Improving the quality of acute pain services: experiences of treatment of 5212 patients
*Lin Shiqing, Xu Kangqing, Yang Peng, Shu Haihua, Xu Miao, Huang Wenqi
Department of Anesthesiology, First Affiliated Hospital of Sun-Yat Sen University, Guangzhou, China
- Fig. 1. The position and responsibility of APS team
- Table 1. Surgery sites
- Table 2. Analgesia techniques, drugs and duration
- Tab. 3. VAS score, analgesic effect and patients’ satisfaction
- Tab. 4. Complications and analgesia termination
- Tab. 5. Non-complication-related causes of terminating analgesia ahead of schedule
Background. In a retrospective, non-randomized, observational study, we compared methods of postoperative analgesia in 5212 cases treated in 2003 and 2004.
Methods. Patients were allocated to two groups: Group A included 2,796 patients treated in 2004; Group B included 2,419 treated in 2003. The acute pain team was staffed by anaesthesiologists who performed daily visits to patients receiving the APS. They dealt with complaints and complications, evaluated the effectiveness of analgesia, and kept records. The visiting anaesthesiologists rotated weekly in group A, and daily in group B.
Results. Analgesic effects, VAS, patient satisfaction, and the incidence of complications were compared between the two groups. The number of patients with an analgesic effect evaluated as “bad” was significantly lower in group A than in group B (p<0.05). The proportion of patients in whom satisfaction was evaluated as “good” was significantly higher in group A compared to group B (p<0.05); “moderate” and “bad” satisfaction scores were significantly lower in group A than in group B (p<0.05). There was no significant difference in the incidence of complications between the two groups (p>0.05). The number of cases in which analgesia was no longer required was lower in group A than in group B (p<0.05).
Conclusion. During postoperative management of analgesia by an acute pain service, a weekly rotation of anaesthesiologist staffing is more effective in improving patient satisfaction than a daily rotation.
Following increasing attention on improvement of perioperative pain management, a number of standard measures were established, including the acute pain service (APS) . APS was first brought forward by Ready et al.  in the USA in 1986 and applied worldwide afterwards. There are many patterns of APS organization, some based on anaesthesiologists assisted by nurses [2, 3], and others – on nurses supervised by anaesthesiologists [4, 5, 6]. An ideal acute pain team (APT) should consist of anaesthesiologists, nurses in post-anaesthesia care unit (PACU), ward nurses and specialized personnel of various responsibilities . Considering the cost-effectiveness and the technology available, further studies are needed to determine the characteristics of an optimal APT. In fact, ATPs have not been completely unified in different hospitals, and their development is still unbalanced [3, 8, 9, 10, 11].
The APS in our hospital was started in 1998. Our APT is mainly anaesthesiologist-based, consisting of the chief of anaesthesiologists, the core group of pain treatment, anaesthesiologists and pain nurses. The duties and responsibilities of each person are shown in Fig. 1. In addition to performing daily ward rounds to evaluate the effect of analgesia and to treat complications of postoperative patients, the APT is responsible for the training of pain nurses and junior doctors, setting up the routine of postoperative pain management and carrying out the research into postoperative pain issues.
In our pain management practice, despite setting up clear responsibilities and practice guidelines for the APT, a variety of problems have been encountered, e.g. hard-to-resolve patients’ dissatisfaction, high incidences of terminating analgesia ahead of schedule. In order to solve those problems, in 2004 we switched to a new management pattern, which changed the rotation schedule of visiting anaesthesiologists from daily to weekly. The aim of the present paper is to analyse the differences in analgesic effects and patients’ satisfaction between two different APS management patterns (daily and weekly rotation) and to determine the effect of improved APS management on postoperative pain relief.
The medical files reviewed were divided into 2 groups. Group A included records of 2,796 adult (>14-year-old) patients who received surgery and postoperative analgesia from 1 January, 2004 to 31 December, 2004; Group B included records of 2,419 adult patients who received surgery and postoperative analgesia during 1 January, 2003 to 31 December, 2003. The operative sites of patients are shown in Table 1.
Two kinds of analgesia technique were used: continuous epidural analgesia (CEA) and intravenous patient-controlled analgesia (PCA). The drugs used were either a mixture of an opioid and local anaesthetic, or a sole opioid. The analgesia duration ranged from 1 day to 3 days (Table 2).
The management pattern in group A was weekly rotation of the visiting anaesthesiologist. Each day, the intraoperative attending anaesthesiologist prescribed the analgesia method, drugs and postoperative analgesia duration. The major tasks of the visiting anaesthesiologist were to perform ward rounds 3 times a day (8-11 am, 3-5 pm, 7-9 pm) to evaluate the effect of analgesia using the visual analogue score (VAS), to detect and deal with complications, to terminate analgesia if necessary, and to fill in the APS registry form. Each week, the visiting anaesthesiologist had to provide a systematic report of the status of APS to the core group of pain treatment, including the number of patients receiving APS, techniques and drugs used, analgesic effects, patients’ satisfaction, the frequency of complications and corresponding treatments, as well as their comments. The core group discussed the status and made their suggestions.
The management pattern in group B was daily rotation of the visiting anaesthesiologist. Daily major tasks were the same as in group A, yet no systematic reports were prepared.
Data obtained from the APS registry forms were analysed according to the grouping requirement, surgery sites, analgesic techniques, drugs used, analgesia duration, VAS scores (0 – painless, 10 – extremely painful), patients’ satisfaction, complications, and causes of terminating analgesia ahead of schedule.
Patients’ satisfaction was evaluated after the completion of analgesic treatment by inquiring the patients about the intensity of postoperative pain, complications, corresponding treatments, and ward rounds performed, and recorded as good, moderate and bad.
The evaluation of analgesic effects was a comprehensive assessment of the effectiveness of pain relief and safety of analgesia, made by the visiting anaesthesiologist subjectively, according to the patients’ VAS, incidence of complications and treatments. The 3-degree scale - good, moderate and bad – was used.
Complications and treatment: respiratory depression was defined as f<8min-1 and/or SpO2≤90% at the time of receiving postoperative analgesia. Hypotension was treated with fluid infusions and/or vasopressor agents. Ondansetron 8 mg was administrated intravenously for nausea and/or vomiting. Urethral catheterisation was prescribed if urine retention took place. Analgesia was suspended or terminated if patients could not tolerate severe itching and shivering. If the complication was relieved, the suspended analgesia could be restarted with lesser dosage, otherwise treatment was terminated.
Termination of analgesia ahead of schedule was defined as discontinuation of analgesic treatment ahead of the designed time due to complications or other reasons. The causes were divided into complication-related and non-complication-related ones.
The obtained data were statistically analysed. The chi-square test was applied to quanta data, and the t-test was used for continuous data. P<0.05 was considered statistically significant.
There were no significant differences between the two examined groups according to the number of cases, proportion of operative sites, analgesic techniques, drugs, and analgesia duration (Table 1 and 2).
In all patients, the postoperative severity score was lower that 3 according to VAS. In 2687 (96.1%) patients in group A and in 2311(95.5%) patients in group B the pain therapy was assessed as good. The number of cases recorded as ‘bad’ effects was significantly lower in group A than that in group B ( p<0.05) (Table 3).
The patient satisfaction evaluated as “good” was significantly higher whereas “moderate” and “bad” significantly lower in group A compared to group B (p<00.05) (Table 3).
There were no significant intergroup differences in complications. However, the number of cases of terminating analgesia ahead of schedule because of complications in group A was significantly lower than in group B (p<0.05) (Table 4). Moreover, non-complication-related termination of pain treatment occurred less often in group A compared to group B (p<0.05) (Table 5).
APS experiences revealed that an appropriate organizational structure of pain relief was as important as the technique of pain management used [12, 13[. Many authors [14, 15] observed that, despite individualization of PCA and its reliable effects, 86% of patients still experienced moderate to severe postoperative pain, which could not be markedly relieved in 60% to 80% of cases. It was found that improvement of postoperative analgesia depended on the analgesic technology used and personnel organization implemented as well as optimization of management procedures and specification of personnel responsibilities .
The present management patterns of APS are still to be standardized. It is believed that the APS should be run by a multidisciplinary team. The team should assume day-to-day responsibilities to assess and manage postoperative pain in all patients, to record the assessment in such a way as to facilitate regular follow-up, to instruct patients and their families, to educate ward staff , to establish guidelines/protocols for appropriate pain medication, and to collect data to monitor the effectiveness of pain management [16, 17,18]. The research findings assessing the impact of APT on processes of postoperative pain relief are still insufficient and further studied should be carried out.
The proportion of patients’ dissatisfaction with APS ranged from 0.5% to 2.2% [4, 19, 20]. In 2003 (group B), the proportion of patients’ dissatisfaction was higher. However, pain perception is highly individual and to some extend influenced by patient`s culture and preoperative expectations, so pain intensity and patients’ satisfaction do not always correlate [21, 22, 23]. Our results have shown that the number of patients with the analgesic effect evaluated as ‘bad’ in group A was lower than that in group B, although the average VAS was found to be the same. Compared to daily rotation, the pattern of weekly rotation resulted in lower proportions of dissatisfaction. The reasons for improved analgesic effects and higher patient satisfaction are likely to be associated with better personal contact and communication between anaesthesiologists, ward staff, and patients, which makes the patients more active and results in more efficient pain management provided by anaesthesiologists.
According to Chen, positive coping mechanisms induced by correct communication between medical staff and patients are essential for improvement of patients’ satisfaction [5, 24, 25, 26]. Similarly, caring attitudes play a key role in the overall satisfaction/dissatisfaction of patients [26, 27, 28]. The pattern of weekly rotation is followed throughout the treatment, maintaining the continuity of monitoring and therapy of postoperative pain. This pattern greatly reinforces the anaesthesiologist’s consciousness of his/her responsibility and helps to understand the patients’ perioperative condition more systematically and in a more detailed way, thus the anaesthesiologist can respond to the patients’ complaints in time.
Treatment of analgesia-related complications is the key issue of APS [17, 29]. The pattern of weekly rotation not only detects and treats the complications more promptly and effectively, but also reduces the possibility of equipment dysfunction. Thanks to that, the incidence of termination of analgesia ahead of schedule due to non-complication-related factors was reduced, which additionally improved patients` satisfaction.
As far as the pain assessment is concerned, thanks to continuous recordings in the pattern of weekly rotation, the intact and detailed pain recording data are obtained, which is an important part of APS [17, 18].
Although our efforts to improve APS management increased the satisfaction of patients, there are still many limitations, e.g. our APS is mainly anaesthesiologist-based, which means high costs and may not be easy to apply to all hospitals. It has been reported that nurse-based APS may be more cost-effective and easier to popularize [30, 31] yet such schedules require further studies. High quality acute pain services can only be provided with combined efforts of anaesthesiologists, nurses and surgeons [32, 33].
The pattern of weekly rotation results in more normative and highly effective APS management. Lack of effective postoperative analgesia management is the main cause of insufficient pain relief.
1. Ready LB, Oden R, Chadwick HS: Development of an anesthesiology-based postoperative management service. Anesthesiology 1998, 68: 100.
2. Hung CT, Lau LL, Chan CK: Acute pain services in Hong Kong: facilities, volume, and quality. Hong Kong Med J 2002; 8: 196-201.
3. Nagi H: Acute pain services in the United Kingdom. Acute Pain 2004; 5: 89-1077.
4. Arie S, Edna Z, Margalit K: Establishing a nurse-based, anesthesiologist-supervised inpatient acute pain services: experience of 4617 patients. J Clin Anesth 2004; 16: 415-420.
5. Chen XZ, Xu XF: Nurse-based, anesthesiologist-supervised pain management model in gynecologic surgical procedure. Chinese Journal of Nursing 2005; 40: 87-9.
6. Rawal N: 10 years of acute pain services-achievements and challenges. Reg Anesth Pain Med 1999; 24: 68-73.
7. Mackey DC, Ehener M, Home BL: PCA and APS in the U.S.A. Anesthesiology 1995, 83: 433.
8. Rawal N, Allvin R: Acute pain services in Europe: the 17-nation survey of 105 hospitals. The EuroPain Acute Pain Working Party 1998; 15: 354-63.
9. Edward M, Tarnia T, Peter N: A survey of postoperative pain management in fourteen hospitals in the UK. Acute Pain 2005; 7: 13-20.
10. Rawal N: European approaches to postoperative pain management. Techniques in Regional Anesthesia and Pain Management 1997; 1: 93-100.
11. Powell AE, Davies HTO, Bannister J: Rhetoric and reality on acute pain services in the UK: a national postal questionnaire survey. Br J Anaesth 2004; 92: 689-93.
12. Spacek A: Modern concepts of acute and chronic pain management. Biomedicine& Pharmacotherapy 2006; 60: 329-35.
13. Paul B: Auditing your acute pain services – a UK NHS model. Acute Pain 2004; 5: 109-12.
14. Dolin SJ, Cashman JN, Bland JM: Effectiveness of acute postoperative pain management: evidence from published data. Br J Anaesth 2002; 89: 409-423.
15. Watt Watson J, Stevens B: Impact of preoperative education on pain management outcomes after coronary artery bypass graft surgery: a pilot study. Can J Nurs Res 2000; 31: 41-56.
16. Association of Anaesthetists of Great Britain and Ireland: the anaesthesia team, 1998.
17. June L Dahl: Improving the practice of pain management. JAMA 2000; 284: 2785.
18. McDonnell A, Nicholl J, Read SM: Acute pain teams and the management of postoperative pain: a systematic review and meta-analysis. Journal of Advanced Nursing 2003; 41: 261-273.
19. Tan CH: A baseline audit of the efficacy and safety of an acute pain services (APS) for cesarean section patients. Acute Pain 2003; 4: 99-104.
20. Yao YT: A preliminary experience of acute pain services in Peking Union Medical Collage Hospital. Acute Pain 2006; 8: 3-6.
21. Comley AL, DeMeyer E: Assessing patient satisfaction with pain management through a continuous quality improvement effort. J Pain Sympt Manage 2001; 21: 24-40.
22. Brodner G, Mertes N, Buerkle H: Acute pain management: analysis implication and consequence after prospective experience with 6349 surgical patients. Eur J Anesth 2000; 17: 566-575.
23. Pellino TA, Ward SE: Perceived control mediates the relationship between pain severity and patient satisfaction. J Pain Sympt Manage 1998; 15: 110-116.
24. Wilder-Smith CH, Schuler L: Postoperative analgesia: pain by choice? The influence of patients’ attitudes and patient education. Pain 1992; 50: 257-62.
25. American Pain Society Quality Improment Committee. Quality improvement guidelines for treatment of acute pain and cancer pain. JAMA 1995; 274: 1847-80.
26. Roth W, Kling J, Gockel I: Dissatisfaction with post-operative pain management - a prospective analysis of 1071 patients. Acute Pain 2005; 7: 75-83.
27. Calvin A, Becker H, Biering P: Measuring patient opinion of pain management. J Pain Sympt Manage 1999; 17: 17-26.
28. Robert N, Mitchell J, Phyllis R.N: Assessment of postoperative pain management: patient satisfaction and perceived helpfulness. The Clinical Journal of Pain 1997; 13: 229-236.
29. Nortclife SA, Shah J, Buggy DJ: Prevention of postoperative nausea and vomiting after spinal morphinefor Caesarean section: comparison of cyclizine, dexamethasone and placebo. Br J Anaesth, 2003; 90: 665-670.
30. Rauck RL: Cost-effectiveness and cost/benefit ratio of acute pain management. Reg Anesth 1996; 21 ( Suppl. 6): 139-43.
31. Rawal N, Berggren L: Organization of acute pain services: a low-cost model. Pain 1994; 57: 117-123.
32. VanDenKerkhof EG, Goldstein DH, Wilson R: A survey
of directors of Canadian academic acute pain management services: the nursing team members role – a brief report. Can J Anaesth 2002; 49: 579-82.
33. Rawal N: Acute pain services revisited-good from far, far from good? Reg Anesth Pain Med 2002; 27: 117-21.
Department of Anesthesiology,
First Affiliated Hospital of Sun-Yat Sen University,
Guangzhou 510080, Guandong Province, PR China