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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 38-46

Anesthesia-related perioperative patient safety services in Indian public and private hospitals with or without teaching programs: A matched analysis of qualitative survey data

Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Date of Submission27-Jul-2020
Date of Acceptance11-May-2021
Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Habib Md Reazaul Karim
Faculty Room No. A001. Block A, AIIMS Raipur Hospital Complex, GE Road, Tatibandh, Raipur - 492 099, Chhattisgarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_102_20

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Introduction: The World Health Organization is emphasizing global patient safety for more than a decade. However, very less is known about the patient safety environment in the perioperative settings in developing countries. The present secondary analysis aimed to compare the anesthesia-related patient safety measures and services in Indian public versus private and teaching versus nonteaching hospitals.
Materials and Methods: The present study is a post hoc, subgroup analysis of a previously conducted cross-sectional, questionnaire-based, online survey during February–May 2019. Responses from the postgraduate trainee and consultant/qualified practitioners were included. Data related to the practice pattern and availability of standard, advanced monitoring, and equipment were then categorized based on the hospital funding source and availability of teaching program; compared using the Fisher's exact test, and P < 0.05 was considered statistically significant.
Results: Six hundred responses were included. The majority (60.7%) were from the private sector; 57.3% worked in teaching hospitals. Overall, anesthesia-related patient safety and equipment were deficient across the entire range of hospitals. However, there was no difference between matched public and private hospitals (P > 0.05 for most), except the anonymous incident reporting, which was significantly higher in the corporate teaching hospitals (P < 0.0001). Teaching hospitals had significantly better safety measures (P < 0.0001 for most parameters) than nonteaching hospitals.
Conclusion: Public sector hospitals in India are not having significantly different anesthesia services related to patient safety monitoring and equipment than private sector hospitals. However, the safety measures are relatively low in many aspects across all sectors, which need attention.
The following core competencies are addressed in this article: Patient care, Systems-based practice.

Keywords: Anesthesia, economy, health care service, patient safety

How to cite this article:
Karim HM, Kumar M, Sinha M. Anesthesia-related perioperative patient safety services in Indian public and private hospitals with or without teaching programs: A matched analysis of qualitative survey data. Int J Acad Med 2022;8:38-46

How to cite this URL:
Karim HM, Kumar M, Sinha M. Anesthesia-related perioperative patient safety services in Indian public and private hospitals with or without teaching programs: A matched analysis of qualitative survey data. Int J Acad Med [serial online] 2022 [cited 2023 Jun 5];8:38-46. Available from: https://www.ijam-web.org/text.asp?2022/8/1/38/341181

  Introduction Top

The Iron triangle of health care, as described by Lawton Robert Burns, consists of three interdependent goals, i.e. patient access, efficiency/cost containment, and high-quality care.[1] Over or under due to any one of these three can affect the others. Else ways, cost containment, can affect the quality of service, compromising patient safety, and outcome. The Indian health-care system is diverse and mainly consists of public and private sector hospitals.[2],[3] The health expenditure in the public sector is dependent on the government budget, while the private sector is mostly dependent on their promoters/owners. Although policies regulate the health-care system, research on India's health care regulation and policies indicates several gaps in policy design and implementation.[3]

The World Health Organization's (WHO) global patient safety campaign is crucial for patient safety during surgery. The health service quality of developing countries carries a critical significance. India is the habitat of nearly 17.75% population of the world,[4] making this more relevant. Moreover, the Indian diverse and enormous health-care system is also likely to have differences in quality, and knowing these might help the health-care authorities better plan and implement the policies. Continued improvement of anesthesia-related safety has contributed to the reduction in perioperative mortality.[5] Over and above-skilled anesthesiologists, anesthesia safety depends on the equipment, drugs, and health-care facility.[6] We hypothesize that funding might impact the anesthesia-related patient safety measures across different hospitals.

  Methods Top

The present research is a post hoc subgroup, secondary data analysis from a cross-sectional, national-level survey conducted from February 2019 to May 2019.[7] The reporting follows Standards for Reporting Qualitative Research to enhance the quality and transparency of health research (EQUATOR). Departmental permission was obtained with an exemption for ethical approvals, and as per the clinical trial registry-India, the survey did not require registration. The electronic survey was created and conducted using free online survey software and questionnaire tool service from Google Forms (Google LLC.; Mountain View, California, United States [U.S.]). The survey questionnaire consisted of specific aspects for workplace information about the practitioner's hospital, including hospital type (i.e., Autonomous teaching institute [ATI], government medical colleges [GMC], private medical colleges [PMC], corporate teaching hospitals [CTH], government sector nonteaching hospital [GNTH ], and private sector nonteaching hospital [PNTH]), of the responder.

The original online survey used 18 questions in the different anesthesia and patient safety service-related aspects, namely preanesthetic preparation for the case to be conducted, patient-related standard, and advanced monitoring.[7] The questionnaire was prepared based on the different prevailing guideline from the national and international societies like the All India Difficult Airway Association guideline were taken as the basis for airway management, the American Society of Anesthesiologists (ASA) for patient monitoring, the American Society of Regional Anesthesia for regional anesthesia-related safety and preparation, the Association of Anesthesiologists of Great Britain and Ireland, and the WHO-World Federation of Societies of Anesthesiologists international guideline for patient safety.

We hypothesized that the availability of the patient safety-related monitoring and equipment for both public versus private and teaching versus nonteaching subgroups are not similar and assumed a minimum of 50% differences among the subgroups (i.e. 66.7% vs. 33.3% when totaled to 100%). However, as not all hospitals of even the highest standard are expected to have entire monitoring, further refinement of our assumption was done based on the findings of the original study.[6] The original survey found that advanced yet essential monitoring such as oxygen analyzer, anesthesia gas analyzer, and minimum alveolar concentration monitoring were present between 30% and 70% among the responders.[7] We took the average, i.e. (70 + 30)/2 = 50% as the baseline availability among the entire cohort and corrected the assumed availability for the baseline, i.e. 66.7% of 50 = approximately 33% versus 33% of 50 = approximately 17%. The sample size was calculated using the Fleiss method with continuity correction, and the online free epidemiological tool “OpenEpi” (www.openepi.com) was used for the purpose. The absolute precision of 5% and a power of 80% were taken, and the required sample came to be 129 per group. Considering the nonrandomized nature of sampling, a design effect of 1.4 was also applied to reach the final sample size of 181 (minimum) in each group for a 95% confidence level.

The responses were directly downloaded from the Google form as an Excel file master chart and processed for grossly incomplete and duplicate responses for exclusion from the analysis and apparent discrepancy for possible correction for data processing. If the discrepancy was not apparent, it was left as it is. The cohort was then subgrouped based on the teaching facility, and ATI, GMC, PMC, and CTH were taken as teaching hospitals, whereas PNTH and GNTH were taken as nonteaching hospital setups. Similarly, the cohort was also sub-grouped based on the administration and funding into public and private, and ATI, GMC, and GNTH were taken as public setup hospitals, whereas CTH, PMC, and PNTH were taken private hospital setups. Further to reduce the bias and reach a better interpretation, a matched analysis was performed by comparing ATI with CTH, GMC with PMC, and GNTH with PNTH. The parameters related to the preparation for the case, patient monitoring both basic and advanced, and patient safety-related equipment, drug, and auditing were calculated for both the subgroups for the comparison.

Absolute numbers and percentages are used to represent the distribution of different responses across categories. Further data management was done using the Fisher's exact test to compare the frequencies among different groups and sub-groups. All tests were two-tailed, and a P < 0.05 was considered statistically significant. The INSTAT software version. 3 (GraphPad Prism Software Inc., La Jolla, CA, U.S.) was used for the purpose.

  Results Top

The survey response collection and data management process are represented in the flow chart in [Figure 1]. A total of 600 responses were included for the analysis, whereas the majority 364 (60.7%) responses were from the private sector. On the other hand, 344 (57.3%) were working in teaching hospitals. Nearly half of the responders working in the public sector and teaching hospitals had work experience of ≤5 years [Table 1].
Figure 1: Flow chart showing enrolment, data collection, and processing

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Table 1: Working-place and experience wise distribution of the responders expressed in absolute number, percentage scale and compared using Fisher's exact test

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While there were no statistically significant differences in the WHO surgical safety checklist between teaching versus nonteaching (54.6% vs. 61.7%, P = 0.228), private setups were following the same significantly more than public sectors (P < 0.0001). Preoperative preparation, machine and equipment check, and drug preparations were performed mainly by residents in teaching hospitals, while these tasks were mainly performed by technicians, nurses, and consultants in the private setups [Table 2]. Peripheral oxyhemoglobin saturation (SpO2) and noninvasive blood pressure (NIBP) monitoring were equally present across the public, private, teaching, and nonteaching setups. However, advanced monitoring was significantly lower in private setups than public and nonteaching setups versus teaching setups [Table 2]. Although there was an insignificant difference in capnography monitoring (EtCO2) between public versus private hospitals, nonteaching hospitals were having a significantly lower EtCO2 monitoring facility (78.5% vs. 95.6%, P < 0.0001) [Table 2].
Table 2: Preoperative preparation, basic and advanced monitoring availability across the different setups expressed in absolute number and percentage scale, and their comparison using the Fisher's exact test

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There was no difference between public and private setups regarding patient and procedure safety-related equipment availability, but a significantly higher proportion of teaching facilities had this equipment available compared to nonteaching setups [Table 3].
Table 3: Availability of procedure related advanced equipment and practice of incident reporting across different hospital set-ups compared using Fisher's exact test

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In the matched analysis, it was found that CTH and PMC had a comparable standard and advanced monitoring available as compared to ATI and GMC, respectively. The same was also true for nonteaching hospitals of public and private sectors except for anesthesia gas monitoring, which was significantly more available in public sector nonteaching hospitals (60% vs. 31.5%, P= 0.01) [Table 4]. Similar results were also noted for patient and procedure safety-related equipment availability, and ATI versus CTH, GMC versus PMC, and GNTH versus PNTH were mainly statistically insignificant [Table 5].
Table 4: Matched comparison of experience, preoperative preparation practices and monitoring availability expressed in absolute number and percentage scale, tested using Fisher's exact test

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Table 5: Matched comparison of advanced equipment availability and anonymous incident reporting practices across the set-ups tested using Fisher's exact test

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  Discussion Top

The present secondary analysis of a previously conducted online survey is probably the first to compare the anesthesia-related patient safety services among the public and private hospitals with or without teaching programs in India. The findings indicate that overall anesthesia-related safety services are weak across the entire health-care system irrespective of funding authority and background. While it is an encouraging finding that nearly entire setups had SpO2, NIBP, and number of setup were not having EtCO2, which is part of ASA standard monitoring and essential for patient safety point of view perioperative care. Interestingly, although most of the setups in the CTHs and ATI were having advanced monitoring, these were unavailable in many of the medical colleges of both public and private sectors and most of the nonteaching hospitals.

On the other hand, patient safety recommendation indicates these, i.e. oxygen concentration, anesthesia gas concentration, depth of anesthesia monitoring as essential monitoring.[8],[9] Notably, anesthesia service-related safety equipment was very much lacking even in the institutes and CTHs. Therefore, patient safety can be assumed as jeopardized in those setups too.

The other important finding of the present analysis de-bunks a common perception. It is presumed that the private sector may meet patients' inquiries, and private sector tertiary and quaternary hospitals may meet the patients' higher expectations as it is mostly fully paid services to the peoples who can afford. However, in public hospitals, the health-care providers need to act as per the laid down standards irrespective of the paying capability of the patients and at a concessional price or free of cost. A study indicates that individual income and hospital expenditure have an impact on selecting health-care facilities.[10] Therefore, it is believed that patients who come to the private hospitals would expect and be serviced more.[11] A Turkish study indicates that inpatient service quality is better in private setups.[12] Another study and the quality of health services in public and private setups of Iran from the patients' perspective observed a significant difference in the quality and public sector hospital.[13] Although quality and safety go side by side, the Turkish and Iranian analysis included many quality perspectives, including waiting time, supportive services, etc.[13] Contrary to that, we have assessed only anesthesia-related services and not the quality of services as a whole. Nevertheless, the present survey findings indicate that apex level public sector hospitals are not having significantly fewer monitoring facilities than apex level private sector corporate hospitals. Further, the medical colleges and nonteaching hospitals' facilities were also similar compared between public versus private sectors. Although CTHs were having more anesthesia service-related equipment than the public sector apex institutes, the difference was statistically insignificant. However, an anonymous adverse incident reporting system was significantly higher in CTHs than any other setups. Whereas frequent incident reporting is regarded as necessary to promote the patient safety culture.[14]

The present survey also found that anesthesia-related safety monitoring and equipment were significantly more available in teaching hospital setups than in nonteaching hospitals. It may be attributed to the services they provide, i.e. teaching, training, research, and patient care. Even at the patient care level, teaching hospitals are significantly more likely to provide care for patients requiring a transfer from other hospitals for advanced care.[15] As advanced care of patients and research often need advanced equipment, and such hospitals are usually tertiary and quaternary hospital setups, this difference is very much expected.

The present study depicts the patient safety scenario of India; yet, the result has importance even for health-care systems of advanced countries like the U.S. The recently enacted legislation, i.e. the patient protection and affordable care act (PPACA), mandates health-care coverage for almost everyone in the U.S.[16] Nevertheless, the health care system of the U.S. is full of diversity.[17] Although perioperative patient safety has improved significantly over the last half-century,[18] the ASA closed claim database analysis and the review of life-threatening perioperative complications indicate equipment as a contributing factor.[4] Hence, the hybrid health-care systems of the U.S. or any other country which is having public, private, and household expenditures such as India, might also have similar concerns of anesthesia-related patient safety, even though of varied intensity. Further, with a critical role of health insurance in the U.S. and many other advanced health-care systems, which is also the basis of PPACA of the U.S., complications and claims arising from such safety-related issues may pose a conflict between patients, insurers, and health-care provider.

The present survey is, however, having a few limitations too. First, although the study has a power of 80% power with 95% confidence, 600 responses from an extensive health-care system like India are small in size. Second, the present analysis assessed only the environmental factors, especially resources and facilities in different health-care systems related to patient safety during anesthesia practice, and not human factors related to anesthesia safety services.[11] Third, the survey is not an in-depth analysis of even of the equipment. The types of equipment and their safety level may vary, for example, the anesthesia machine may be Boyle's machine or anesthesia workstation or care stations. A recent survey found that many hospitals are still using the Boyle's machine, especially in district level and secondary level hospitals situated in semi-urban locations.[19] The safety and quality expectations cannot be similar in such different types of the same equipment.

Despite these limitations, the present survey bears a critical role because all patients undergoing surgery are in a risky perioperative environment. The WHO is emphasizing global patient safety for more than a decade. However, significantly less is known about the patient safety environment in perioperative settings, especially in developing countries. The present survey result indicates that patient safety and quality related to anesthesia services still need gross improvement in all sectors and levels of health-care facilities in India. Although basic (standard) monitoring is mostly available, advanced monitoring and equipment for better perioperative care and prevention of complications lack even in India's tertiary and quaternary levels.

  Conclusion Top

Public sector hospitals of India are not having significantly different (less) anesthesia service-related patient safety monitoring and equipment than private sector hospitals. Teaching hospitals have significantly more availability of monitoring and equipment compared to nonteaching hospitals. Anonymous incident reporting is the highest in CTH and significantly higher than any other group. However, the safety measures are relatively low in many aspects, especially for advanced monitoring and equipment in the entire sector, requiring attention.


We acknowledge the help of Mrs. Shikha Srivastava, Research Assistant of Dr. Habib Md Reazaul Karim, for helping in data segregation and calculation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to be exempt by the Institutional Review Board/Ethics Committee review. Additional permissions from the department were obtained. Finally, this clinical study did not require Clinical Trial Registry as per Clinical Trail Registry-India [www.ctri.nic.in] guidance/criteria.

  References Top

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