic will be recommended if the fellow eye had previous surgery with this technique, if resources allow.
* Patients reported less pain and anxiety and significantly higher satisfaction scores with hand holder present in theatre. This provided positive feedback, demonstrating a valuable role for handholders and further motivation for staff. This also proved useful information for nursing colleagues and administrators who are considering reducing theatre budgets by cutting funding for staff, including handholders.
* Satisfaction was higher and anxiety was the same in patients selected to have sedation compared to those who were not – suggesting that sedation reduces anxiety and increases satisfaction.
* The three outcomes were independent of the grade of anaesthetist, suggesting a possibility to increase the role of the anaesthetic nurse practitioner in daycase sub-Tenons technique cataractsurgery as a more cost-effective alternative to an anaesthetist.
We will advocate the use of a peribulbar technique if a patient has previously had this technique on the fellow eye
References
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About the authors
Neil Modi
MBBS, SSc, DHMSA
ST1 in Ophthalmology, Royal Cornwall Hospital
Dr Steve Shaw
Statistician,
University of Plymouth
Dr Keith G Allman
MD FRCA
Consultant Anaesthetist, Royal Devon and Exeter
NHS Trust
Mr Peter R Simcock
MRCP FRCS FRCOphth DO
Consultant Ophthalmologist, Royal Devon and Exeter NHS Trust
Copyright Association for Perioperative Practice Jan 2008
(c) 2008 British Journal of Perioperative Nursing. Provided by ProQuest Information and Learning. All rights Reserved.
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