Patient stress and satisfaction when allowed the presence of an accompanying person during endoscopy

doi:10.4236/ojgas.2013.31012

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Open Journal of Gastroenterology, 2013, 3, 78-83 OJGas

http://dx.doi.org/10.4236/ojgas.2013.31012 Published Online February 2013 (http://www.scirp.org/journal/ojgas/)

Patient stress and satisfaction when allowed the presence of

an accompanying person during endoscopy

Jesse Lachter1,2, Benjamin Ephraim Bluen1

1Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel

2Gastroenterology Institute, Rambam Health Care Campus, Haifa, Israel

Email: [email protected], [email protected]

Received 17 November 2012; revised 18 December 2012; accepted 24 December 2012

ABSTRACT

Introduction: Patients undergoing esophagogastro-

duodenoscopy (EGD) have variable stress and anxiety

and therefore commonly receive medications as seda-

tive-anxiolytics. These medications have small but

significant risks. To possibly make procedures safer

and to increase patient satisfaction, this study aimed

to measure the effects of allowing an accompanying

person (AP) to be present in the endoscopy suite dur-

ing EGD. Patients and Methods: Forty-two patients

were randomly divided into two groups who would

either be or not be offered to have an AP during en-

doscopy. Spielberger’s well-validated state and trait

anxiety evaluations were administered to patients

before and after EGD. APs also completed question-

naires as to their reactions after EGD. Results: 84.2%

of the patients after EGD recommended accompani-

ment. Patients who underwent EGD with an AP

tended (p < 0.06) to have decreased measurable anxi-

ety compared to patients who were not offered an AP.

The benefit was significant for persons with higher

levels of anxiety prior to EGD (p < 0.04). Patients

undergoing EGD for the first time had significantly

more anxiety than those with previous EGD experi-

ence (p < 0.034). There was no significant reduction

in sedative dosage when APs were present. Conclu-

sions: Offering to permit the presence of an accom-

panying person during EGD was often shown to im-

prove patient satisfaction and reduce anxiety.

Keywords: Endoscopy Escort; Sedation; Satisfaction

1. INTRODUCTION

It is understandable for patients to experience some

stress preceding and during EGD. One appropriate way

to reduce this anxiety is to use sedatives. Such medica-

tion has been found to have minimal but occasionally

significant morbidity. However, based on a study in-

cluding over 320,000 endoscopies, more than half of the

major complications including mortality in endoscopic

procedures may be attributable to the medications used

[1].

Any intervention which may reduce anx iety, and t her eby

reduce the need for sedation, might therefore be hy-

pothesized to help reduce morbid ity and mortality. Anxi-

ety, which is not easily quantified, has been made ap-

proximately measureable using physiologic parameters

including heart rate, blood pressure and degree of sweat-

ing and by using validated questionnaires such as that of

Spielberger, which test both state and trait anxiety [2].

High anxiety levels have various adverse effects not only

in medical but also in daily situations, including negative

affective response, more prolonged and difficult recov-

eries, and increased need for pain and anxiolytic medica-

tion [3]. Furthermore, reducing anxiety may reduce medi -

cal phobia (disproportionate fears) which might other-

wise lead to avoidance of beneficial procedures [4]. This

is especially true for patients undergoing their first en-

doscopic exam [5]. When patients feel lack of control,

anxiety is increased. Reducing anxiety lessens the amount

of time and support resources needed for recovery, which

furthermore results in increased patient satisfaction and

adherence to medical plans.

While the patient is irrefutably the primary client, a

patient's surrounding environment includes significant

others who may have a profound impact on his or her

physical and mental health. The people who the patient

knows and trusts may influence adherence to medical

therapy. These “significant others” or APs may also be

seen as secondary clients. Including these APs in part of

any medical intervention such as EGD may help to

achieve successful outcomes by leveraging their pres-

ence and role to help reduce the stress and anxiety of the

patients undergoing endoscopy.

It is from the experience of the first author, having

visited endoscopy centers worldwide that allowing the

presence of an AP during EGD is quite rare in the United

States, Canada, and in Western Europe with a notable

OPEN ACCESS

J. Lachter, B. E. Bluen / Open Journal of Gastroenterology 3 (2013) 78-83 79

exception to be in Chin a where such pr actice is common.

A questionnaire of 400 men and women ages 16 - 65

years old in England identified that the most important

factor in the examination was the attitude of the doctor;

allowing an AP during examinations was viewed by pa-

tients as a sign of respect [6]. Although the issues of

anxiety and sedatives have been addressed at length by

the American and European practice guidelines, they

have not related to the influence of allowing an AP dur-

ing EGD [7]. Therefore, two additional goals of this

study are to raise awareness of this option and to en-

courage further investigation to assess the impact of pa-

tients’ significant others in large-scale studies.

Attempts have been undertaken to reduce stress by

various psychological preparations. Such preparations

for EGD have included provision of information (orally

and in pamphlets), modeling (seeing a videotape before

EGD), hypnosis and other relaxation techniques [8]. As

an unfortunate consequence of the modern healthcare

system and training centers, over-worked house officers

often either lack the time, the awareness, and/or the

overall ability to optimally manage va rious patient social

and behavioral concerns [9]. This further emphasizes the

value of psychological pr eparations and the presence of a

significant other during EGD as a low-cost method to

reduce anxiety and perhaps thus also to reduce associated

anesthesia-related morbidity.

The influence of psychological preparation for gastro-

scopy was investigated by Mahajam et al. in a study in-

volving pediatric patients with a mean age of 12.2 years

who underwent endoscopy. Studying a control group

having regular preparation vs. additional psychological

preparation including dolls of photography books simu-

lating EGD procedures demonstrated statistically sig-

nificant decreases in autonomic nervous system stimula-

tion and pro cedural anxiety. This led to decreased p aren-

tal anxiety and helped to strengthen doctor-patient rela-

tionships [10]. In a similar manner, the anxiety of a pa-

tient’s significant other may be decreased by pre-proce-

dural psychological preparation.

Individualization of approach and considering the ho-

listic approach to a patient as a part of a social network

that includes others is key to patient satisfaction. It is

important to realize that patients vary in terms of the

extent of worry over EGD. For example, younger pa-

tients have been shown to be most concerned about

EGD-related pain and procedural complications whereas

elderly patients were most concerned about potential

findings [5]. Also key is to identify specific groups of

patients who have a high risk of elevated anxiety levels

prior to procedures. Increased anxiety is a phenomenon

which has been shown to be particularly prevalent in

certain patient groups, notably younger patients and

those undergoing gastroenterological procedures for their

first time. Extra emphasis should be placed on helping

such individuals to relieve any excessive anxiety [6]. The

outlined anxiety may be reduced by the presence of an

AP may in turn allow the reduction or eliminatio n of the

use of anti-anxiety medications, most commonly benzo-

diazepines, which according to major studies are respon-

sible for the majority of the morbidity and mortality from

upper gastrointestinal endoscopy [1].

2. AIM

By having an accompanying person present in the endo-

scopy suite, persons who chose to have such an accom-

panying person present might become less anxious be-

fore and during the procedure. This study hypothesized

that measureable anxiety and satisfaction of patients and

APs within the medical encounter might be affected by

offering this option to patients.

3. PATIENTS AND METHODS

Every patient was instructed to come for EGD with an

accompanying person, without explanation for such be-

ing given. This is standard operating procedure, because

anyone receiving sedation should be accompanied after-

wards. 42 outpatients were randomized to either have

offered to them the presence of an AP during the proce-

dure or not. With the help of a trained interviewer, every

patient prior to EGD underwent testing using the Spiel-

berger anxiety scales for state anxiety and situational

anxiety. The sedation used for these procedures was a

standard dosage of fentanyl 0.05 mg IV in addition to

midazolam titrated until considered sufficiently effective

(1 - 5 mg). No oral or topical spray anesthetic was used.

After EGD, the patients again completed a question-

naire measuring anxiety. Every patient had heart rate,

blood, pressure, and d egree of sweating no ted on ce at the

beginning and once at the end of the EGD. The accom-

panying persons also completed a questionnaire, includ-

ing scaled questions regarding satisfaction with the medi-

cal encounter and evaluation of their experience. Data

was analyzed using the Statistical Program for the Social

Sciences (SPSS) and by X2 analysis.

This study was approved in advance by the Helsinki

Committee (Institutional Review Board) of the Rambam

Healthcare Campus. The study was not funded and thus

there are no relevant disclosures.

4. RESULTS

Forty-two patients were selected with 23 controls and 19

subjects. The control group consisted of 56.5% (13/22)

male and 43.5% (10/23) female patients; the experimen-

tal group contained 47.4% male (9/19) and 52.6% (10/19)

female subjects. Patients were sampled from a variety of

J. Lachter, B. E. Bluen / Open Journal of Gastroenterology 3 (2013) 78-83

OPEN ACCESS

different ethnic backgrounds mostly including those from

Israeli, Russian, Romanian, and Ethiop ian heritages. APs

consisted of mostly spouses (34%), children (20%), or

fa mily memb er s ( 12% ).

After endoscopy, results from questionnaires filled out

by patients who underwent EGD with the presence of an

AP showed that 83% (16/19) of the experimental group

patients recommended that procedural accompaniment

be offered (see Table 1). Including the control group, a

total of nearly 59% of subjects requested to have APs

during EGD whereas 38% declined, and 3% of patients

were undecided, which likely reflects the high anxiety

rate in the pre-procedure waiting room and from EGD

itself. After EGD, 72.2% of APs recommended having

an AP present during EGD while 16.7% recommended

against the presence of an AP during the procedure while

11.1% were undecided (see Table 2).

Statistical analysis demonstrated that patients under-

going EGD for the first time had higher state anxiety

than those who had previous endoscopy experience (p <

0.034). This was accomplished by comparing the state

anxiety X2 values. These were determined to be 2.86 for

patients who underwent EGD for the first time and 2.16

for patients who had undergone prior EGD. Further analy-

sis of state anxiety revealed that patients who underwent

EGD with an accompanying person tended (trend p <

0.06) to have a lessening of state anxiety as compared to

those who underwent EGD alone, with average state

anxiety scores of controls being 2.30 vs. 2.42 of the ex-

perimental group. This also brought about a trend to in-

creased patient satisfaction after the procedure, although

this was not found to be statistically significant. The

benefit of having an AP was greatest (and statistically

significant p < 0.05) for the subgroup of patients with the

highest initial state anxiety. The overall patient and phy-

sician experience was summarized in the artwork in the

accompanying Figures 1 and 2.

There were no statistically significan t differences not ed

in the change of heart rate, sweating, or blood pressure

between the two groups. Also, there was no reduction in

the dose of any of the sedatives or analgesics used amongst

the patients when allowed th e presence of an AP.

5. DISCUSSION

Allowing the presence of an accompanying person dur-

ing EGD came to be considered for research after many

patients and their family members requested this sponta-

neously, and was based on the commonly observed ob-

vious anxiety of many patients before EGD. After occa-

sionally acceding to requests for the presence of an ac-

companying person, some endoscopists found that there

was negligible if any interference in the procedure, al-

though it should be noted that other endoscopists may

feel uncomfortable with allowing the presence of an ac-

company i n g p erson during endosco py.

Patients with high anxiety prior to EGD appeared to

benefit from the presence of an AP during the procedure.

84% of experimental group patients and 72.2% of APs

recommended for having accompaniment of a significant

other during upper endoscopy (see Tables 1 and 2). The

most profound benefit was seen in patients with an ele-

vated pre-test anxiety who demonstrated a statistically

significant decrease (p < 0.05) in anxiety as compared to

the same patient category without an AP. Although the

optimal treatment for every patient’s emotional status

must be individualized, it appears that highly anxious

patients benefit the most from an AP during EGD. An-

other group of patients that may benefit from an AP dur-

ing EGD are those undergoing EGD for the first time. As

might reasonably have been expected, this group dis-

played statistically significant (p < 0.034) higher levels

of anxiety than those who had previously underwent

EGD. Patients and physicians alike expressed increased

satisfaction from EGD likely due to the anxiety reduction

most prominent in patients with high pre-procedural

anxiety (see Figures 1 and 2).

In another high-anxiety setting in which the presence

of APs was assessed was the emergency department. In

evaluating AP satisfaction in the high -anxiety emergency

department setting, 63.2% of APs to be very satisfied,

28.2% slightly satisfied, and the remainder of APs being

unsatisfied. It was also noted that these significant others

also served to highlight the feeling of isolation of the

patients in which they accompanied [11]. There, it was

Table 1. Did patients undergoing EGD recommend having a significant other present?

Patient desire for escort Number of patients-experim ental

group Percent (%)Number of patients-control

group Percent (%) Total Percent (%)

Yes 16 84.2 4 26.7 20 58.8

No 3 15.9 10 66.7 13 38.2

Undecided 0 0 1 6.7 1 2.9

Displayed in this chart are the recommendations of control and experimental group patients in regards to the presence of an AP during upper endoscopy. A key

observation is that 84% of experimental group patients recommend having a significant other (AP) prese nt during the procedure.

J. Lachter, B. E. Bluen / Open Journal of Gastroenterology 3 (2013) 78-83 81

Table 2. Recommendations of significant others after being

present during EGD.

For/against accompaniment Frequency Percent (%)

For 13 72.2

Against 3 16.7

Undecided 2 11.1

Total 18 100.0

Listed in the table ar e the reco mmendatio ns of APs af ter EGD. Greater than

72% of APs advocated for accompaniment of a significant other during

EGD.

Figure 1. Illustrates how high-anxiety states of pa-

tients may affect EGD. Not only do the changes

in heart rate and blood pressure affect the patient,

but they also have deleterious consequences on

the operating endoscopist that together may in-

crease the overall complication rate.

Figure 2. Conveys the potential benefits of

having an AP present during EGD. Due to the

APs influence, a now-calmer patient and a

more comfortable performing endoscopist may

result in reduced procedural and anesthesia-

related complications while increasing patient

satisfaction.

demonstrated that a lower anxiety level of APs correlated

with increased satisfaction upon leaving the department

[12].

The concept of having one’s significant other present

has been applied to obstetric wards as well. While per-

sonal preference may play a role, local experi ence s h o w ed

that after several birthing centers allowed for accompa-

nying persons during delivery, increased patient demand

strongly encouraged allowing the presence of additional

people in the delivery room amongst staff who otherwise

would have preferred not to make such an allowance.

This includes an AP present during forms of birth in-

cluding assisted deliveries and Cesarean sections [13]. In

regards to OB-GYN practice, it was demonstrated by

Afaneh et al. that although a majority of patients (65%)

felt no need for an AP, a small but significant group of

patients requested accompaniment regardless of the gen-

der of the examiner. Therefore, patients should be of-

fered the option of having an AP with their opinion re-

spected and documented [14]. One can perceive addi-

tional settings and procedu res includ ing EGD that lead to

high-anxiety states in which persons might come to feel

entitled to have an accompanying person present.

In reducing patient stress and anxiety, it has been

thought that this may lead to a reduction in the amount of

anesthesia administered prior to and during EGD, thus

improving procedural safety. As sedatives are more lib-

erally administered in modern medicine, a much larger

sample study population is needed to correlate respective

sedative doses with their associated levels of anxiety. A

potential alternative to this study would be to include a

group of patients with an AP who would not receive any

anesthesia which would then be compared to the other

study groups. However, this would be a drastic change as

compared to administering a half-dose of midazolam and

then measuring whether this dose-reduction would lead

to equivalent patient satisfaction and anxiety reduction.

As the safety profile of the administered sedatives is

quite good [15], power analysis suggests that a very larg e

sample population is necessary to demonstrate potential

benefits. This study was designed more of a “proof of

concept” in that patients’ significant others decrease anx i-

ety instead of directly addressing the quantity of seda-

tives required to achieve equivalent results. Nevertheless,

the presence of an AP decreasing patient anxiety and

increasing procedural satisfaction are important areas of

interest in gastroenterological procedures. In the emerg-

ing era of emphasis placed on quality indicators, such

cost-effective improvements by a patient’s significant

other may be proven in larger follow-up studies to aug-

ment procedural efficiency and lessen EGD-related com-

plications.

The present results were similar compared to a study

by Shapiro and Tamir, who used non-validated qualita-

J. Lachter, B. E. Bluen / Open Journal of Gastroenterology 3 (2013) 78-83

tive comparisons of anxiety and fearfulness [16]. The

present study utilized th e Spielberger state and trait anxi-

ety scores as quantitative indices, which have been vali-

dated in Hebrew and are widely used as benchmarks,

were employed for a rigorous and generalizable assess-

ment of anxiety [2]. In addition, the biological parame-

ters of anxiety, heart rate blood pressure and sweating

were also assessed. Both genders were evaluated equally

as well as patients from diverse cultural backgrounds. As

the reduction in anxiety particularly in high-anxiety pa-

tients was demonstrated to be similar in principle to the

reduction in anxiety of having an AP present during a

birthing procedure it may be offered to selected indi-

viduals as a low-cost therapy that may reduce overall

anesthesia-related complications and strengthen patient

adherence for future beneficial procedures.

The potential drawbacks of allowing an AP, such as

taking phone calls or interfering with the procedure were

not seen. It has been subsequent experience that only

rarely must an endoscopist ask an AP to leave the room

due to circumstances such as AP discomfort or AP de-

flecting of attention from the patient.

6. LIMITATIONS

This is a single center small sample size study, which

involves one cu lture of people. Only a much larger stud y

could be expected to show reduction of the major anes-

thesia-related side effects because they are uncommon.

However, the culture is very diverse, and these numbers,

while small already point to significant benefits which

accrue to centers which allow the presence of an AP.

7. CONCLUSIONS

Offering to allow an accompanying person to be present

during EGD tended to:

1) Reduce patient anxiety, especially for high-anxiety

patients and first-timers.

2) Increase patient and family satisfaction with the

endoscopy encounter.

8. ACKNOWLEDGEMENTS

The authors wish to acknowledge the contributions to this study of Dr.

Hadas Wiseman, Psychologist at Haifa University, Israel, and to Dov

Shperling Shemer, for the artwork which he drew and donated to ac-

company this article to tell its message in a pleasant, memorable, and

lighthearted way.

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