The “Pain-free hospital” project carried out under the auspices of the Polish Society for Pain Research is to launch the best standards of pain management and improve the quality of treatment in Polish hospitals. Severe and moderate pain sensations affect up to 80% of patients after surgery [1]. High quality analgesia depends on better organization rather than new drugs or techniques [2]. The “Pain-free hospital” certification is mainly associated with the changes in habits and introduction of recommendations which could free pain management from preferences and inclinations of physicians and nurses. Such management approaches are connected with additional work, which should be carried out regularly and documented appropriately.

The reports concerning such issues are lacking; therefore, it seems worthy to determine the efficacy of pain treatment according to the “Pain-free hospital” programme and the PROSPECT group guidelines in patients after hernia repair in a county hospital [3, 4].

METHODS

The study based on criteria of the “Pain-free hospital” certification involved:

1) provision of information to patients about effective methods of postoperative pain relief, pain measurements according to the visual analogue scale (VAS) and regular control of pain by the ward staff;

2) measurements of pain and patient`s satisfaction according to VAS at least 4 times a day;

3) assessment of pain severity and analgesia-related patient`s satisfaction recorded in analgesic management records, which was used as a marker of therapy efficacy;

4) participation of the medical personnel (anaesthesiologists, surgeons and nurses) in trainings in postoperative pain relief. The basic pain-related definitions, assessment of postoperative pain severity and methods of treatment – multimodal analgesia, were elaborated. The participants were also informed about consequences of inadequate analgesia, e.g. activation of the sympathetic system and persistent postoperative pain. Moreover, the goals of individual professional groups in the treatment of postoperative pain were discussed;

5) monitoring of side effects of the treatment administered.

The study involved patients scheduled for inguinal and umbilical hernia repair procedures.

The control group consisted of patients who received postoperatively iv ketoprofen 50-100 mg every 8 h, at persistent severe pain – intradermal morphine 5 mg. Those patients had been treated before the guidelines of postoperative pain management were introduced, thus the assessment was retrospective.

The study group encompassed patients treated according to the “Pain-free hospital” programme. Before surgery, patients were informed about pain examinations and adequate analgesic therapy. Moreover, they were instructed about VAS. Pain treatment was adjusted to the type of surgery according to the PROSPECT group guidelines (Table 1). Patients were premedicated with oral midazolam 0.1-0.5 mg kg-1 (max. 15 mg) and paracetamol 1g or ibuprofen 400 mg. In each case, analgesia for surgery was supplemented with local infiltration anaesthesia or peripheral nerve block using bupivacaine. In the postoperative period, patients received iv paracetamol 1g every 6 h and ketoprofen 100 mg. Oral drugs were administered as promptly as possible. In cases of insufficient analgesia and pain assessed as VAS <5, patients received tramadol 100 mg in the 0.5 h intravenous infusion. If pain was evaluated as VAS >5, iv morphine was administered in the doses: 1 mg for patients of body weight <65 kg or 2 mg for patients of body weight > 65 kg every 5-10 min until pain sensations were relieved. The treatment-related satisfaction was assessed by patients according to the 10-point scale.

The additional medical interventions were defined in the control group as administration of additional doses of analgesics on demand and in the study group as immediate use of additional drugs not included in the primary treatment protocol.

The number and types of drugs used for pain management were analysed. Moreover, age and gender of patients, type of hernia, method of anaesthesia, and duration of hospitalization were assessed.

The results were statistically analysed. Descriptive values were used to characterize both groups using a mean and range depending on their distribution in individual groups (normal distribution). For normal distribution, groups were compared using the Shapiro-Wilk test. Results were analysed with the Student’s t and Mann-Whitney test. Numerical data were presented as means and ranges and compared using the χ2 test. P<0.05 was considered as statistically significant.

RESULTS

The study included 100 patients, allocated to two groups − control and study, 50 patients each. There were no significant intergroup differences in age and gender of patients, type of surgery and anaesthesia (Table 2).

Additional interventions in the study group were needed in one patient whereas in the control group in 9 patients (p=0.023).

In the study group, 39 (78%) patients assessed their analgesic satisfaction as 9 whereas 11 (22%) as 10, according to the 10-point scale. In the control group, such an analysis was not performed due to the retrospective character of examinations.

During postoperative therapy, on average, 309 mg of ketoprofen (0-1000 mg) in the control group and 200 mg (0-300 mg) in the study group were administered. In the latter, patients additionally received paracetamol, the mean dose in the postoperative period was 1.72 g (1-4 g). Morphine was administered 6 times in the control group and 1 time in the study group.

In both groups, no adverse side effects of the analgesics used were observed. In the study group, 4 patients developed urine retention and required catheters; in the control group the same problems were found in 8 patients. There was no correlation between urine retention and increased postoperative pain.

The duration of hospitalization in both groups was comparable; in the majority of cases, patients were discharged during the first postoperative day. On average, the study group patients were hospitalized for 1.28 day (min 0.5; max. 3 days) whereas control patients for 1.26 day (min. 0.5; max. 4 days). The prolonged hospitalization did not correlate with more severe postoperative pain. The pain was mostly caused by older age (>70 years) and/or anxiety to leave the hospital due to lack of home care.

DISCUSSION

We compared the number of required additional interventions (additional analgesics) in the postoperative period before and after the introduction of the guidelines of the “Pain-free hospital” programme. It was assumed that measurement of patients’ analgesia-related satisfaction was suitable to assess the efficacy of pain treatment. The patients` satisfaction was analysed as the main variable dependent on the therapy administered. The assessment of patients` satisfaction was introduced into practice together with the “Pain-free hospital” certification. For these reasons, in the control group, it was assumed that lack of satisfaction caused by inadequate analgesia was documented by additional administration of analgesics, although such an assumption carried the risk of false positive errors. Lack of interventions might have been caused after all not by lack of pain but fear of patients of hospital staff or opioids. Nevertheless, it was assumed that determinations of the actual number of additional interventions using statistical methods in the study group should have higher importance for concluding about the treatment efficacy in clinical practice.

In the group treated according to the guidelines, the incidence of additional interventions was significantly lower, which evidences the rightness of the management implemented. This result is also confirmed by the fact that 100% of patients were satisfied with the treatment.

The effectiveness of pain treatment is conditioned by many factors, e.g. pathogenesis of pain, therapy, and patient-related factors, including their attitude during the treatment process. It has been observed that aware patients more eagerly succumb to therapy and the treatment administered to them is more effective [5]. Thanks to pain assessment, their needs are considered and patients are involved in the treatment; however, personnel trainings and improved communication skills are required as assessment of complaints by patients is often underestimated  by physicians and nurses [6].

The “Pain-free hospital” programme is the project of organization of ward work and care of patients, considering their needs related to pain treatment. The implementation of certification is associated with increased workload concerning the preparation of patients for surgeries, determination of their complaints and documentation of pain assessment and management. Our study demonstrates that in this way the number of unanticipated procedures is decreased simultaneously improving the patient`s comfort. The presented data do not regard only the treatment outcomes but also show the possibilities of management modifications during the postoperative period.

Pain treatment is mostly dependent on the extent of surgery and should be adjusted to the type of surgical procedure carried out – which was demonstrated in the PROSPECT group study. This means that a patient undergoing surgery due to cholecystitis and a patient after hernia repair require separate treatment protocols [4].

According to literature data, pain after hernia repair is characterized by moderate intensity and its treatment using multimodal analgesia with local anaesthesia and non-opioid analgesics reduces demands for narcotic drugs, hence adverse side effects might be avoided and convalescence is faster. Moreover, lower consumption of ketoprofen, belonging to non-steroidal anti-inflammatory drugs, is important as their use is associated with side effects. Such drugs may increase the risk of strokes, heart and kidney failures, whose incidences grow with age. Ketoprofen is a good analgesic yet the risks-to-benefits of its use should be weighted [7, 8].

In our study, the duration of hospital stay did not decrease and the number of non-opioid analgesics administered to patients was found higher in the study group. Considering cost-effectiveness, the hospital did not gain the intended profits; the rotation of patients was not accelerated and additional drug-related expenditure was necessary. On the other hand, benefits of patients measured by their satisfaction imply that the costs incurred should be considered right.

Thanks to advances in medicine, patients with various co-morbidities can undergo surgical procedures; in such cases, perioperative stress and pain might induce serious complications. The “Pain-free hospital” project is to improve the quality of services, which is particularly important in such patients. Surgery is currently not only a radical life-saving procedure undertaken in cases of absolute necessity, irrespective of its mutilating consequences. It is believed that surgical procedures should be performed in the least severe way for patients, especially when their aim is not to save life but to improve the comfort of living.

CONCLUSIONS

1. There is a well-grounded need to introduce modern methods of pain treatment to everyday practice of postoperative wards.

2. The “Pain-free hospital” project and PROSPECT group guidelines help to choose appropriate methods of treatment; however, the use of such methods requires involvement of the entire physician-nurse teams. 

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REFERENCES

1.    Apfelbaum J, Chen C, Mehta S, Gan T: Postoperative pain experience: results from national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003; 97: 534-540.

2.    Bonnet f, Marret E: Postoperative pain management and outcome after surgery. Best practice and research. Clinical Anaesthesiology 2007; 21: 99-107.

3.    Polskie Towarzystwo badania bólu. Szpital bez bólu. www.szpitalbezbolu.pl/kryteria-przyznawania-certyfikatu.html

4.    Kehlet H, Wilkinson R, Fischer HBJ, Camu F: On behalf of the PROSPECT Working Group. PROSPECT: Evidence-based, procedure-specific postoperative pain management. Best practice and research. Clinical Anaesthesiology 2007; 21: 149-159.

5.    Franneby U, Gunnarsson U, Wollert S, Sandblom G: Discordance between the patient’s and surgeon’s perception of complications following hernia surgery. Hernia 2005; 9: 145-149.

6.    Klopfenstein CE, Herrmann FR, Mamie C, Van Gessel E, Forster A: Pain intensity and pain relief after surgery. Acta Anaesthesiol Scand 2000; 44: 58-62.

7.    Procedure specific postoperative pain management. www.postoppain.org/content.aspx?nid=64595

8.    Śmietańska I: Leczenie bólu pooperacyjnego; w: Anestezja geriatryczna (Red.: Trojanowska I, Wołowicka L), PZWL, Warszawa, 2010: 317-330.
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address:

*Irmina Śmietańska
Klinika Anestezjologii i Intensywnej Terapii
Uniwersytet Medyczny w Gdańsku
tel.: 58 349 24 06
e-mail: anias@amg.gda.pl

received: 17.06.2010
accepted: 16.09.2010