Journal of Clinical Anesthesia 43 (2017) 15–23

Contents lists available at ScienceDirect

Journal of Clinical Anesthesia

Original Contribution

Measuring satisfaction and anesthesia related outcomes in a surgical day

care centre: A three-year single-centre observational study☆
A. Teunkens, MD a,b,⁎, K. Vanhaecht, PhD c, K. Vermeulen, MD b, S. Fieuws d, M. Van de Velde, MD, PhD, EDRA a,b,
S. Rex, MD, PhD a,b, L. Bruyneel, PhD c
a
Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium
b
Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium
c
Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium
d
I-Biostat, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium

a r t i c l e i n f o a b s t r a c t

Article history: Study objective: To evaluate patient satisfaction and patient reported anaesthesia related outcome parameters
Received 5 June 2017 after outpatient surgery.
Received in revised form 1 September 2017 Design: A three-year (2013–2016) observational study.
Accepted 24 September 2017 Setting: A surgical day care centre embedded in a tertiary care, university hospital.
Patients: Adult Dutch-speaking patients who underwent surgery under general or regional anaesthesia on an out-
Keywords:
patient basis (n = 5424).
Ambulatory care
Outpatient surgery
Interventions: A questionnaire was developed to evaluate patients' satisfaction with care during their
Patient satisfaction hospitalisation in the surgical day centre, as well as to assess their reports of anaesthesia related outcomes.
Patient reported outcome measures Measurements: Various aspects of care were measured, including care by nurses, care by doctors, organisational
and safety items. Variation in satisfaction and surgery and anaesthesia related outcomes as a function of different
categories (gender, age, education, type of anaesthesia, discipline and era) were also investigated.
Main results: Confirmatory factor analysis showed an excellent fit to the hypothesized factors of the survey. Sat-
isfaction scores were very high for different aspects of care, resulting in 98% of patients being (very) satisfied
(59.1% very satisfied, 38.9% satisfied). Male (p = 0.0003), higher educated (p b 0.0001) and older patients (p b
0.0001) were more likely to be very satisfied. Postoperative nausea and vomiting (PONV) were frequent (nausea:
13.9%, vomiting: 3.3%), and more present in female than in male patients (p b 0.0001). Pain scores at the PACU
differed among disciplines (p b 0.0001) were higher in female patients compared to male patients (3.41% versus
2.54%, p b 0.0001) and after general anaesthesia compared to regional anaesthesia (3.25% versus 0.39%, p b
0.0001) and decreased with higher age (p = 0.0001) and education level (p = 0.0033).
Conclusions: Whereas satisfaction with all aspects of care is generally high, the results regarding pain and PONV
should inspire quality improvement initiatives. The questionnaire developed in this study can be a vehicle to as-
sess and improve the quality of care in surgical day care centres.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction
Patient satisfaction is an important parameter in healthcare and an
established indicator to evaluate the quality provided by an ambulatory
surgical centre [1]. A clinical audit is a valuable tool in the quest towards
quality improvement of healthcare.
However, patient satisfaction is a complex and subjective concept,
determined by many different variables such as the organization of
☆ Conflicts of interest: none declared.
⁎ Corresponding author at: Herestraat 49, 3000 Leuven, Belgium.
E-mail address: an.teunkens@uzleuven.be (A. Teunkens).
care, the quality of provided care, the perceived outcomes and patient
expectations [2–5].
During the last few years various authors have investigated satisfac-
tion with anaesthesia and several questionnaires have been developed,
but there is no universally accepted method [6–8]. All existing ap-
proaches have important strengths and weaknesses [9]. Because of the
multiple influencing factors the questionnaire needs to be multidimen-
sional and include questions probing for aspects of information, com-
munication, professional competence, physical comfort/discomfort
and adverse anaesthesia outcomes [10–12].
Ambulatory surgery has grown exponentially over the last several
decades. Whereas most quality investigations focus on inpatients, the
quality of ambulatory anaesthesia and care also needs a critical

https://doi.org/10.1016/j.jclinane.2017.09.007
0952-8180/© 2017 Elsevier Inc. All rights reserved.
16 A. Teunkens et al. / Journal of Clinical Anesthesia 43 (2017) 15–23
evaluation. The aim of this study was to measure patient satisfaction
and specific anaesthesia related outcomes. A questionnaire was devel-
oped and validated to survey various aspects of ambulatory care. Not
only satisfaction with aspects of care delivered by nurses and doctors
but also organisational and safety items were evaluated. We measured
different anaesthesia or surgery related outcome factors. Also differ-
ences between specific patients groups with regard to satisfaction and
anaesthesia outcomes were examined. A special focus was on pain
and postoperative nausea and vomiting (PONV) which are the most im-
portant outcome measures of ambulatory surgery [13,14].
2. Methods
2.1. Setting
The surgical day care centre, that is embedded in the University Hos-
pitals Leuven, in Flanders the Dutch speaking part of Belgium, operates
independently with an own entrance, waiting room, surgical theatre,
Post Anaesthesia Care Unit (PACU) and Day Care Ward (DCW). About
7500 ambulatory interventions are performed annually of which 65%
are in adults. 90% of patients receive general anaesthesia and 10% re-
gional anaesthesia. A large majority of our patients (2014: 95.04%;
2015: 95.08%; 2016: 95.06%) have Dutch as their native language.
Between May 1, 2013 and April 30, 2016, 5820 questionnaires were
distributed.
2.2. Participants
Patients aged 18 years and older, undergoing surgery under general
or regional anaesthesia, were invited to fill in the questionnaire volun-
tarily. Patients, who had a low level of proficiency in Dutch, suffered
from mental illness or for whom it was impossible to complete the
questionnaire themselves or by one of the accompanying relatives,
were excluded.
For this observational study, in which no participants were exposed
to any physical or psychological intervention, patient informed consent
was not mandatory according to Belgian legislation. [Belgian Legislation
of May 7, 2004: “Wet inzake experimenten op de menselijke persoon”
(“Law on experiments involving the human subject”); Article 8, 2°; Ar-
ticle 3, §1]. All surgeons providing care at the surgical day care centre
and the chief physician of the University Hospitals approved the ques-
tionnaire and agreed to ask the patients to collaborate. All question-
naires were analysed confidentially and anonymously according to the
Belgian legislation on privacy [15]. The questionnaire was handed over
in the preoperative box and explained by the attending nurse along
with an explanatory letter. Patients were given the option to leave the
questionnaire in a locked box at discharge and be contacted by phone
about pain scores at home, or to alternatively send the questionnaires
back by regular mail 24 h after discharge. A reply paid envelope was
provided for returning the questionnaire if needed.
2.3. Study outcomes
The primary outcome parameter of the study was to develop a vali-
dated questionnaire to measure patients' satisfaction with all aspects of
care within a surgical day centre. Second, anaesthesia or surgery related
outcomes were evaluated. We examined differences across patients'
gender, age, education, and type of anaesthesia, across disciplines, and
over time.
2.4. Questionnaire development
The questionnaire was developed by the Department of Quality
Control and modified from the HCAHPS® questionnaire [16]. Questions
regarding care delivered by nurses and doctors, discharge, hospital
environment and overall rating were retained while other questions
were deleted for not being applicable to our context (ethnic origin,
race, native language). It was also adapted for the outpatient setting be-
cause some of its original items were not applicable to ambulatory care
and a specific ambulatory surgery questionnaire was not available.
Questions regarding help with the use of the bedpan or bathroom and
those evaluating emotional, mental or general health were omitted.
Other items were added: waiting times, postoperative pain, occurrence
of PONV, type of anaesthesia, indications for awareness and incidence of
readmission [17]. These items are factors affecting patient satisfaction
and/or are clinical indicators of anaesthesia outcome.
In the final version, the questionnaire contained 62 questions for 8
dimensions: ‘Your hospitalisation and reception at the day care centre’,
‘Care by doctors’, ‘Care by nurses’, ‘Communication concerning care and
treatment’, ‘Your Anaesthesia’, ‘Safety in UZ Leuven’, ‘Discharge from
the hospital’, ‘Accessibility, logistics and hotel services’. Some of the
items were dichotomous questions (‘yes’, ‘no’), other items were scored
on a 4 point Likert scale (‘very dissatisfied’, ‘dissatisfied’, ‘satisfied’, ‘very
satisfied’ or ‘never’, ‘sometimes’, ‘usually’, ‘always’) or a 3 point scale
(‘none’, ‘mild’, ‘serious’). Pain scores were evaluated with a numeric rat-
ing scale (NRS: 0 = no pain, 10 = unbearable pain). (See Appendix A:
English translation of the questionnaire).
Patients were not only asked to score the different items but could
also give their opinion via free-form text or could point out suggestions
to change practice.
2.5. Validity of the questionnaire
First, confirmatory factor analysis (CFA) was applied to assess con-
struct validity of the surgical day care survey. CFA implies an evaluation
of whether the hypothesized dimensionality fits our sample. The di-
mensions are referred to as factors. Each factor contains a set of factor
indicators, which are questions from the questionnaire. This relation-
ship between factors and factor indicators is assessed through factor
loadings, with loadings closer to 1 representing a stronger relationship.
Our CFA relies on an independent cluster model (ICM) in which it is as-
sumed that each factor indicator loads on the targeted factor only,
meaning that that cross-loadings between factor indicators and non-
target factors are assumed to be exactly zero. We applied this assump-
tion to 49 questions related to the following 7 factors: ‘Your hospitaliza-
tion and reception at the day care centre’, ‘Care by doctors’, ‘Care by
nurses’, ‘Communication concerning care and treatment’, ‘Safety in UZ
Leuven’, ‘Discharge from the hospital’, and ‘Accessibility, logistics and
hotel services’. The domain of ‘Anaesthesia’ was not included in this
analysis because not all items were relevant to all patients. All 49
items included in this analysis are shown in Table 2. Responses for the
questions ‘Did you receive any contradictory information from nurses’,
and ‘Did you receive any contradictory information from doctors’ were
reverse coded so that a higher score reflects the best possible score for
the hospital, in line with the other questions. All indicators were treated
as categorical. Because of the mix of response categories, we applied
both a CFA model in which the original response categories were used
as well as a model in which response categories were dichotomized.
The latter implies collapsing into ‘(very) dissatisfied’ versus ‘(very)
satisfied’ and ‘never/sometimes’ versus ‘usually/always’. Model fit eval-
uation was based on Hu and Bentler's [18] cut-off criteria for the Com-
parative Fit Index (CFI, ranges between 0 and 1; acceptable if N 0.90,
preferably N0.95) [19], the Tucker–Lewis Index (TLI, ranges between 0
and 1; acceptable if N 0.90, preferably N 0.95) [20], and the Root Mean
Square Error of Approximation (RMSEA, ranges between 0 and 1;
acceptable if b 0.05) [21]. Factor loadings b0.5 were considered for
removal [22]. Generally, a sample size of at least 300 participants is re-
quired for confirmatory factor analysis [23].
Second, descriptive statistics for the factors that resulted from CFA
are provided. Factors were calculated as the percentage of top box
scores (i.e. patients responding ‘always’, ‘very satisfied’, and ‘yes’/‘no’
(depending on the nature of the question, see earlier)) of the items
 A. Teunkens et al. / Journal of Clinical Anesthesia 43 (2017) 15–23 17

that CFA showed to have a high factor loading. An overall percentage of Table 1
top box scores are shown as well as an approximation of the evolution Socio-demographic data.

in top box scores over time. Since no time stamp was available for Characteristics Percentage (n/N)
when the survey was completed, we calculated the percentage of top Gender
box scores for the first thousand questionnaires, the next thousand Male 42.9% (2083/4853)
questionnaires etc. to reflect the evolution in patient satisfaction over Female 57.1% (2770/4853)
time. Age
b24 10.3% (520/5050)
Third, to assess criterion validity we related the factors to global
25–34 16.5% (834/5050)
satisfaction. Criterion validity reflects the extent to which a measure re- 35–44 18.5% (934/5050)
lates to other measures as predicted by theory. Factors were operation- 45–54 22.9% (1158/5050)
alized as the sum of top box scores. Two factors contained more than ten 55–64 18.5% (937/5050)
items and were treated as continuous predictors in the logistic regres- 65–74 11.3% (572/5050)
N75 1.9% (95/5050)
sion analysis. Other factors were treated as categorical predictors. Two Anaesthesia
questions measured global satisfaction and their response categories GA 92.8% (4720/5088)
were operationalized as follows: ‘How satisfied are you in generally RA 7.2% (368/5088)
with your stay at the day care centre’ (‘very satisfied’ (coded as 1) versus Discipline
Abdominal 20.1% (1076/5361)
‘satisfied’/‘dissatisfied’/‘very dissatisfied’ (coded as 0)) and ‘Would you
Gynaecological 15.9% (852/5361)
recommend this hospital at friends and family’ (‘definitely yes’ (coded Stomatology 3.7% (197/5361)
as 1) versus ‘probably yes’, ‘probably no’, ‘definitely no’ (coded as 0)). Breast surgery 2.5% (135/5361)
A series of simple logistic regression analyses were applied to estimate Nose-throat-ear 14.8% (796/5361)
the association between each of the factors and the two global satisfac- Plastic 1.8% (97/5361)
Dental 2.9% (155/5361)
tion measures separately. Findings include estimates and confidence in-
Traumatology 5.7% (307/5361)
tervals for the area under the receiver operating characteristic curve Urology 7.6% (407/5361)
(AUC). Orthopaedic 19.4% (1041/5361)
Other 5.6% (298/5361)
Number of admittances
1 53.4% (2528/4737)
2.6. Statistical analysis 2 27.8% (1318/4737)
3 10.8% (496/4737)
In addition to the above statistical techniques for assessing construct ≥4 8.3% (395/4737)
and criterion validity of the patient survey, an additive multivariable lo- Educational level
Primary school 3.5% (169/4802)
gistic regression model was used to evaluate differences in the presence
High school 42.0% (2018/4802)
of a top-box score as a function of gender, age (categorised), education, College/university degree 54.4% (20,615/4802)
type of anaesthesia, discipline and era (categorised). This was done for
the question pertaining to general satisfaction, for each of the dimen-
sions of satisfaction separately (using a binomial model for the probabil- 3.2. Construct validity of the patient survey
ity of a top-box score for an item referring to a dimension) and for
incidence of nausea and incidence of vomiting. No model reduction Even though CFA is highly restrictive and in many situations leads to
strategies were considered. Using a similar approach, an additive multi- poor model fit, our CFA solution shows an excellent fit to the hypothe-
variable linear regression model was used for evaluation of differences sized factors. This is the case for both the model in which the original
in mean NRS. Least-squares means are reported for all models, setting data are used as well as for the model in which data are dichotomized
the coefficients for the weights of the means to be proportional to (Table 2). Psychometric multidimensionality thus consists of 7 factors
those in the sample. Because of the comprehensive database, there that almost fully concur with the 7 hypothesized factors and cover 45
was a sufficient power to detect small differences, which might not al- of 49 items. Worth noting is that missing data values were remarkable
ways be clinically relevant. The focus should therefore be put on the higher for items related to the factors of discharge from the hospital
size of the differences and not on the mere significance (p b 0.05). and accessibility, logistics and hotel services.
The descriptive analysis and logistic regressions were performed
using SAS software, (version 9.4 of the SAS System for Windows, 3.3. Criterion validity of satisfaction factors
SAS Institute Inc., Cary, NC, USA). The CFA was estimated with Mplus
(version7.1). Table 3 displays further information on these factors. Items are orga-
nized into factors suggested by CFA analysis and which were named
identical to the hypothesized factors (column one). The number of
3. Results items included and hypothesized is shown in column two. The third col-
umn displays the top box percentage, which is the percentage of re-
3.1. Descriptive information sponses to factor items that received the best possible answer. Simple
arithmetic averages are used. The six columns on the right list the esti-
We distributed 5820 questionnaires and 5424 were returned, corre- mates, p-values, and AUC for overall fair associations between the top
sponding to a return rate of 93%. box responses and the two global satisfaction measures.
Socio-demographic data are shown in Table 1. There was an equal
distribution between men and women. Most patients were between 3.4. Patient satisfaction
45 and 54 years old and had at least a high school degree. Slightly
more than half (53%) of patients were admitted only once in the hospi- In general, satisfaction was very high throughout the complete ques-
tal during the last 24 months, and almost all (95%) patients declared tionnaire resulting in a global satisfaction of 98% (59.1% very satisfied
their medical problem was resolved after the surgical intervention. +38.9% satisfied).
Ninety-three per cent received general anaesthesia. Abdominal, Multivariable logistic regression showed that for top-box scores of
orthopaedic, gynaecologic and ENT surgery were the most common both general satisfaction and specific satisfaction dimensions the cate-
disciplines. gories of multiple explanatory variables included in the model had
18 A. Teunkens et al. / Journal of Clinical Anesthesia 43 (2017) 15–23

Table 2
Standardized loading pattern for confirmatory factor analysis with 7 specific factors.

Dimensions and items Missing F1 F2 F3 F4 F5 F6 F7

data values

Your hospitalization and reception at the day care centre

1. How satisfied are you with your welcome in the surgical day centre? 0.35% 0.506
2. How satisfied are you with the period you had to wait before your admission? 0.65% 0.601
3. How satisfied are you with the received information concerning the estimated costs of your hospital stay? 2.65% 0.546

Care by doctors
1. How satisfied are you about the way you were treated by the doctor/specialist with regard to: respect 2.69% 1.003
and courtesy?
2. How satisfied are you about the way you were treated by the doctor/specialist with regard to: 3.37% 0.952
explanation about your condition, investigations, treatment, surgery?
3. How satisfied are you about the way you were treated by the doctor/specialist with regard to: attention 4.17% 0.971
received from doctors?
4. How satisfied are you about the way you were treated by the doctor/specialist with regard to: the 8.48% 0.977
follow-up by the doctor?
5. How satisfied are you about the way you were treated by the doctor/specialist with regard to: your privacy? 6.07% 0.959
6. Did you sometimes receive conflicting information from different doctors? 4.41% 0.312

Care by nurses
1. How satisfied are you about the way you were handled by the nurses with regard to: friendliness and 0.50% 0.987
helpfulness?
2. How satisfied are you about the way you were handled by the nurses with regard to: privacy? 1.57% 0.982
3. How satisfied are you about the way you were handled by the nurses with regard to: the speed of which 3.19% 0.996
the nurses responded to your calls?
4. How satisfied are you about the way you were handled by the nurses with regard to: the attention the 0.96% 0.816
nurses spent to you?
5. Did you receive from different nurses sometimes conflicting information? 1.14% 0.366

Communication concerning care and treatment

1. How satisfied are you with the explanation you received from doctors/nurses regarding: what the 3.83% 0.927
surgery entailed and why it was needed?
2. How satisfied are you with the explanation you received from doctors/nurses regarding: any side 6.66% 0.897
effects/consequences of surgery?
3. How satisfied are you with the explanation you received from doctors/nurses regarding: what 6.91% 0.916
constitutes aftercare?
4. How satisfied are with the waiting times during your stay: in the waiting room (at registration)? 1.51% 0.629
5. How satisfied are with the waiting times during your stay: in the preparation box (before surgery)? 2.06% 0.729
6. How satisfied are with the waiting times during your stay: in the ward (after surgery, before discharge)? 5.35% 0.874
7. How satisfied are you with your contact with the operating theatre itself, related to: kindness? 1.53% 1.042
8. How satisfied are you with your contact with the operating theatre itself, related to: helpfulness? 1.92% 1.052
9. How satisfied are you with your contact with the operating theatre itself, related to: privacy? 2.84% 1.018
10. How satisfied are you with your contact with the operating theatre itself, related to: temperature? 2.56% 0.738
11. How satisfied are you with your contact with the operating theatre itself, related to: explanation you've 2.99% 0.922
received?
12. Did they ask for permission for your surgery and/or a certain anaesthesia technique? 2.34% 0.142
13. Were you informed of the administration of medication? 2.12% 0.307

Safety in UZ Leuven
1. Did you feel safe with the hospital staff? 3.58% 0.693
2. Did nurse/doctors check if you have any allergies? 3.41% 0.554
3. Before the administration of medication, were your name, date of birth and wristband checked? 6.71% 0.784
4. Before having surgery was your name, date of birth and your wristband checked? 4.13% 0.761

The discharge from the hospital

1. How satisfied are you with the information received at discharge regarding: the use of medication? 13.11% 1.018
2. How satisfied are you with the information received at discharge regarding: any complaints or health 16.91% 0.932
problems you need to pay attention to?
3. How satisfied are you with the information received at discharge regarding: activities you could do or 18.73% 0.895
couldn't do?
4. How satisfied are you with the information received at discharge regarding: the help you would probably 18.90% 0.962
need at home?
5. How satisfied are you with the information received at discharge regarding: contact details in case of problems? 18.40% 0.889
6. How satisfied are you with the way your discharge took place? 18.49% 0.740

Accessibility, logistics and hotel services

1. How satisfied are you with the accessibility of the hospital? 10.38% 0.719
2. How satisfied are you with the parking facilities around the hospital? 10.84% 0.557
3. How satisfied are you with the signage in the hospital? 11.03% 0.634
4. How satisfied are you with the patient transport within the hospital? 14.44% 0.990
5. How satisfied are you with the cleanliness/maintenance of the rooms (waiting room, corridors) of the hospital? 10.93% 1.016
6. How satisfied are you with the tranquillity at the floor? 11.62% 0.685
7. How satisfied are you with the meals? 18.27% 0.708
8. How satisfied are you with your room? 22.75% 0.614
9. How satisfied are you with the available information such as: brochures? 20.21% 0.931
10. How satisfied are you with the available information such as: UZ Leuven magazine? 22.14% 1.005
11. How satisfied are you with the available information from UZ Leuven website? 23.41% 0.916
12. How satisfied are you with the available information from information screens? 8.11% 0.980
 A. Teunkens et al. / Journal of Clinical Anesthesia 43 (2017) 15–23 19

Table 2 (continued)
Factor correlations

Factors Your hospitalization and Care by Care by Communication concerning Safety in The discharge Accessibility, logistics
reception at the day care centre doctors nurses care and/or treatment UZ Leuven from the hospital and hotel services
Your hospitalization and
reception at the day care
centre
Care by doctors 0.706
Care by nurses 0.699 0.935
Communication concerning 0.780 0.885 0.902
care and/or treatment
Safety in UZ Leuven 0.088 0.222 0.183 0.284
The discharge from the hospital 0.660 0.699 0.690 0.764 0.348
Accessibility, logistics and hotel 0.596 0.660 0.667 0.751 0.261 0.741
services

Factor loadings represent the relationship of each survey item to the hypothesized dimension, with loadings closer to 1 representing a stronger relationship.

statistically significant differences in satisfaction ratings (Table 4). Age
and education were significant in all instances, with older and higher
educated patients being more likely to provide a top-box score. Male pa-
tients were mostly more satisfied compared to female patients. Patients
in the regional anaesthesia group were more satisfied with care by doc-
tors and communication concerning care or treatment. Findings for the
different disciplines are ambiguous. Last, all satisfaction scores evolved
positively over time.
3.5. Anaesthesia and surgery related outcomes
Findings for specific anaesthesia and surgery related outcomes are
shown in Table 5. An overall incidence of unplanned admissions of 2%
and readmissions of 3.4% was noted.
Multivariable logistic regression showed for some of this anaesthesia
related outcome parameters significant differences in function of multi-
ple explanatory variables (Table 6).
PONV was statistically more present in female than in male patients
(nausea: 16.4% vs. 8.6%, vomiting: 3.7% vs. 1.5%, p b 0.0001). The older
the patient, the lower the incidence of postoperative nausea (p b
0.0001). For vomiting a trend towards age was not present. Although
not statistically significant, there was more nausea in the general than
in the regional anaesthesia group (12.8% vs 8.5%, p = 0.0979) as well
as vomiting (2.5% vs 1.7%, p = 0.4817). The incidence of nausea was sta-
tistically different between the different disciplines (p = 0.0207), but
vomiting was not (p = 0.1212). The highest incidence of nausea
(17.0%) and vomiting (6.8%) was observed in dental surgery. Urologic
patients had the lowest incidence of PONV (nausea: 9.1%, vomiting:
1.1%).

Table 3
Description and association between factors and global satisfaction.

Items included (theorized), Regression analysis

n
Top box Very satisfied with stay Definitely recommend hospital
responses, n
Estimate p-value AUC (95% CI) Estimate p-value AUC (95% CI)

Factors from confirmatory

factor analysis
Your hospitalization 3 (3) 0/3 0 0.736 0 0.698
1/3 1.0619 b0.0001 (0.720–0.751) 0.9639 b0.0001 (0.679–0.717)
2/3 2.0063 b0.0001 1.5116 b0.0001
3/3 2.7242 b0.0001 2.3481 b0.0001
Care by doctors 5 (6) 0/5 0 0.747 0 0.705
1/5 0.1540 0.3993 (0.729–0.764) −0.06240 0.6873 (0.684–0.727)
2/5 1.0523 b0.0001 0.4248 0.0097
3/5 1.4440 b0.0001 0.5620 0.0009
4/5 1.7610 b0.0001 0.9013 b0.0001
5/5 2.4362 b0.0001 1.6284 b0.0001
Care by nurses 4 (5) 0/4 0 0.739 0 0.697
1/4 0.9198 0.0039 (0.719–0.759) 0.4834 0.0571 (0.672–0.722)
2/4 0.6716 0.0324 0.6806 0.0049
3/4 1.3872 b0.0001 0.7019 b0.0001
4/4 2.9736 b0.0001 1.8431 b0.0001
Communication concerning 11 (13) Treated as 0.3451 b0.0001 0.737 0.2090 b0.0001 0.716
care or treatment continuous (0.719–0.755) (0.694–0.738)
Safety in UZ Leuven 4 (4) 0/4 All patients had at least two top box scores.
1/4
2/4 0 0.732 0 0.697
3/4 0.4755 0.3240 (0.714–0.750) 0.6792 0.0311 (0.675–0.719)
4/4 1.0653 0.0009 1.2673 b0.0001
Discharge from the hospital 6 (6) 0/6 0 0.735 0 0.699
1/6 1.2971 b0.0001 (0.714–0.756) 0.5648 0.0021 (0.673–0.725)
2/6 1.3405 b0.0001 0.7931 0.0002
3/6 1.7248 b0.0001 1.1167 b0.0001
4/6 1.9916 b0.0001 1.5489 b0.0001
5/6 1.5512 b0.0001 0.8943 b0.0001
6/6 3.4911 b0.0001 2.4523 b0.0001
Accessibility, logistics and hotel 12 (12) Treated as 0.2780 b0.0001 0.765 0.1643 b0.0001 0.735
services continuous (0.730–0.799) (0.690–0.779)

AUC = Area under the curve; CI = Confidence Interval.

20 A. Teunkens et al. / Journal of Clinical Anesthesia 43 (2017) 15–23

Table 4
Patient satisfaction as a function of gender, age, education, type of anesthesia, discipline and era.

General Your Care by Care by Communication concerning Safety in Discharge from Accessibility, logistics
satisfaction hospitalisation doctors nurses care or treatment UZ Leuven the hospital and hotel services

Gender 0.0003 0.0010 0.0019 0.7842 b0.0001 0.6089 0.0064 b0.0001

Female 57.6% 48.8% 72.2% 85.1% 69.0% 93.4% 61.2% 48.6%
Male 64.1% 52.4% 74.5% 85.0% 71.1% 93.6% 63.4% 54.0%
Age b0.0001 b0.0001 b0.0001 b0.0001 b0.0001 b0.0001 b0.0001 b0.0001
b24 52.6% 42.0% 65.0% 78.8% 62.9% 91.5% 56.1% 48.6%
25–34 48.7% 43.3% 64.6% 80.7% 61.0% 91.3% 50.9% 45.7%
35–44 58.4% 49.2% 71.1% 83.0% 66.9% 92.8% 57.9% 48.3%
45–54 61.6% 51.1% 75.7% 87.4% 72.2% 94.0% 62.5% 51.1%
55–64 69.0% 56.0% 78.3% 88.3% 75.7% 94.7% 69.6% 54.8%
65–74 69.6% 58.8% 80.8% 87.8% 77.1% 95.4% 75.6% 57.7%
N75 73.3% 58.2% 75.2% 87.7% 78.3% 94.6% 69.4% 59.3%
Education b0.0001 0.0046 b0.0001 b0.0001 b0.0001 0.0122 b0.0001 b0.0001
No education or elementary school 48.0% 45.9% 78.1% 78.3% 65.4% 96.8% 61.8% 48.9%
High school, first part 53.4% 46.8% 71.2% 78.7% 66.8% 93.2% 55.7% 45.0%
High school, second part 58.7% 50.9% 74.2% 84.7% 71.0% 94.0% 64.7% 52.0%
Higher education, short type 61.0% 48.9% 72.2% 85.8% 69.8% 93.1% 61.3% 51.0%
Higher education, long type 60.1% 51.7% 70.2% 86.2% 69.8% 92.6% 61.1% 51.3%
University 67.6% 52.8% 74.6% 87.7% 70.6% 92.8% 63.0% 52.4%
Anaesthesia 0.4909 0.3753 0.0131 0.5893 0.0271 0.9754 0.6735 0.4012
GA 60.6% 50.2% 73.0% 85.1% 69.7% 93.5% 62.2% 51.0%
RA 58.3% 52.0% 76.3% 84.4% 71.8% 93.4% 61.5% 50.0%
Discipline 0.0016 0.0027 b0.0001 0.1279 b0.0001 0.0867 b0.0001 b0.0001
Abdominal 56.4% 50.2% 70.6% 84.5% 67.7% 92.9% 60.2% 48.7%
Gynaecological 63.4% 49.3% 76.1% 85.0% 71.4% 93.9% 63.9% 54.8%
Stomatology 49.0% 46.8% 71.4% 82.4% 69.7% 93.4% 62.8% 51.9%
Breast surgery 61.5% 54.6% 84.1% 84.9% 72.5% 94.7% 59.5% 52.7%
Nose-throat-ear 63.2% 48.5% 73.4% 85.0% 72.4% 94.2% 62.9% 51.1%
Plastic 66.7% 43.9% 74.3% 82.7% 66.5% 93.3% 57.7% 49.4%
Dental 59.4% 47.7% 72.7% 83.4% 68.5% 94.9% 62.5% 48.4%
Traumatology 54.1% 56.4% 67.5% 84.3% 67.6% 93.6% 56.2% 46.2%
Urology 57.2% 48.1% 71.1% 83.6% 67.7% 93.9% 61.2% 48.6%
Orthopaedic 61.7% 53.5% 71.7% 87.0% 68.8% 92.0% 62.2% 50.9%
Other 68.7% 49.2% 81.9% 86.3% 74.6% 94.4% 69.2% 53.1%
Time 0.0007 0.0031 b0.0001 b0.0001 b0.0001 0.0417 b0.0001 b0.0001
Questionnaires 1–1000 57.7% 50.8% 72.5% 84.1% 69.4% 92.5% 61.7% 47.5%
Questionnaires 1001–2000 58.4% 47.9% 70.8% 82.7% 67.2% 93.0% 61.1% 47.7%
Questionnaires 2001–3000 57.2% 49.0% 71.4% 84.9% 69.0% 93.8% 59.4% 51.9%
Questionnaires 3001–4000 63.4% 52.1% 75.6% 86.8% 72.3% 93.8% 63.2% 52.2%
Questionnaires 4001–5424 65.8% 52.7% 76.3% 87.1% 72.3% 94.2% 65.3% 56.3%

All results are obtained from a multivariable logistic regression.

Least-squares means are reported from all models (setting the coefficients for the weights of the means to be proportional to those in the sample).

Mean pain scores (NRS score: 0 = no pain, 10 = unbearable pain)
were significantly higher in females compared to males (PACU: 3.41
vs 2.54, p b 0.0001; DCW: 2.15 vs 1.82, p b 0.0001, at home: 1.26 vs
0.94; p = 0.0003). After general anaesthesia compared with regional
anaesthesia, mean pain scores were higher at the PACU and the DCW
(PACU: 3.25 vs. 0.39, p b 0.0001; DCW: 2.07 vs. 1.29, p b 0.0001).
Mean pain scores also differed among the different disciplines (p b
0.0001), especially traumatology, orthopaedic and abdominal patients
scored relatively higher. In contrast with the satisfaction scores, these
anaesthesia and surgery related outcomes did not change over time.
4. Discussion

Patient satisfaction is one of the primary health care outcomes and

Table 5 must be evaluated with a valid questionnaire. In 2016, within the US
Anaesthesia and surgery related outcomes.
CAHPS programme researchers developed a questionnaire specific for
Outcomes Incidence outpatient and ambulatory surgery (https://oascahps.org). This ques-
Pain during injection of propofol 27.3% tionnaire contains almost the same items as those used in this study,
Sore throat 29.8% except for the questions about waiting times (not included in CAHPS)
Memory disturbances 10.5% and ethnic origin, race and native language (included in CAHPS). Our
PONV questionnaire is unique in simultaneously evaluating patient satisfac-
Nausea 13.9%
Vomiting 3.3%
tion as well as anaesthesia and surgery related outcomes in the same
Severe pain (VAS N 6) questionnaire.
PACU 13.2% Our study has a number of other strengths, including high return
DCW 3.1% rate and the use of appropriate statistical techniques that demon-
At home 1.8%
strate good construct and criterion validity. The study has limitations
Home readiness at discharge 98.1%
Unplanned admission 2.0% as well. Unfortunately, not all patients who were admitted to the day
Readmission 3.4% care centre and met the inclusion criteria (≥ 18 years, general or re-
Surgical reason 75.0% gional anaesthesia, no mental disease) received a questionnaire.
Anaesthetic reason 13.2% The most common reasons were that the patients were not interest-
Social reason 11.8%
ed in participating, the forgetfulness of the attending nurse in the
 A. Teunkens et al. / Journal of Clinical Anesthesia 43 (2017) 15–23 21

Table 6
Anaesthesia related outcomes as a function of gender, age, education, type of anesthesia, discipline and era.

Nausea p-value Vomiting p-value Pain PACU p-value mean Pain DCW p-value mean Pain at home p-value mean
incidence % incidence % VAS VAS VAS

Gender b0.0001 b0.0001 b0.0001 b0.0001 0.0003

Female 16.4% 3.7% 3.41 2.15 1.26
Male 8.6% 1.5% 2.54 1.82 0.94
Age b0.0001 0.2491 0.0001 0.0027 0.0599
b24 20.2% 3.3% 3.04 2.17 1.15
25–34 15.4% 2.6% 3.39 2.25 1.28
35–44 14.1% 2.4% 3.22 2.07 1.27
45–54 12.6% 3.3% 2.99 1.88 1.08
55–64 9.3% 2.4% 2.77 1.86 0.96
65–74 7.0% 1.0% 2.71 1.85 0.91
N75 11.8% 2.6% 3.09 2.27 1.25
Education 0.9676 0.2607 0.0033 0.0008 0.8080
No education or elementary 11.8% 3.0% 3.43 2.35 1.42
school
High school, first part 13.2% 2.5% 3.16 2.07 1.09
High school, second part 12.2% 2.8% 3.08 2.16 1.10
Higher education, short type 12.6% 3.2% 3.06 1.98 1.11
Higher education, long type 13.6% 1.4% 3.24 1.96 1.14
University 12.1% 1.9% 2.72 1.75 1.13
Anaesthesia 0.0979 0.4817 b0.0001 b0.0001 0.7398
GA 12.8% 2.5% 3.25 2.07 1.12
RA 8.5% 1.7% 0.39 1.29 1.07
Discipline 0.0207 0.1212 b0.0001 b0.0001 b0.0001
Abdominal 16.6% 3.5% 3.40 2.41 1.51
Gynaecological 11.6% 2.5% 2.52 1.67 0.74
Stomatology 13.0% 2.6% 2.81 2.20 1.53
Breast surgery 9.7% 1.4% 2.86 1.89 1.09
Nose-throat-ear 10.7% 2.2% 2.56 1.51 0.70
Plastic 16.5% 0.9% 2.75 2.17 1.12
Dental 17.0% 6.8% 2.56 1.96 1.70
Traumatology 12.1% 1.9% 3.93 2.53 1.49
Urology 9.1% 1.1% 2.13 1.41 0.95
Orthopaedic 12.6% 2.7% 4.09 2.47 1.35
Other 11.7% 2.9% 2.27 1.76 0.70
Time 0.7240 0.5471 0.0942 0.1045 0.3084
Questionnaires 1–1000 13.8% 2.6% 2.87 1.98 1.22
Questionnaires 1001–2000 12.4% 2.9% 3.05 2.05 1.15
Questionnaires 2001–3000 11.7% 1.8% 2.93 1.85 0.99
Questionnaires 3001–4000 12.9% 2.5% 3.12 2.01 1.05
Questionnaires 4001–5424 12.0% 2.5% 3.21 2.14 1.18

All results are obtained from a multivariable logistic regression.

Least-squares means are reported from all models (setting the coefficients for the weights of the means to be proportional to those in the sample).
VAS: visual analogue scale from 0 to 10 (0 = no pain, 10 = unbearable pain).

preoperative unit, the lack of Dutch proficiency and the lack of time
to explain the questionnaire in the preoperative unit due to the
high turnover in the operation room. In case of repeated surgery, pa-
tients filled in the questionnaire only once.
Another limitation is the application of our questionnaire in a single-
centre only. Further testing could assess measurement invariance, for
which we could expand on our confirmatory factor analytic model by
conducting multiple group confirmatory factor analysis. This would
allow us to study whether across groups (across male and female
patients; across disciplines; across cultures when the questionnaire is
applied in other countries; etc.), over time, or across survey modes
(electronic versus paper based), the same pattern of association be-
tween items and factors and the same number of factors occur. Demon-
strating strong measurement invariance is a requirement for drawing
valid comparisons across groups, over time or across survey modes [24].
Last, high missing data values were noted for the factors of discharge
from the hospital and accessibility, logistics and hotel services. While
the latter is less worrisome and could be explained by the limited
amount of time patients spend in our day care centre, non-completion
of questions related to discharge management should be further inves-
tigated. Especially since discharge management was poorly rated it
should be studied whether non-completion also reflects not having re-
ceived discharge information.
In general, patients were very satisfied with the quality of care in our
day care surgical centre. This finding is in agreement with the literature
describing a satisfaction score with health care of N80% [3,4]. However,
the fact that the patients were asked to participate in the study, hereby
suggesting we were concerned for their wellbeing and satisfaction
could have influenced their scoring. Satisfaction scores were also inves-
tigated as a function of different variables. We noted higher scores at
the end of the audit then in the beginning. A possible explanation is
the extensive feedback mechanism that was implemented in our centre,
with a complete team attentively and continuously searching for an im-
provement of care. Older people are in our audit more satisfied than
younger ones and men are more satisfied than women. These findings
confirm other data from literature [3,12].
Pain scores were similar in our ambulatory centre compared to those
generally reported in the literature [25]. Certainly at the PACU, pain
scores were still unacceptably high (31.4% of the patients having a
NRS N 4, 13.2% even having a NRS N 6). In the DCW the incidence of pa-
tients having a NRS N 4 decreased to 12.7%, and at home, only 4.9% of pa-
tients complained of moderate or severe pain. However these scores are
substantially lower compared to the results of Beauregard et al. [14].
They reported pain scores higher than 4 in 40% of patients during
their hospitalization and 35% of patients at discharge, but paracetamol
or nonsteroidal anti-inflammatory agents were not used systematically,
22 A. Teunkens et al. / Journal of Clinical Anesthesia 43 (2017) 15–23
which is usually the case in our unit. In a prospective study of ambula-
tory cholecystectomies Kavanagh et al. concluded that 23% of patients
had severe pain 24 h after discharge [26], whereas only 4.9% of patients
had a pain score N4 and only 1.8% N 6 at home in our audit. Postoperative
pain after day surgery still remains underestimated, and perioperative
analgesic treatment should be more aggressive and be more adjusted
to the individual needs of every patient. However, anaesthesiologists
are often restrictive in giving strong opioids postoperatively because
the PACU stay might be prolonged and the incidence of PONV will
increase.
Lovatsis et al. and Segerdahl et al. reported only 60% of patients being
satisfied with their pain treatment after ambulatory surgery compared
to a N80% satisfaction score in our audit. Our results are in accordance
with those of Beauregard et al. [14,27]. This paradox between high sat-
isfaction scores despite the high pain levels is often observed in other
surveys [28]. The reason is probably that patients expect a certain
level of pain postoperatively and as long as the nurses and doctors pay
attention to their pain and discuss the importance of a good pain treat-
ment patients are satisfied.
Pain scores were significantly lower in the regional anaesthesia
group compared to the general anaesthesia group. This finding is overall
accepted in literature [29]. Nevertheless, it did not influence global sat-
isfaction scores. In other studies there was not sufficient data to deter-
mine if type of anaesthesia, analgesic technique or degree of analgesia
influences patient satisfaction [30,31].
Our findings must be interpreted with caution. Because of the large
sample size, small differences are detected as statistically different, but
these differences may be clinically irrelevant [32,33]. For example, the
value of minimum clinically important difference (MICD) in acute pain
described in the literature, differs from 8 to 40 mm (on a100 mm
scale). Whereas MICD is always context-specific and influenced by
patient's baseline pain, the clinical relevance of our results, although
being statistically significant, is difficult to evaluate [34,35].
Nausea is reported in 13.9% of patients and vomiting in 3.3% of pa-
tients in our audit.
The overall incidence of vomiting reported in literature is 30%, and
the incidence of nausea is about 50%. This incidence increases to 80%
in high-risk patients [36].
After ambulatory surgery the incidence of nausea is about 30% and
decreases to 6.8% when a peripheral nerve block is used [13]. This result
is comparable to our incidence of nausea after RA of 8.5%, but after gen-
eral anaesthesia, our incidence is much lower (12.8%). This can be due to
the fact we use prophylactic medication to prevent PONV in a very strict
and standardized fashion.
Every antiemetic intervention can reduce the risk with approxi-
mately 25% [13]. In our day-care centre, all patients received at
least one anti-emetic in case of general anaesthesia. The incidence
of PONV was higher in females and younger patients representing
risk factors for PONV [37]. Unfortunately, we are not able to distin-
guish the difference between PONV and post discharge nausea and
vomiting (PDNV). PDNV is an under-recognised and undertreated
problem after ambulatory surgery that can influence patient satisfac-
tion, is negatively related to patients quality of life and is an impor-
tant outcome indicator after day care surgery [13,38,39]. Pain can
influence this late PDNV [40].
The incidence of unplanned admission is 2.0% which is lower than
the 3% usually accepted in guidelines for day surgery, whereas in the lit-
erature it varies between 0.9% and 9.4% [41]. In our audit, only 13.2% of
unplanned admissions were due to an anaesthetic reason which is
much lower as the incidence reported by Whippey (20%) and by
Margovsky (37%) [41,42]. This could be due to a careful selection of pa-
tients and operations during the preoperative consultation, which is
mandatory before a patient can be planned in the day-centre. Further-
more, the low incidence of PONV, high satisfaction score regarding post-
operative pain treatment can also contribute to this lower incidence of
unplanned admissions.
5. Conclusion
Measuring patient satisfaction is an important tool for continuous
quality improvement in an ambulatory surgical unit. Due to its complex
psychological and also subjective context, there is still no standardized
instrument to measure patient satisfaction.
Our questionnaire was developed to simultaneously evaluate satis-
faction and anaesthesia and surgery related outcomes in a surgical day
centre. Findings for construct validity showed an excellent fit to the
hypothesized factors. Overall satisfaction was very high but specific as-
pects of the care process, such as discharge information, show much
room for improvement.
Pain scores were considered too high and also PONV incidence
should be decreased. This can be achieved by using regional anaesthesia
for surgery whenever possible.
Acknowledgements
We would like to thank our study nurse Christel Huygens for her
valuable assistance and all the nurses of the surgical day centre for their
cooperation.
Disclosure
None of the authors has any conflict of interest to report.
The authors did not receive any funding to support this study.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jclinane.2017.09.007.
References
[1] Yellen E, Davis GC. Patient satisfaction in ambulatory surgery. AORN J 2001;74 (483–
6–489–94–496–8).
[2] Heidegger T, Saal D, Nübling M. Patient satisfaction with anaesthesia - Part 1: satis-
faction as part of outcome - and what satisfies patients. Anaesthesia 2013;68:
1165–72. https://doi.org/10.1111/anae.12347.
[3] Whitty PM, Shaw IH, Goodwin DR. Patient satisfaction with general anaesthesia. Too
difficult to measure? Anaesthesia 1996;51:327–32.
[4] Fung D, Cohen MM. Measuring patient satisfaction with anesthesia care: a review of
current methodology. Anesth Analg 1998;87:1089–98.
[5] Bruyneel L, Li B, Ausserhofer D, Lesaffre E, Dumitrescu I, Smith HL, et al. Organization
of hospital nursing, provision of nursing care, and patient experiences with
care in Europe. Med Care Res Rev 2015;72:643–64. https://doi.org/10.1177/
1077558715589188.
[6] Chou SC, Boldy D. Patient perceived quality-of-care in hospital in the context of clin-
ical pathways: development of an approach. J Qual Clin Pract 1999;19:89–93.
[7] Joan. Measuring patient assessments of the quality of outpatient care: a systematic
review; 2008 1–7.
[8] Nübling M, Saal D, Heidegger T. Patient satisfaction with anaesthesia - Part 2: con-
struction and quality assessment of questionnaires. Anaesthesia 2013;68:1173–8.
https://doi.org/10.1111/anae.12348.
[9] Chanthong P, Abrishami A, Wong J, Herrera F, Chung F. Systematic review of ques-
tionnaires measuring patient satisfaction in ambulatory anesthesia. Anesthesiology
2009;110:1061–7. https://doi.org/10.1097/ALN.0b013e31819db079.
[10] Bauer M, Böhrer H, Aichele G, Bach A, Martin E. Measuring patient satisfaction with
anaesthesia: perioperative questionnaire versus standardised face-to-face interview.
Acta Anaesthesiol Scand 2001;45:65–72.
[11] Schiff JH, Fornaschon AS, Frankenhauser S, Schiff M, Snyder-Ramos SA, Martin E,
et al. The Heidelberg Peri-anaesthetic Questionnaire–development of a new refined
psychometric questionnaire. Anaesthesia 2008;63:1096–104. https://doi.org/10.
1111/j.1365-2044.2008.05576.x.
[12] Caljouw MAA, van Beuzekom M, Boer F. Patient's satisfaction with perioperative
care: development, validation, and application of a questionnaire. Br J Anaesth
2008;100:637–44. https://doi.org/10.1093/bja/aen034.
[13] Kolodzie K, Apfel CC. Nausea and vomiting after office-based anesthesia. Curr Opin
Anaesthesiol 2009;22:532–8. https://doi.org/10.1097/ACO.0b013e32832dba81.
[14] Beauregard L, Pomp A, Choinière M. Severity and impact of pain after day-surgery.
Can J Anesth 1998;45:304–11. https://doi.org/10.1007/BF03012019.
[15] Wade DT. Ethics, audit, and research: all shades of grey. BMJ 2005;330:468–71.
https://doi.org/10.1136/bmj.330.7489.468.
[16] Giordano LA, Elliott MN, Goldstein E, Lehrman WG, Spencer PA. Development, im-
plementation, and public reporting of the HCAHPS survey. Med Care Res Rev
2010;67:27–37. https://doi.org/10.1177/1077558709341065.
 A. Teunkens et al. / Journal of Clinical Anesthesia 43 (2017) 15–23
[17] Myles PS, Williams DL, Hendrata M, Anderson H, Weeks AM. Patient satisfaction
after anaesthesia and surgery: results of a prospective survey of 10,811 patients.
Br J Anaesth 2000;84:6–10.
[18] Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis:
conventional criteria versus new alternatives. Struct Equ Model Multidiscip J
2009;6:1–55. https://doi.org/10.1080/10705519909540118.
[19] Bentler PM. Fit indexes, lagrange multipliers, constraint changes and incomplete
data in structural models. Multivar Behav Res 1990;25:163–72. https://doi.org/10.
1207/s15327906mbr2502_3.
[20] Tucker LR, Lewis C. A reliability coefficient for maximum likelihood factor analysis.
Psychometrika 1973;38:1–10. https://doi.org/10.1007/BF02291170.
[21] Steiger JH. Structural model evaluation and modification: an interval estima-
tion approach. Multivar Behav Res 1990;25:173–80. https://doi.org/10.1207/
s15327906mbr2502_4.
[22] Hair JF. Multivariate data analysis; 2009.
[23] Chen FF. Sensitivity of goodness of fit indexes to lack of measurement invariance.
Struct Equ Model Multidiscip J 2007;14:464–504. https://doi.org/10.1080/
10705510701301834.
[24] Steenkamp J-BEM, Baumgartner H. Assessing measurement invariance in cross-na-
tional consumer research. J Consum Res 1998;25:78–90. https://doi.org/10.1086/
209528.
[25] Schug SA, Chong C. Pain management after ambulatory surgery. Curr Opin
Anaesthesiol 2009;22:738–43. https://doi.org/10.1097/ACO.0b013e32833020f4.
[26] Kavanagh T, Hu P, Minogue S. Daycase laparoscopic cholecystectomy: a prospective
study of post-discharge pain, analgesic and antiemetic requirements. Ir J Med Sci
2008;177:111–5. https://doi.org/10.1007/s11845-008-0131-5.
[27] Segerdahl M, Warren-Stomberg M, Rawal N, Brattwall M, Jakobsson J. Clinical prac-
tice and routines for day surgery in Sweden: results from a nation-wide survey. Acta
Anaesthesiol Scand 2008;52:117–24. https://doi.org/10.1111/j.1399-6576.2007.
01472.x.
[28] Comley AL, DeMeyer E. Assessing patient satisfaction with pain management
through a continuous quality improvement effort. J Pain Symptom Manage 2001;
21:27–40.
[29] Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general
anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled tri-
als. Anesth Analg 2005;101:1634–42. https://doi.org/10.1213/01.ANE.0000180829.
70036.4F.
[30] Liu SS, Wu CL. The effect of analgesic technique on postoperative patient-reported
outcomes including analgesia: a systematic review. Anesth Analg 2007;105:
789–808. https://doi.org/10.1213/01.ane.0000278089.16848.1e.
23
[31] Wu CL, Naqibuddin M, Fleisher LA. Measurement of patient satisfaction as an out-
come of regional anesthesia and analgesia: a systematic review. Reg Anesth Pain
Med 2001;26:196–208. https://doi.org/10.1053/rapm.2001.22257.
[32] Walder B, Maillard J, Lübbeke A. Minimal clinically important difference: a novel ap-
proach to measure changes in outcome in perioperative medicine. Eur J Anaesthesiol
2015;32:77–8. https://doi.org/10.1097/EJA.0000000000000147.
[33] Shulman M, Myles P. Measuring perioperative outcome. Curr Opin Anaesthesiol
2016;29:733–8. https://doi.org/10.1097/ACO.0000000000000383.
[34] Olsen MF, Bjerre E, Hansen MD, Hilden J, Landler NE, Tendal B, et al. Pain relief that
matters to patients: systematic review of empirical studies assessing the minimum
clinically important difference in acute pain. BMC Med 2017;15:35. https://doi.org/
10.1186/s12916-016-0775-3.
[35] Sloman R, Wruble AW, Rosen G, Rom M. Determination of clinically meaningful
levels of pain reduction in patients experiencing acute postoperative pain. Pain
Manag Nurs 2006;7:153–8. https://doi.org/10.1016/j.pmn.2006.09.001.
[36] Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, et al. Consensus guide-
lines for the management of postoperative nausea and vomiting. Anesth Analg
2014;118:85–113. https://doi.org/10.1213/ANE.0000000000000002.
[37] Geralemou S, Gan TJ. Assessing the value of risk indices of postoperative nausea and
vomiting in ambulatory surgical patients. Curr Opin Anaesthesiol 2016:1–6. https://
doi.org/10.1097/ACO.0000000000000400.
[38] Apfel CC, Philip BK, Cakmakkaya OS, Shilling A, Shi Y-Y, Leslie JB, et al. Who is at risk
for postdischarge nausea and vomiting after ambulatory surgery? Anesthesiology
2012;117:475–86. https://doi.org/10.1097/ALN.0b013e318267ef31.
[39] Odom-Forren J, Hooper V, Moser DK, Hall LA, Lennie TA, Holtman J, et al.
Postdischarge nausea and vomiting: management strategies and outcomes over 7
days. J Perianesth Nurs 2014;29:275–84. https://doi.org/10.1016/j.jopan.2013.12.
007.
[40] Odom-Forren J, Jalota L, Moser DK, Lennie TA, Hall LA, Holtman J, et al. Incidence and
predictors of postdischarge nausea and vomiting in a 7-day population. J Clin Anesth
2013;25:551–9. https://doi.org/10.1016/j.jclinane.2013.05.008.
[41] Whippey A, Kostandoff G, Paul J, Ma J, Thabane L, Ma HK. Les prédicteurs d'une admis-
sion non anticipée après une chirurgie ambulatoire: une étude cas-témoin rétrospec-
tive. Can J Anesth 2013;60:675–83. https://doi.org/10.1007/s12630-013-9935-5.
[42] Margovsky A. Unplanned admissions in day-case surgery as a clinical indicator for
quality assurance. Aust N Z J Surg 2000;70:216–20.
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