Journal of Indian Association of Pediatric Surgeons
Journal of Indian Association of Pediatric Surgeons
                                                   Official journal of the Indian Association of Pediatric Surgeons                           
Year : 2017  |  Volume : 22  |  Issue : 4  |  Page : 226--231

Parental satisfaction with pediatric day-care surgery and its determinants in a tertiary care hospital

Cenita James Sam1, Pavai A Arunachalam1, Sivamani Manivasagan2, T Surya1,  
1 Department of Pediatric Surgery, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
2 Department of Community Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India

Correspondence Address:
Cenita James Sam
Department of Pediatric Surgery, PSG Institute of Medical Sciences and Research, Coimbatore - 641 004, Tamil Nadu


Objective: The objective is to assess the level of parental satisfaction of pediatric day-care surgery and its different determinants. Materials and Methods: This is a descriptive study performed in a tertiary care hospital in India among parents of pediatric day-care surgery patients from June 2013 to March 2015. The core questionnaire for the assessment of patient satisfaction for general day care (COPS-D) was used. Variables related to surgery, overall satisfaction, one open-ended question, and socio-demographic data were also collected. Calculated sample size was 121. Results: The mean and standard deviation of parental satisfaction were estimated in eight domains of day care (COPS-D) using Likert scale 1–5. Preadmission visit had a mean of 4.63 (0.52), day of surgery 4.65 (0.58), operating room 4.76 (0.51), nursing care 4.46 (0.79), medical care 4.89 (0.48), information 4.51 (0.68), autonomy 4.64 (0.56), and discharge 4.50 (0.72). In elder children, there was less satisfaction on the information and discharge domains. Overall satisfaction was good in 88% of patients and was less than satisfactory when they had significant pain. Conclusion: Perception of quality of pediatric day-care surgery was assessed with a questionnaire and was found to be good. Variables related to surgery such as pain may be included in the questionnaire for assessing satisfaction in the day-care surgery.

How to cite this article:
Sam CJ, Arunachalam PA, Manivasagan S, Surya T. Parental satisfaction with pediatric day-care surgery and its determinants in a tertiary care hospital.J Indian Assoc Pediatr Surg 2017;22:226-231

How to cite this URL:
Sam CJ, Arunachalam PA, Manivasagan S, Surya T. Parental satisfaction with pediatric day-care surgery and its determinants in a tertiary care hospital. J Indian Assoc Pediatr Surg [serial online] 2017 [cited 2020 Aug 7 ];22:226-231
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Full Text


Day-care surgery is being practiced worldwide. For a child, it gives quicker return to a familiar home environment without compromising the safety of the child. This is an efficient way of reducing the costs and waiting time, maximizing the use of resources, and avoiding an unnecessary stay in the hospital.[1] Day-care surgery ranges from 20% to 68% of surgery being performed in various pediatric surgical units.[2] This is possible due to the advanced medical technology and a better understanding of what can be performed safely in a day.[3] Effective preoperative assessment and preparation with protocol-driven discharge are fundamental for safe day-care surgery.

Quality and safety in health care are of paramount importance.[4] The WHO has emphasized the importance of the patient's perspective in the evaluation of health-care delivery. After providing infrastructure and proper personnel to assure quality and safety, it is important to assess the services using a structured patient's satisfaction questionnaire. Measuring satisfaction is problematic as the evaluations are personal and subjective.[5] Expressed satisfaction reflects the patient's knowledge and expectations than the quality of the service received.[6] However, monitoring user satisfaction is important for quality care assessment and benefits patient care if their feedback influences subsequent service delivery.

Two groups of determinants of satisfaction were distinguished in reviewing literature: those relating to the characteristics of respondents and those relating to health service delivery features. The patient's expectation is an important determinant among individual factors.[7] Care process is an important determinant regarding health delivery system.[8] Other determinants specific to day-care surgery are postoperative complications, postoperative pain, waiting time before surgery, readmission, and the clinical outcome.[3]

The different approaches to measure the patient satisfaction are based on health service attributes, holistic approach, expectation-based surveys, and those evolved from economic theory.[5],[7] Among these, holistic approach includes all important determinants of patient satisfaction.[7] The patient satisfaction surveys using validated instrument should be able to measure the structure, process, and outcome of a health-care system.[9],[10] The patient satisfaction score is indispensable to the assessment of quality.[8],[11]

In different countries, systems are established to monitor the performance of health-care institutions using a framework of structure, process, and outcome indicators.[12] The aim of our study was to assess the level of parental satisfaction with pediatric day-care surgery and to find out the different determinants that influence the parental satisfaction.

 Materials and Methods

This is a descriptive study conducted in PSG Institute of Medical Sciences and Research, a tertiary care private medical college hospital, in South India. The study period was from June 2013 to March 2015 among parents of pediatric day-care surgery patients. The Institutional Ethical Board approval was obtained (No: 13 / 036).

Inclusion criteria were children aged 1–15 years undergoing day-care surgery with the American Society of Anesthesiologists I and II and who can reach the hospital within 2 h in case of emergency. Exclusion criteria were children under 1 year and those who needed emergency surgery. Children under 1 year are generally admitted. The operations performed in day care are procedures as herniotomy, circumcision, and orchidopexy.

These children had a pre-operative assessment few days before the planned surgery. Parents were explained about day-care procedure, expected problems, anesthesia, and cost of surgery by the doctor and clinical nurse assistant. On the day of surgery, they were seen in the day-care area; surgery was performed under general anesthesia with or without caudal analgesia. They were monitored for 4 h and more if necessary. If the child had no problems, he was sent home after being seen by the treating surgeon on oral paracetamol for next 3 days. If necessary, they were admitted for observation. A follow-up visit was scheduled after 1 week.

Study tool

The core questionnaire for the assessment of patient satisfaction for general day care (COPS-D),[13] was chosen as it is a validated questionnaire designed for day care including day-care surgery. It assesses eight dimensions/domains: as preadmission visit (4 items), admission at the day-care center (3 items), operation room (3 items), nursing care (2 items), medical care (2 items), information (4 items), autonomy (3 items), and discharge and after care (3 items). The response for each item is assessed by 1–5 Likert scale; 1 being unsatisfied and 5 as very satisfied. Average of the item score constituted the domain score. Together all these categories aim to achieve a total picture of the quality of care. The reported internal consistency of the eight dimensions was good (α =0.82–0.90).

In addition, questions about variables related to surgery such as waiting time for surgery, postoperative complications such as vomiting, postoperative pain, readmission, and outcome of surgery were also included in the study. Postoperative pain was assessed on a numeric rating scale of 0–10. There was one item about the overall satisfaction of the quality of care which was marked on a scale of 1–10. One open-ended question was added for parent to comment regarding the services they have received on the day of surgery to counter the drawback of quantitative surveys. The responses were classified as compliments, complaints, and suggestions. Socio-demographic data were also collected.

The questionnaire was translated into the regional language and it was verified with back translation. The questionnaire was given to the parents when they came for their child's first postoperative visit, which was usually a week after surgery by the outpatient department staff. Informed consent was obtained from the respondent. Questionnaire response was kept anonymous. Incomplete questionnaires were excluded from the study. Privacy of the participants was ensured by excluding identification details from the study questionnaire. All questions were directed to the parents of the patients.

Sample size

We considered 75% as the anticipated satisfaction level of day-care surgery patients. At a confidence level of 95% and with 12% of relative precision, with the nonresponse rate of 30%, an overall sample size of 121 was derived. A total of 121 consecutive parents of day-care surgery patients were included in this study. Responses were entered in Epi Info ™ (Centre for Disease Control and Prevention, Atlanta, USA) and results were analyzed using R software (R version 3.0.1. The R foundation for Statistical Computing. Vienna, Austria). Descriptive statistics such as means and standard deviation, percentage, Chi-square test, and ANOVA test were used in the analysis. A P value < 0.05 was considered statistically significant.



All 121 respondents returned the questionnaire. Twelve questionnaires were excluded from the study for many missing values making the sample size to 109. The characteristics of the study population are presented in [Table 1]. Male children predominated in our study (85.3%). Children under 4 years were 62.38%. Graduates were 53.21% and illiterates were <3% in our study group. Income was classified according to four quartiles. Circumcision (n = 55), hydrocele (n = 19), hernia (n = 12), tongue tie release (n = 11), orchidopexy (n = 5), node biopsy (n = 5), mass excision (n = 7), and meatoplasty (n = 1) were the surgical procedures performed as day care during the study. Six patients underwent two procedures.{Table 1}

Satisfaction scores

Analysis of rating of satisfaction of eight domains of the day care in Likert scale of COPS-D [Figure 1] showed that parents were satisfied in most of the domains. However, by comparing satisfaction of various domains with different age groups by ANOVA test [Table 2], there was relatively less satisfaction in domains of information and discharge in the older age group (11–15 years) and this was statistically significant. Sex of the child, education status of the parent, and income did not make any difference in the satisfaction score of various domains.{Figure 1}{Table 2}

Overall satisfaction score and other variables related to surgery

Overall satisfaction score of patients was fair (score 4–7) in 10 (9.17%) and good (score 8–10) in 96 (88%) patients. Three had not recorded this score, but none had written unsatisfactory. One-fourth of children who underwent day care had more than mild pain. There were moderate pain in 17 patients (15.59%) and severe pain in 11 patients (10.09%). Overall satisfaction score of patients who had more than mild pain was less than those who had mild pain and it was statistically significant [Table 3].{Table 3}

Postoperative complications were present in 17 patients (15.60%) and it was temporary and mostly related to anesthesia. The problems encountered were nausea/vomiting (n = 5), urinary retention (n = 3), drowsiness (n = 2), headache (n = 2), sore throat (n = 1), bleeding (n = 2), and others (n = 2) as postoperative fever and wound infection. There was a delay in the operation theater (OT) in 13 patients (11.92%) of our study group. Both postoperative complications and delay in OT have not made any statistically significant difference in overall satisfaction score. Children who needed readmission were 2 (1.83%) out of 109. The outcome of surgery was good in all patients except one whose status was not recorded and hence, its relationship to satisfaction could not be established.

Suggestions for improvement

Open-ended question was answered by 50 parents (45.87%). Compliments were given by 33 (30.27%), 6 (5.50%) gave a suggestion, and complaints were received from ten parents (9.17%). The complaints were about the delay at the pharmacy or dietary services. They also suggested improvement in waiting area, services provided by the staff nurses in the recovery area.


Most of the study patients were male, the reason being the day-care procedures such as circumcision itself are more common in male children. Many of the study patients were under 4 years for the same reason and this is similar in pediatric day-care services in other hospitals.[2] Level of satisfaction was almost equal among the various income groups, but this may not be representative as this is a private hospital. There were no significant differences in satisfaction score among parents of varying educational level in the current study. However, in other studies, it has been noted that higher the education, lesser was the satisfaction. It has been argued that the parents with higher education come the awareness and their expectation from the health providers goes up.[14]

Parental satisfaction score of various domains of care in day-care surgery patients in the current study had ranged from 4.46 to 4.89 out of 5 (i.e., 89.2%–97.8%). However, areas such as information about day care and discharge need some improvement, especially when catering for children above 10 years. There was no similar study (using domains) to compare among pediatric age group. A study conducted in a private sector hospital in North India among inpatients reported satisfaction in various domains ranging from 64.8% to 98.2%.[15]

The secondary outcome of this study showed that although the overall outcomes of the day-care surgery in children were good, there were some areas of care which need to be improved. They were delay in performing surgery which needs better planning, postoperative pain relief, and postoperative complications. Mandhan et al., have reported postoperative pain in 40% of their day-care surgery children while in our study 26% had more than mild pain. However, the nature of pain was not graded in their study.[16] Myles et al. noted that patients who had postoperative pain were less satisfied like the current study and hence, this factor has to be taken into consideration to improve the quality of day-care surgery.[17]

The occurrence of postoperative complications in the current study was 15.60%. Mandhan et al., reported complication of 44% (n = 368) out of which surgical complications were only 4%. In addition to complications we have noted, the study reports about feeding disturbance in first 24 h.[16] It had not affected the overall satisfaction scores. It is probably because parents were primed for it in their preoperative visit and the effects were temporary. Delay in OT to start the procedure (11.92%) had not affected satisfaction in the current study; although, it had been a significant factor affecting patient's satisfaction in other day-care surgery studies.[2]

Only 2 (1.83%) out of 17 who had postoperative complications, needed readmission. Readmission rate of 1%–2% is suggested as acceptable in day-care surgery. Day-care surgery performed in government sector in India showed readmission rate of 5.7%.[18] Other studies showed readmission rate varying from 0.2% to 6.2%.[16] In the current study, the overall outcome could be explained by proper selection of cases. However, parents need to be informed about waiting time in OT, postoperative pain, and immediate postoperative complications as they seem to be an integral part of day-care surgery.

Overall satisfaction score (in the scale of 1–10) was 88% in the current study population. Other pediatric day-care surgery centers from developed countries showed 93%–97% satisfaction level.[16],[19] The patient satisfaction level reported among inpatients in Indian studies range from 23.4% in the government sector to as high as 84% in a private tertiary care.[14],[20]

Open-ended question had helped us to identify what patients appreciate and the specific area which needed improvements such as recovery area, dietary services, and pharmacy services. This information was passed on to hospital quality control department for making necessary changes.

Limitation of the study

Gratitude bias is possible in the study as it was conducted by the same department. However, we had tried to reduce this effect by giving a self-response questionnaire and questionnaire response was kept anonymous.


The patients look at a facility every time the service is delivered and form distinct opinions about its effectiveness. Health-care organizations that aspire to excellence must constantly assess the quality of their service experience through their patients' eyes. The patient feedback may be routinely practiced to improve the health-care system. Variables related to surgery as pain may be included in a questionnaire assessing satisfaction in day-care surgery as it affects overall satisfaction score.


The author would like to thank Mr. Raja, clinical assistant, for assisting in collection and entry of data.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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