Patient satisfaction with postoperative pain management--effect of preoperative factors

Quality of nursing care in pain management in orthopedic surgical patients: a scoping review

OBJECTIVE

To map the evidence on quality nursing care practices in pain management in orthopedic surgical patients.

METHOD

Scoping review, as per the JBI Manual recommendations. Searches were performed in the MEDLINE (PubMed), LILACS (Regional VHL), Scopus, Embase, Web of Science, Cochrane, Cinahl databases, and gray literature, regardless of language and period. Selection and extraction were performed by two independent reviewers, using inclusion/exclusion criteria, and the extracted data were organized to reflect key themes or recurring patterns related to the purpose of the review.

RESULTS

A total of 94 studies were included, most from the United States, corresponding to 34% of the sample, and published between 1997 and 2022. The findings were categorized into: nursing quality practices in pain management related to the organization and monitoring of units, and pre- and post-operative period.

CONCLUSION

The research revealed that quality nursing care practices in pain management in orthopedic surgical patients encompass a variety of approaches, from the use of nonpharmacological practices and patient education to the use of pain assessment scales, staff training, to innovative pharmacological procedures.

Quality of Postoperative Pain Management in Orthopedic Patients and Its Impact on Sleep Quality and Patient Satisfaction: An Integrative Review

Pain is one of the most common manifestations in the postoperative stage and it has a detrimental effect on both sleep and patient satisfaction. Consequently, this integrative review seeks to identify the outcomes of pain management specifically concerning sleep quality and patient satisfaction among the patients receiving orthopedic surgeries. In a stepwise manner, peer-reviewed articles manually searched in four databases including Scopus, Science Direct, PubMed, and CINAML (Cumulated Index to Nursing and Allied Health Literature) published between 2019 and 2023 were selected. The current review finally encompassed 22 studies. The review elaborates and reaffirms the notion that pain after surgery is still a critical issue that impacts the quality of patients' sleep as well as their overall satisfaction. Chronic sleep disturbance is generally linked with pain while other factors such as light exposure and hospital environment were found to influence sleep quality. It is thus crucial to develop clear multifaceted pain management guidelines that include patient-tailored pharmacological and non-pharmacological interventions aimed at helping patients recover better, sleep better, and be satisfied with the procedures and results.

Adductor Canal Block Versus Local Infiltration Analgesia for Postoperative Pain Management in Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a common surgical procedure for patients with knee osteoarthritis, often associated with postoperative pain. Effective pain management strategies are essential for improving patient outcomes and satisfaction. This study aimed to compare the efficacy of two analgesic modalities, local infiltration analgesia (LIA) and adductor canal block (ACB), in providing postoperative pain relief for patients undergoing TKA.

METHODS

This prospective randomized comparative study included 60 patients undergoing TKA for knee osteoarthritis under subarachnoid block (spinal anaesthesia). Patients were divided into two groups: LIA group (local wound infiltration with periarticular injection of bupivacaine 0.125% + dexmedetomidine 1 mcg/kg) and ACB group (ACB with bupivacaine 0.125% + 1 mcg/kg dexmedetomidine). Pain relief was assessed using the Numerical Rating Scale (NRS) score, time to first rescue analgesic requirement (NRS > 3), and total amount of analgesic needed in the first 24 hours post-surgery.

RESULTS

The time to first perception of pain with NRS > 3 was 11.30±0.8 hours in the ACB group and 9.40 ± 1.1 hours in the LIA group, with a statistically significant difference (p < 0.001). Additionally, the total number of rescue analgesic doses given in the first 24 hours post-operatively differed significantly between the two groups (p = 0.046).

CONCLUSION

The study concludes that ACB is an effective postoperative analgesic modality, superior to local infiltration analgesia, for patients undergoing TKA.

Comparison of erector spinae plane block and serratus anterior plane block for postoperative analgesia in uniportal thoracoscopic lobectomy: a randomized controlled trial

BACKGROUND

Postoperative pain remains a significant concern following uniportal thoracoscopic surgery. The analgesic efficacy of erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) in terms of postoperative opioid consumption in uniportal thoracoscopic surgery still needs further studies.

METHODS

A randomized controlled trial was conducted, enrolling 150 patients who underwent uniportal thoracoscopic lobectomy. The patients were randomly allocated to three groups in a 1:1:1 ratio: the ESPB group (administered 20 ml of 0.5% ropivacaine), the SAPB group (administered 20 ml of 0.5% ropivacaine), and the standard care (control) group. The primary endpoint was the consumption of sufentanil during the first 24 h following surgery. Secondary endpoints assessed the area under the curve (AUC) of pain numerical rating scale (NRS) scores, occurrence of moderate to severe pain, time to initial sufentanil request, and postoperative adverse events.

RESULTS

No significant difference was observed in the consumption of sufentanil during the first 24 h following surgery between the ESPB and SAPB groups (adjusted difference, 1.53 [95% CI, -5.15 to 2.08]). However, in comparison to the control group, both intervention groups demonstrated a significant decrease in sufentanil consumption, with adjusted differences of -9.97 [95% CI, -13.10 to -6.84] for the ESPB group and -12.55 [95% CI, -15.63 to -9.47] for the SAPB group. There were no significant differences in AUC of NRS scores during rest and movement between the ESPB and SAPB groups, with adjusted differences of -7.10 [95% CI, 1.33 to -15.55] for the rest condition and 5.61 [95% CI, -13.23 to 2.01] for the movement condition. At 6 h postoperatively, there were fewer patients with moderate to severe pain in the ESPB group compared with those in the SAPB group (adjusted difference, -1.37% [95% CI, -2.29% to -0.45%]. The time to first sufentanil request significantly differed among the three groups (ESPB vs Control P < 0.01, SAPB vs Control P < 0.01, ESPB vs SAPB P = 0.015).

CONCLUSIONS

In patients undergoing uniportal thoracoscopic lobectomy, although the differences between the two groups are not statistically significant, both the ESPB and SAPB demonstrate effective reduction in postoperative opioid consumption and the need for rescue analgesics compared to the control group. Moreover, the ESPB group experienced a significantly lower incidence of moderate to severe pain at 6 h postoperatively compared to the SAPB group.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (registration No: ChiCTR1900021695, Date of registration: March 5th, 2019).

Relationship Between Quality of Care and Patient Care Outcomes for Postoperative Pain in Major Orthopedic Surgery: Analytical and Cross-Sectional Study

The quality of care provided for the management of postoperative pain and patient outcomes are key criteria for healthcare institutions. This study aimed to determine the relationship between the quality of care provided for the alleviation of postoperative pain experienced among patients undergoing major orthopedic surgery and the patient care outcomes. The study was designed as an analytical and cross-sectional study. The rates of pain severity and sleep interference, activity interference, affective experiences, and adverse effects due to postoperative pain were higher in female patients than in male patients. A significant positive correlation was identified between the quality of postoperative pain care and the perception of care (p < .05). Implementing nursing interventions to improve pain management and increase the quality of care appears to be vital elements for reducing adverse effects caused by pain and increasing the satisfaction with postoperative pain care.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

Hintergrund

Nichtopioidanalgetika werden bei vielen Patienten zur perioperativen Analgesie eingesetzt. Zu einigen praktischen Fragen beim Einsatz von Nichtopioidanalgetika liegen z. T. nur wenig Informationen aus Studien vor, und in Krankenhäusern existieren häufig keine Konzepte zum Vorgehen, z. B. zur Patientenaufklärung und zum Zeitpunkt der perioperativen Gabe.

Methodik

Eine Expertengruppe der beteiligten Fachgesellschaften hat konsensbasierte Empfehlungen zum perioperativen Einsatz von Nichtopioidanalgetika erarbeitet und in einem strukturierten formalen Konsensusprozess verabschiedet.

Ergebnisse

Die Arbeitsgruppe stimmt überein, dass Nichtopioidanalgetika Bestandteil eines perioperativen multimodalen Analgesiekonzepts sein sollen und Patienten präoperativ über Nutzen, Risiken und alternative Behandlungsmöglichkeiten aufgeklärt werden sollen. Die präoperative Patienteninformation und -edukation soll auch eine Schmerz- und Analgetikaanamnese umfassen und Patienten mit Risikofaktoren für starke Schmerzen und eine Schmerzchronifizierung sollen identifiziert werden. Unter Berücksichtigung von Kontraindikationen können Nichtopioidanalgetika abhängig von der Operationsdauer auch schon prä- oder intraoperativ gegeben werden, um nach Beendigung der Anästhesie ausreichende Plasmakonzentrationen zu erzielen. Nichtopioidanalgetika oder Kombinationen von (Nichtopioid‑)Analgetika sollen nur für einen begrenzten Zeitraum gegeben werden. Ein gemeinsam erarbeiteter abteilungsübergreifender Behandlungsstandard mit dem Nichtopioidanalgetikum erster Wahl, weiteren Therapieoptionen sowie adäquaten Dosierungen, ergänzt durch eingriffsspezifische Konzepte, soll schriftlich hinterlegt werden. Bei Entlassung aus dem Krankenhaus soll der nachbehandelnde Arzt zu perioperativ gegebenen und aktuell noch eingenommenen Analgetika schriftliche Informationen erhalten. Patienten sollen zu möglichen Nebenwirkungen der Analgetika und ihrer Symptome, die auch nach Krankenhausentlassung auftreten können, und die befristete Einnahmedauer informiert werden.

Schlussfolgerung

Die Anwendung von Nichtopioidanalgetika soll als Bestandteil eines perioperativen multimodalen Analgesiekonzepts mit klaren Vorgaben zu Indikationen, Kontraindikationen, Dosierungen und Behandlungsdauer in einem abteilungsübergreifenden Behandlungsstandard schriftlich hinterlegt werden.

Zusatzmaterial online

Die Offenlegung von Interessen ist in der Online-Version dieses Artikels (10.1007/s00104-021-01421-w) enthalten.

Effectiveness of Fascia Iliaca Compartment Block after Elective Total Hip Replacement: A Prospective, Randomized, Controlled Study

Objective: An assessment of the feasibility of fascia iliaca compartment block (FICB) combined with nonopioid analgesics and patient controlled analgesia (PCA), oxycodone, in the perioperative anaesthetic management for elective total hip replacement (THR). Design: A randomised, single-center, open-label study. Setting: A single hospital. The study was conducted from October 2018 to May 2019. Participants: In total, 109 patients were scheduled for elective total hip replacement. Interventions: Postoperative FICB with 0.375% ropivacaine in conjunction with nonopioid analgesics (paracetamol, metamizole, and pregabalin) and oxycodone as rescue analgesia. Measurements: Pain intensity was measured using the Numeric Pain Rating Scale (NRS) at rest and during rehabilitation, the total dose of postoperative oxycodone required, the occurrence of opioid-related adverse events, patient hospitalisation time, and level of satisfaction. Follow-up period: 48 h. Main Results: A total of 109 patients were randomised into two groups and, of these, 9 were subsequently excluded from the analysis (three conversions to general anaesthesia, two failures to perform FICB, four failures to use the PCA pump). Patients in the FICB group received standard intravenous analgesia with FICB, and those in the control group were managed with standard intravenous analgesia only. Pain level measured with NRS was significantly lower at rest and during rehabilitation in the FICB group. Oxycodone use in the first 48 h was significantly higher in the control group (p < 0.001); additionally, the time to the first dose of rescue analgesia was significantly shorter (p < 0.001). In the control group, there was a higher rate of side effects and a significantly longer hospitalisation time (p < 0.001). Similarly, higher satisfaction with the applied analgesic treatment was noted in the FICB group. Conclusions: FICB in elective THR treatments is an effective form of analgesia, which reduces the need for opioids, the number of complications, the length of hospitalisation, and which ensures a high level of patient satisfaction with the analgesic treatment used. Trial registration: ClinicalTrials.gov No. NCT04690647.

Assessment of Patient's Satisfaction and Associated Factors regarding Postoperative Pain Management at the University of Gondar Compressive Specialized Hospital, Northwest Ethiopia

Objective

We aimed to assess the level of patient's satisfaction and associated factors regarding postoperative pain management.

Methods

An institution-based cross-sectional study was conducted from April to May 2018 at the University of Gondar, and comprehensive specialized hospital data were collected through semistructured questionnaire and chart review. Level of satisfaction was measured using five-point Likert scale. Statistical analysis was done using SPSS software version 23. Both bivariable and multivariable logistic regression analyses were done. Variables of P value ≤0.2 in the bivariable analysis were a candidate for multivariable logistic regression. A P value ≤0.05 was considered as significantly associated with patient's level of satisfaction at 95% CI.

Results

A total of 418 patients were included in this study with a response rate of 98.58%. The overall proportion of patients who were satisfied with pain management services was 72.2% (95% CI: 67.7-76.6). ASA1 (AOR = 3.55: 95% CI = 1.20-10.55) and ASA2 patients (AOR = 3.72: 95% CI = 1.04-13.28), absence of postoperative pain (AOR = 1.86: 95% CI = 1.02-3.39), peripheral nerve block done (AOR = 9.14: 95% CI = 3.93 20.86), received analgesic before request (AOR = 6.90: 95% CI = 3.72-12.83), and received systemic analgesics (AOR = 6.10: 95% CI = 1.17-33.91) were significantly associated with the level of satisfaction.

Conclusion

The level of patient satisfaction with postoperative pain management was considerably low. Hence, it is vital to implement time-interval pain assessment method during the first 24 hours of postoperative period and treat accordingly based on the WHO pain ladder. Moreover, we suggested that all patients who underwent major surgery should receive peripheral nerve block as part of multimodal analgesia to decrease the incidence and severity of post op pain.

Should Preoperative Fascia Iliaca Block Be Used for Hip Arthroscopic Labral Repair and Femoroacetabular Impingement Treatment? A Prospective Single Blinded Randomized Study

PURPOSE

To evaluate the analgesic effect of preoperative fascia iliaca block on postoperative morphine equivalent dose, pain level, and patient satisfaction for patients electing to undergo primary hip arthroscopic labral repair with osteochondroplasty.

METHODS

This prospective study included 60 patients (fascia iliaca block group: n = 27; control group: n = 33) undergoing elective arthroscopic hip surgery by a single board-certified orthopedic surgeon, fellowship trained in hip arthroscopy. Participants for the study included patients older than 10 years of age and younger than 85 years of age, American Society of Anesthesiologists classifications I to III, diagnosed with symptomatic femoroacetabular impingement, and/or hip labral tear, and/or cartilage damage, and electing to undergo arthroscopic hip surgery. Patients were randomized by surgical date to receive preoperative fascia iliaca block or control (no fascia iliaca block). Preoperative fascia iliaca block was administered by 1 of 4 board certified anesthesiologists using identical anesthetic (35-40 mL ropivacaine 0.35%). Postoperative morphine equivalent dose, self-reported pain level (visual analog scale) and patient satisfaction were measure postoperatively.

RESULTS

There were no significant differences between the control group and the fascia iliaca block group in sex, age, height, weight, or body mass index. There was a significant difference between the 2 groups in distribution of American Society of Anesthesiologists classification (p = .031). There were no significant differences in postoperative morphine equivalent dose for patients receiving fascia iliaca block compared with the control group. There were no significant differences in self-reported visual analog scale pain and patient satisfaction between the 2 groups at any of the measured time points following surgery.

CONCLUSIONS

Based on the results of this study, routine preoperative fascia iliaca block for elective hip arthroscopic labral repair and treatment of femoroacetabular impingement is not recommended.

LEVEL OF EVIDENCE

Level II, prospective single blinded randomized study.

Pain Management and Its Possible Implementation Research in North Ethiopia: A before and after Study

BACKGROUND

Though there is an effective intervention, pain after surgical intervention is undermanaged worldwide. A systematic implementation is required to increase the utilization of available evidence-based intervention to manage the inevitable pain after surgery. The aim of this research project is to develop a scalable model for managing pain after cesarean section by implementing the World Health Organization's (WHO) pain management guidelines through a combination of implementation research and quality improvement methods.

METHODS

We implemented the World Health Organization (WHO) pain management guidelines using effective implementation strategies. First, we conducted a formative qualitative exploration to identify enablers and obstacles. In addition, we took base-line assessment on pain management implementation process and outcome using a checklist prepared from the guideline and an adapted American Pain Outcome assessment tool version 2010, respectively. Then, we integrated the guidelines into the existing practice by using collaborative iterative learning strategy. We analyzed the data by Statistical Packages for Social Sciences (SPSS) version 21. We compared the before and after data using chi-squared and Fischer's exact test. A change in any measurement was considered as significant at p value 0.05.

RESULT

We collected data from 106 mothers before and 110 mothers after intervention implementation. We successfully integrated pain as a fifth vital sign in more than 87% (p value <0.001) of patient, and fidelity was approximately 59% (p value <0.001). In addition, we significantly improved pain outcome measures after the implementation of the intervention. Conclusion and Recommendations. A systematic approach to implement pain management guidelines was successful. We recommend the ward sustain these gains and that hospital, the region, and the nation to replicate the success.

Knowledge on Nonpharmacological Methods of Pain Management among Nurses at Bindura Hospital, Zimbabwe

This study is a quantitative descriptive study, which was conducted with an aim to assess the knowledge on nonpharmacological methods of pain management among registered general nurses at Bindura Hospital. This is because most nurses focus more on pharmacological pain management than nonpharmacological therapies which are given less attention or accord. This study used a descriptive study design, which is a nonexperimental research design so as to obtain information about registered nurses knowledge on nonpharmacological pain management. A convenience sampling technique was utilised to select a sample of seventy-five participants. Data were collected by the researcher who distributed self-administered questionnaires to available registered nurses after obtaining informed consent at Bindura Provincial Hospital. The mean knowledge score for this study was 48.6% and was below a pass mark of 50% and far below 80% which is the minimal acceptable level of knowledge on the Nurses Knowledge and Attitude Scale. A minimum knowledge score of 16% was obtained from participants showing lack of knowledge on indications of nonpharmacological pain therapies and a maximum knowledge score of 97.3% was shown on knowledge on nonpharmacological techniques. The following conclusion was drawn from the research findings; the study showed that the nurses have poor knowledge regarding nonpharmacological pain management as indicated by mean knowledge score of 48.6%. The researcher therefore recommends that the nursing practice should take an initiative in ensuring that all practicing nurses practice the highest possible pain management nursing care and that opportunities should be made available for nurses to be educated in effective pain management utilising nonpharmacological therapies.

Concerns for Older Adult Patients with Acute Hip Fracture

PURPOSE

The purpose of this study was to identify concerns among older adult patients with acute hip fracture.

MATERIALS AND METHODS

This study was performed with 152 consecutive patients with hip fracture. Details were obtained on perioperative concerns about hip fracture using a questionnaire that was specifically designed for this study and was administered face to face upon admission. The study inclusion criteria were age older than 65 years and having experienced femur neck, intertrochanteric, or subtrochanteric fracture. The exclusion criteria were not understanding the study purpose, having difficulty communicating, or refusing to participate.

RESULTS

Older adult patients with acute hip fracture expressed concerns regarding excessive pain, medical staff, postoperative recovery, rehabilitation, and hospital expenses. In addition, fear of falling from the bed and anxiety regarding re-fracture were the patients' most significant concerns.

CONCLUSION

Older adult patients reported fear of falling from bed and re-fracture as primary concerns. To overcome these concerns, fracture liaison services to prevent re-fracture should be introduced and enforced.

Postoperative pain management practices and their effectiveness after major gynecological surgery: An observational study in a tertiary care hospital

Background and Aims:

Despite advances in postoperative pain management, patients continue to experience moderate to severe pain. This study was designed to assess the strategy, effectiveness, and safety of postoperative pain management in patients undergoing major gynecological surgery.

Material and Methods:

This observational study included postoperative patients having major gynecological surgery from February 2016 to July 2016. Data collected on a predesigned data collection sheet included patient's demographics, postoperative analgesia modality, patient satisfaction, acute pain service assessment of numeric rating scale (NRS), number of breakthrough pains, number of rescue boluses, time required for the pain relief after rescue analgesia, and any complication for 48 h.

Results:

Among 154 patients reviewed, postoperative analgesia was provided with patient-controlled intravenous analgesia in 91 (59.1%) patients, intravenous opioid infusion in 42 (27%), and epidural analgesia in 21 (13.6%) patients with no statistically significant difference in NRS between different analgesic modalities. On analysis of breakthrough pain, 103 (66.8%) patients experienced moderate pain at one time and 53 (51.4%) at two or more times postoperatively. There were 2 (0.6%) patients experiencing severe breakthrough pain due to gaps in service provision and inadequate patient's knowledge. Moderate-to-severe pain perception was irrespective of type of incision and surgery. Vomiting was significantly higher (P = 0.049) in patients receiving opioids.

Conclusion:

Adequacy of postoperative pain is not solely dependent on drugs and techniques but on the overall organization of pain services. However, incidence of nausea and vomiting was significantly higher in patients receiving opioids.

Patient Comprehension and Compliance Survey to Assess Postoperative Pain Regimens in the Orthopaedic Trauma Population

OBJECTIVE

This study aims to determine the groups of patients who are at risk for noncompliance and misunderstanding of their pain regimen.

DESIGN

Survey-based cohort study.

SETTING

Suburban Level-I trauma center.

PATIENTS/PARTICIPANTS

A total of 171 patients between the ages of 18-89 years who underwent surgical fixation of fractures involving the pelvis, long bones, or periarticular regions of the knee, ankle, elbow, and wrist.

MAIN OUTCOME MEASUREMENTS

Patients who cannot accurately reproduce their prescribed pain medication list and patients who modify this pain medication regimen were analyzed by age, employment status, income level, education level, time between surgery and follow-up, and whether pain interfered with activities of daily living.

RESULTS

Overall, 147 patients completed the survey. Seventy percent (n = 114) of patients could not accurately reproduce their pain medication regimen, regardless of age, employment status, income level, education level, time between surgery and follow-up, and whether pain interfered with activities of daily living. Patients (61.2%; n = 90), regardless of the 6 aforementioned demographic factors, also admitted to modifying their pain medication regimen with non-prescribed medications, with 55.8% (n = 82) of patients adding over-the-counter medications to surgeon-prescribed narcotic medications.

CONCLUSIONS

Misunderstanding and noncompliance of surgeon-prescribed pain regimens are prevalent across all patient demographics. Knowledge of the potential effects these augmentative medications can have on fracture healing and any drug-drug interactions that may arise is an important aspect of patient postoperative care. Surgeons must be wary of these trends and screen for any unintended side effects a patient's pain regimen may have.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Analgesic Effects of Preincision Ketamine on Postspinal Caesarean Delivery in Uganda's Tertiary Hospital: A Randomized Clinical Trial

Background. Good postoperative analgesic management improves maternal satisfaction and care of the neonate. Postoperative pain management is a challenge in Mulago Hospital, yet ketamine is accessible and has proven benefit. We determined ketamine's postoperative analgesic effects. Materials and Methods. We did an RCT among consenting parturients that were randomized to receive either intravenous ketamine (0.25 mg/kg) or placebo after spinal anesthetic. Pain was assessed every 30 mins up to 24 hours postoperatively using the numerical rating scale. The first complaint of pain requiring treatment was noted as “time to first breakthrough pain.” Results. We screened 100 patients and recruited 88 that were randomized into two arms of 44 patients that received either ketamine or placebo. Ketamine group had 30-minute longer time to first breakthrough pain and lower 24-hour pain scores. Postoperative diclofenac consumption was lesser in the ketamine group compared to placebo and Kaplan-Meier graphs showed a higher probability of experiencing breakthrough pain earlier in the placebo group. Conclusion. Preincision intravenous ketamine (0.25 mg/kg) offered 30-minute prolongation to postoperative analgesia requirement with reduced 24-hour pain scores. We recommend larger studies to explore this benefit. This trial is registered with Pan African Clinical Trial Registry number PACTR201404000807178.

The Quality of Postoperative Pain Therapy in German Hospitals

BACKGROUND

Many patients in German hospitals complain of inadequate treatment of their postoperative pain. Hospital-related structural and procedural variables may affect pain perception and patient satisfaction. We studied the association of individual variables with outcome quality.

METHODS

Data from the years 2011 to 2014 from the world's largest acute pain registry (QUIPS) were evaluated. The analysis was performed with mixed linear regression models.

RESULTS

We studied registry data from 138 German hospitals concerning four commonly performed types of operations (total number of operations, 21 114) and found that the intensity of pain, functional impairment, and satisfaction with postoperative pain therapy were all highly variable from one hospital to another. Patients in university hospitals complained more often than those in standard care facilities of highly intense pain (odds ratio [OR] 2.44; 95% con - fidence interval [CI] [1.18; 5.04]) and dissatisfaction (OR 3.58 [1.85; 6.93]). In specialized centers as well, pain intensity (OR 1.39 [1.06; 1.83]) and dissatisfaction (OR 1.59 [1.25; 2.02]) were higher. Pain-related limitation of movement was also reported more commonly in university hospitals (OR 2.12 [0.87; 5.16]) and specialized centers (OR 1.87 [1.33; 2.65]) than in standard care facilities. Less pain-related limitation of movement and higher satisfaction were reported in hospitals in which pain was documented in the patients' charts and the patients felt adequately informed about the treatment options.

CONCLUSION

The current state of postoperative pain therapy leaves much room for improvement. Quality indicators in the field of acute pain medicine might help improve patient care.

Enhancing Nurses' Pain Assessment to Improve Patient Satisfaction

Patient satisfaction with pain management has increasing importance with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores tied to reimbursement. Previous studies indicate patient satisfaction is influenced by staff interactions. This single-group pre/post design study aimed to improve satisfaction with pain management in older adults undergoing total joint replacement. This was a single-group pre-/posttest design. Nurse (knowledge assessment) and patient (American Pain Society Patient Outcomes Questionnaire Revised [APS-POQ-R], HCAHPS) responses evaluated pre- and postimplementation of the online educational program. Nurse focus group followed intervention. Nurses' knowledge improved significantly (p < .006) postintervention. HCAHPS scores (3-month average) for items reflecting patient satisfaction improved from 70.2 ± 9.5 to 73.9 ± 6.0. APS-POQ-R scores did not change. Focus group comments indicated need for education regarding linkages between pain management and patient satisfaction. Education on linkages between patient satisfaction and pain management can improve outcomes; education on strategies to further improve practice may enhance ability to achieve benchmarks.

Does preoperative patient's estimated acceptable pain affect the satisfaction with postoperative pain management?

Background

Patient satisfaction with postoperative pain management is an important quality indicator in patient health care, but its determinants are poorly understood. Here, we examined the contribution of the discrepancy between an individual's estimated acceptable and actual postoperative pain scores to the overall satisfaction with pain treatment.

Findings

A total of 93 surgical patients were included in this study. Preoperatively, the subjects were asked to rate their estimated acceptable postoperative pain using a numerical rating scale (NRS). One day after the surgery, the patients were again asked to give NRS ratings of the overall actual pain intensity they had experienced, as well as their satisfaction with the provided pain treatment. The median estimated acceptable and actual NRS values for postoperative pain were 4.0 (3.0-5.0) and 4.0 (2.0-5.0), respectively. Although there was no correlation between the degree of patient satisfaction and preoperative estimated acceptable pain intensity, there was a significant negative correlation between the degree of patient satisfaction and postoperative actual pain intensity. When the preoperative estimated acceptable NRS value was compared with the postoperative actual value for each individual, postoperative NRS was greater in 34 cases (36.6%), less in 43 cases (46.2%), and equal in 16 cases (17.2%). The degree of patient satisfaction was not significantly correlated with the magnitude of difference between preoperative estimated acceptable NRS and postoperative actual NRS.

Conclusions

Our findings suggest that inquiring about the estimated acceptable pain before surgery may not help anesthesiologists to understand the patient's goal of pain management for improving patient satisfaction.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Nurse led Patient Education Programme for patients undergoing a lung resection for primary lung cancer

There has been an increase in the number of patients undergoing lung resection for primary or suspected primary lung cancer in the UK due to improved staging techniques, dedicated thoracic surgeons and other initiatives such as preoperative pulmonary rehabilitation. This has had an impact on local healthcare resources requiring new ways of delivering thoracic surgical services. When considering service changes, patient reported outcomes are pivotal in terms of ensuring that the experience of care is enhanced and may include elements such as involving patients in their care, reducing the length of inpatient stay and reducing postoperative complications. The implementation of a thoracic surgical Patient Education Programme (PEP) has the potential to address these measures and improve the psychological and physical wellbeing of patients who require a lung resection. It may also assist in their care as an inpatient and to enhance recovery after surgery both in the short and long term.

Young people's experiences with scoliosis surgery: a survey of pain, nausea, and global satisfaction

BACKGROUND

Scoliosis surgery is one of the most extensive elective surgical processes performed on young people. Although there is a great store of knowledge of surgical techniques, patients' experiences of going through surgery have not been extensively studied.

PURPOSE

The aim of this study is to describe how a cohort of young people and their parents retrospectively rate postoperative pain and nausea and describe their experiences of scoliosis surgery.

METHODS

In a retrospective cohort study, 87 young people aged 8-25 years with scoliosis who underwent corrective surgery from 2004 to 2007 were invited to complete a questionnaire, as were their parents. The semistructured questionnaire dealt with experiences of pain, nausea, and global satisfaction pre- and posthospitalization, assessed by visual analogue scales. The free text commentaries were analyzed using qualitative content analysis.

RESULTS

A total of 51 patients (59%) and 65 parents (75%) answered the questionnaires. Out of the completed questionnaires, 41 had idiopathic, 23 neuromuscular, and 6 other types of scoliosis. Postoperative patient-rated pain was severe 7.3 (median, interquartile range 5-8.4, visual analogue scale 0-10 cm), and the severe pain lasted for 5 (median, 2.7-7.0) days. Nausea was rated to a median of 5 (1.1-7.3) and lasted for a median of 3 (1-5.2) days. Global satisfaction was rated to a median of 3.2 (1.5-5.2). Postoperative pain was the most prominent issue, and present pain was found in 51% of respondents. Nausea and loss of appetite were common during the entire hospital stay. Waiting for the nurses' assistance, lack of control, and technical failures with the analgesia equipment caused discomfort. Parents experienced a lack of confidence in the nurses and felt helpless to support their child or relieve the child's suffering.

CONCLUSION

Young people who underwent scoliosis surgery reported severe postoperative pain and nausea during the hospitalization period and persistent and recent onset pain after discharge, although they did not indicate global dissatisfaction with the hospital stay.

Quality pain management in the hospital setting from the patient's perspective

BACKGROUND

Pain management is a crucial issue for patients, and patients' perception of care is an important quality outcome criterion for health care institutions. Pain remains a common problem in hospitals, with subsequent deleterious effects on well-being.

OBJECTIVES

To assess the epidemiology of pain (frequency, severity, and interference), patient participation in pain treatment decisions, and patient satisfaction with care in a hospital setting.

METHODS

A point-prevalence study was conducted. Data were collected with the American Pain Society Patient Outcome Questionnaire (Icelandic version). Participants (n = 308) were ≥ 18 years old, alert, and hospitalized for ≥ 24 hours.

RESULTS

The response rate was 73%. The mean age of participants was 67.5 (SD = 17.4; range 18 to 100) years, and 49% were men. Pain prevalence in the past 24 hours was 83%, mean worst pain severity was 4.6 (SD = 3.1), and 35% experienced severe pain (≥ 7 on 0 to 10 scale). Moderate to severe interference with activities and sleep was experienced by 36% and 29% of patients respectively. Patient participation in decision making was weakly associated with spending less time in severe pain and better pain relief. Patient satisfaction was related to spending less time in severe pain, better pain relief, and lower pain severity (P < 0.05).

CONCLUSIONS

Pain was both prevalent and severe in the hospital, but patient participation in decision making was related to better outcomes. Optimal pain management, with emphasis on patient participation in decision making, should be encouraged in an effort to improve the quality of care in hospitals.

Patients' journeys through total joint replacement: patterns of medication use

OBJECTIVE

Medication is used to manage pain that results from both osteoarthritis and total joint replacement (TJR). Research has provided insight into how people living with osteoarthritis use pain relief medication. However, it is not known whether elective TJR affects existing attitudes and behaviours with regard to pain medications. Using qualitative methods, the present study explored patterns of pain relief use around the time of TJR.

METHOD

In-depth face-to-face qualitative interviews were carried out with 24 patients two to four weeks after they had undergone TJR for hip or knee osteoarthritis. Participants were asked to reflect on their use of pain medication pre-surgery, while in hospital and while recovering from their operation at home. Transcripts of the audio-recorded interviews were imported into Atlas.ti® and thematic analysis was used.

RESULTS

Attitudes to pain relief medication and their use are not static. Many participants change their use of pain medication around the time of surgery. This shift was influenced by interactions with health professionals and changing views on the acceptability, necessity and value of pain relief in helping to manage an altered pain experience.

DISCUSSION

Understanding reasons for medication-taking behaviour during the journey through joint replacement may be helpful to health professionals. Health professionals have a fundamental role to play in challenging or reinforcing different treatment beliefs, which is the basis for effective use of pain relief over the pre- to postoperative period.

Numeric rating scale: patients' perceptions of its use in postoperative pain assessments

AIM

The purpose of this study was to describe how patients perceive the use of the numeric rating scale in postoperative pain assessments.

BACKGROUND

There are recommendations to use a pain scale to follow patients' postoperative pain. Most patients prefer the NRS but there is a discrepancy between patients and healthcare professionals how to interpret the ratings from the pain assessments.

METHODS

A descriptive design with a phenomenographic approach was used. Semi structured interviews were held with 25 patients.

RESULTS

Three description categories emerged that illustrate patients' perceptions; use of the NRS facilitated communication of pain, it put demands on healthcare professionals and care routines and it contained interpretation difficulties.

CONCLUSION

The NRS has a place in pain management according to the patients but there is a need for a dialogue to give the patients the opportunity to describe their pain and set a common goal.

Expectations and experiences of open abdominal aortic aneurysm repair patients: a mixed methods study

AIMS AND OBJECTIVES

To establish what patients' expectations of postoperative pain were when undergoing open surgical repair of abdominal aortic aneurysm. A review of the relevant literature highlighted the fact that there had been no such studies conducted within a similar such homogenous group. Therefore, this study aimed to explore pain expectations prospectively and then compare these with the patients' actual experiences.

BACKGROUND

It has long been established that high levels of satisfaction with pain management are very often reported in patients despite suffering from severe to moderate levels of pain. The reasons for these high satisfaction levels are not always as clear, although it is suggested that patients have an expectation of postoperative pain.

DESIGN

The study set out to establish what expectations of pain patients had and the factors that might influence them within the abdominal aortic aneurysm subject group. A mixed methods approach was used.

METHOD

Pain expectations were gathered preoperatively using a Likert scale of pain scoring. These were then compared with the recorded postoperative pain scores. This was followed by a semi-structured interview.

RESULTS

The study illustrated that patients expected to have postoperative pain as a natural consequence of their operations. Patients appeared to draw upon their previous experiences. Pain expectation levels were statistically significant, 60% of patients expected to have pain postoperatively.

CONCLUSION

This study demonstrated that patients expect to have postoperative pain. Such expectations might influence the individual's relationship and experience of their postoperative management.

RELEVANCE TO CLINICAL PRACTICE

The study highlights the need for nurses to evaluate the preoperative information given to patients and to listen to expectations they voice. Patient expectations of pain are sometimes that they expect to have pain, and it is the management of this pain that makes a difference to them.

Preoperative education and use of analgesic before onset of pain routinely for post-thoracotomy pain control can reduce pain effect and total amount of analgesics administered postoperatively

The purpose of this study was to investigate the efficiency of preoperative pain management education and the role of analgesics administration before the onset of pain postoperatively. The study was a prospective, randomized, and single-blind clinical trial, which was conducted January 1, 2008 through October 1, 2008 in the Thoracic Surgery Unit of Akdeniz University Hospital. A total of 70 patients who underwent thoracotomy (35 in the control group and 35 in the study group) were included in the study. Of the patients, 70% (n = 49) were male and 30% (n = 21) were female. Mean age was 51 ± 10 years (range = 25-65). The same analgesia method was used for all patients; the same surgical team performed each operation. Methods, including preemptive analgesia and placement of pleural or thoracic catheter for using analgesics, that were likely to affect pain level, were not used. The same analgesia medication was used for both patient groups. But the study group, additionally, was educated on how to deal with pain preoperatively and on the pharmacological methods to be used after surgery. An intramuscular diclofenac Na 75 mg was administered to the study group regardless of whether or not they reported pain in the first two postoperative hours. The control group did not receive preoperative education, and analgesics were not administered to them unless they reported pain in the postoperative period. The routine analgesics protocol was as follows: diclofenac Na 75 mg (once a day) intramuscular administered upon the complaint of pain following extubation in the postoperative period and 20 mg mepederin intravenously (maximum dose, 100 mg/day), in addition, when the patient expressed pain. Pain severity was assessed during the second, fourth, eighth, 16th, 24th, and 48th hours, and marked using the Verbal Category Scale and the Behavioral Pain Assessment Scale. Additionally, the total dose of daily analgesics was calculated. The demographic characteristics showed a homogeneous distribution in both patient groups. The rate of pain, which was defined as sharp, stabbing, and exhausting, was higher in the control group than in the study group, and the difference between the two groups was statistically significant (p < .05). As the doses of analgesics used for pain management in both groups were compared, it was determined that analgesic consumption was lower in the study group than in the control group, and the difference was statistically significant (p < .05). As a result, it was determined that preoperative thoracic pain management education and analgesics administered postoperatively, before the onset of pain, reduced the amount of analgesics used in the first postoperative 48 hours.

Jordanian patients' satisfaction with pain management

Pain is still undertreated among hospitalized patients. Recently, patient satisfaction with pain management has received significant attention. This field has not yet been explored among Jordanian patients. The purpose of this study was to determine the knowledge regarding pain characteristics, beliefs, and satisfaction that can be included in planning pain management strategies and protocols within Jordanian hospitals. Using descriptive cross-sectional methodology, the American Pain Society Patient Outcome Questionnaire (APS-POQ) was used to survey 375 inpatients from Jordanian hospitals. Participants reported relatively severe pain and pain interferences while being hospitalized and seemed to be well informed regarding pain and pain management. Participants reported high levels of pain management satisfaction. Also, the Arabic version of the APS-POQ was found to be reliable among the Jordanian population. Findings of this study are similar to those reported by earlier studies in other countries and support the need for applying the caring attitude in managing patients' reports of having pain. This study is the first in Jordan, opening the door for future studies to be conducted in this important field.

Anxiety and quality of recovery in day surgery: A questionnaire study using Hospital Anxiety and Depression Scale and Quality of Recovery Score

The aims of this study were (i) to examine the association between preoperative and postoperative anxiety, and (ii) to examine the association between preoperative anxiety and postoperative recovery, following day surgery under general anaesthesia. Day surgery has become more commonplace owing to advances in pharmacology, anaesthetic and surgical techniques, as it has recognized benefits, such as lower costs and reduced incidence of infection. Recent years have seen increased complexity of day surgery undertaken on a broader range of patients, but with reduced pre-surgery contact with the hospital environment. These recent service changes might have had an effect on the preparation of patients for day surgery, and this in turn might have affected their postoperative recovery. This pilot study used survey methods to examine potential associations between preoperative and postoperative anxiety, and between preoperative anxiety and postoperative recovery. Data were collected in 2008 from a convenience sample of 54 day surgery patients. The instruments used were the Hospital Anxiety and Depression Scale (HADS) and the Quality of Recovery Score (QoR-40). There was a statistically significant relationship between preoperative and postoperative anxiety (χ(2) =11.899, d.f.=1, P=0.001). The T-test showed a statistically significant difference in the mean scores for QoR-40 score for gender, and for the postoperative anxiety and QoR-40. A relationship between preoperative anxiety and postoperative recovery was not shown. Although challenging to implement in view of restricted timescales, appraisal and revision of pre-assessment processes to incorporate an anxiety measurement tool, such as the HADS, should be considered.

The efficacy of patient information sheets in wrist arthroscopy: a randomised controlled trial

PURPOSE

To evaluate the effects of perioperative information for wrist arthroscopy on postoperative pain, return to daily activities, and patient satisfaction.

METHODS

34 women and 21 men aged 19 to 54 (mean, 35) years underwent diagnostic wrist arthroscopy to explore the radiocarpal and midcarpal joints. They were randomised to receive specific preoperative information on the procedure (pictures of the wrist joint anatomy, portal entry sites, and the arthroscope) and written instructions on postoperative care (n=28) or only standard preoperative information and verbal instructions on postoperative care (n=27). The visual analogue score (VAS) for pain and the Quick Dash score for return to daily activities of each patient were recorded before and after wrist arthroscopy. Analgesic intake after wrist arthroscopy was recorded.

RESULTS

The mean post-arthroscopic VAS from days 2 to 6 was significantly lower in the experimental group than controls. This was reflected by the decrease in analgesic intake. The mean post-arthroscopic Quick Dash score was significantly lower in the experimental group than controls (40 vs. 47, p=0.02), indicating earlier return to daily activities.

CONCLUSION

Patients who received specific preoperative information on the procedure and written instructions on postoperative care experienced less pain, consumed less analgesics, and had an earlier return to daily activities.

Patients' experience of pain and pain relief following hip replacement surgery

AIMS

The aim of this study was to describe patients' experience of pain and pain relief following hip replacement surgery.

BACKGROUND

Annually, many patients undergo hip replacement surgery. Previous research has focused largely on the long-term effects on pain for patients who undergo hip replacement surgery and to a lesser degree on their subjective, early postoperative pain experience.

DESIGN

A descriptive qualitative design was used.

METHODS

The study was carried out in an orthopaedic ward at a hospital in Sweden during 2006. Qualitative interviews were conducted with 15 patients who had undergone hip replacement surgery. Data were analysed by means of qualitative content analysis.

RESULTS

The postoperative pain experience was characterised in terms of interrelated contexts of time, various bodily activities and postoperative pain intensity. The postoperative pain intensity was characterised in terms of intensive and worst imaginable, strange feelings and fear and a feeling of faintness. Easing of postoperative pain was related to professional care features, such as nursing staff, pharmacological pain relief and technical aids. Self-care features were related to relieving body positions, endurance and looking ahead.

CONCLUSION

Although the development of total hip replacement surgery has been very successful, there are issues that need to be addressed in relation to postoperative pain management. The findings in this study show that there are reasons for making a more concerted effort to develop postoperative pain management, particularly during the first few days after surgery.

RELEVANCE TO CLINICAL PRACTICE

The results provide some indication that pain management for this group of patients in the early postoperative period needs to be improved to reduce the fear of moving and improve the process of regaining independence. Devoting more attention to the patients during the initial postoperative phase may be the key to improve the training and making it even more effective.

Total joint arthroplasty patients' perception of received knowledge of care

BACKGROUND

The education of orthopaedic patients is an essential component of nursing, because it has been shown to have a positive impact on outcomes of care and treatment.

PURPOSE

To describe total joint arthroplasty patients' perceptions of received knowledge on discharge.

DESIGN/METHOD

Patients (n = 123, mean age 68 years) undergoing total hip or knee arthroplasty self-administered a structured instrument, including 6 different dimensions of knowledge.

RESULTS

Patients perceived that they received most knowledge on the biophysiological dimension and least on the financial dimension. Patients' discharge destination and positive evaluation of hospitalization were related to their perceptions of the knowledge received.

DISCUSSION

Individually tailored education is needed to meet patients' educational needs. Nurses are responsible for ensuring that patients have enough knowledge even if they do not ask for this knowledge.

Adolescents' experience with scoliosis surgery: a qualitative study

This article reports a study of adolescents' narrated experiences of undergoing scoliosis surgery. Six adolescents were interviewed. Open and semistructured questions were asked, and a qualitative content analysis of the text was performed. The results are presented in three main categories followed by subcategories. The three main categories of experience were emotional, physical, and social. The emotional aspects that emerged were fear, nightmares, nervousness, and helplessness. These had a great impact on adolescents' well-being before, during, and after the hospital visit. The physical aspects were mobilization, scars, different hip levels, pain, nausea, appetite, and urinary catheter. These aspects caused much discomfort, mostly during the hospital visit. The social aspects were friends, power, coaching and comfort, and sports. Some of the social aspects had a strong negative impact on the adolescents' well-being mostly after the hospital visit. This study suggests that both before and long after the surgery adolescents have strong emotions that they should be better prepared and helped to manage. To optimize perioperative care an interdisciplinary, a holistic approach must be taken that incorporates the complexity and whole of the adolescent's experiences. The findings of this study suggest that perioperative care of adolescents during scoliosis surgery needs to be optimized. To improve patients' psychologic preparation before surgery pediatric nurses should learn more about the individual patient and make care plans from a holistic perspective. Follow-up after discharge should address emotional, social, and physical aspects of the adolescent's health.

Low-dose ketamine via intravenous patient-controlled analgesia device after various transthoracic procedures improves analgesia and patient and family satisfaction

Ketamine was recently shown to attenuate postoperative pain when used in combination with morphine in patients who had undergone general and orthopedic surgery. We assessed its effects in 46 patients undergoing minimally invasive direct coronary artery bypass, off-pump coronary artery bypass, or thoracotomy and correlated them with patient and family satisfaction. Patient-controlled analgesia (PCA) was available for 72 hours. One group received 2mg/bolus morphine randomly and double-blindly (group MO), and another group received 1mg morphine plus 5mg ketamine/bolus (group MK), both using IV-PCA. The patients' pain and satisfaction rates were assessed three times daily during hospitalization using a visual analog scale. Their families' satisfaction was assessed as well. Although the 3-day mean amount of morphine used by the MK patients was approximately 60% of that used by the MO patients, their levels of pain and satisfaction were better than those of the MO group. There was an inverted and statistically significant correlation between the patients' level of satisfaction on the second postoperative day (POD) and the satisfaction of their families on POD 2, 3, and 7 and the POD 3 patients' pain assessment in the MK group but not in the MO group. There were no differences in hemodynamic, respiratory, side effects, or complication rates between the groups. The conclusion is that the effects of adding a small ketamine dose to half of the standard morphine dose via IV-PCA after thoracotomy was superior to the standard morphine dose in terms of the patients' self-reported pain score and satisfaction, as well as the family satisfaction rate.

Structured approaches to pain management in the ICU

Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts. By nature of their complex medical conditions, these patients present unique challenges to the delivery of optimal pain treatment. Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles. A multidisciplinary and patient-centered continuous quality improvement process is essential to identifying barriers and implementing evidence-based solutions to the problem of undertreated pain in hospital ICUs. This article addresses barriers common to the ICU setting and presents a number of structured approaches that have been shown to be successful in improving pain treatment in patients who are critically ill.

[Patient dissatisfaction with postoperative pain: what are the main reasons?]

INTRODUCTION

Patient satisfaction regarding postoperative pain management (POPM) is not always correlated with pain level relief.

OBJECTIVE

To evaluate the percentage of satisfied patients while splitting satisfaction related with nurses, anaesthesiologists and surgeons during 48h postoperative period.

PATIENTS AND METHODS

The study was performed in 2007 by two investigators in six different surgical suites in a university hospital. Approximatively 15 patients have been randomly selected in each surgical ward. Each patient received during the first or second postoperative day an anonymous questionnaire and was required to complete it with the investigator assistance if necessary. Questions requiring a yes-or-no reply assessed the patient's satisfaction with POPM performed by nurses, surgeons, and anaesthesiologists. In case of dissatisfaction, patients were invited to explain the reasons.

RESULTS

Ninety-two patients were included, 5% of the patients were not satisfied with nurse POPM and nearly 15% were not satisfied with anaesthesiologist or surgeon POPM. The main reasons of dissatisfaction with nurses were the excessive delays between requesting and receiving an analgesic and because of the significant discrepancies in POPM between nurses. Patient discontent regarding surgeons was explained by the lack of interest of the latter for POPM. Patient discontent regarding anaesthesiologists was explained by the lack of anaesthesiologist visit in the postoperative period.

CONCLUSION

There is a relationship between patient dissatisfaction and the lack of attention for POPM by surgeons and the lack of postoperative visit by the anaesthesiologist. A postoperative visit by a team of anaesthesia nurses should improve patient satisfaction with POPM.

Barriers to, and facilitators of post-operative pain management in Iranian nursing: a qualitative research study

BACKGROUND

Unrelieved post-operative pain continues to be a major clinical challenge, despite advances in management. Although nurses have embraced a crucial role in pain management, its extent is often limited in Iranian nursing practice.

AIM

To determine Iranian nurses' perceptions of the barriers and facilitators influencing their management of post-operative pain.

METHODS

This study was qualitative with 26 participant nurses. Data were obtained through semi-structured serial interviews and analysed using the content analysis method.

FINDINGS

Several themes emerged to describe the factors that hindered or facilitated post-operative pain management. These were grouped into two main themes: (1) barriers to pain management after surgery with subgroups such as powerlessness, policies and rules of organization, physicians leading practice, time constraints, limited communication, interruption of activities relating to pain, and (2) factors that facilitated post-operative pain management that included the nurse-patient relationship, nurses' responsibility, the physician as a colleague, and nurses' knowledge and skills.

CONCLUSION

Postoperative pain management in Iran is contextually complex, and may be controversial. Participants believed that in this context accurate pain management is difficult for nurses due to the barriers mentioned. Therefore, nurses make decisions and act as a patient comforter for pain after surgery because of the barriers to effective pain management.

Assessment of quality of care in acute postoperative pain management

BACKGROUND/AIM

Managing of acute postoperative pain should be of great interest for all hospital institutions, as one of the key components of patients satisfaction, which indicates quality, as well as the outcome of treatment. The aim of this study was to assess the quality of nursing care in managing acute postoperative pain and to establish factors which influence patients assessment of the same.

METHOD

The investigation was conducted on the sample of 135 patients hospitalized in surgical clinics of the Clinical Centre of Vojvodina in Novi Sad in the form of cross-sectional study, by interviewing patients during the second postoperative day and collecting sociodemographic variables, type of surgical procedure and applied analgesic therapy which were taken from their medical documentation. The modified questionnaire of the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) was used as the instrument of the investigation. The data were processed with suitable mathematical statistics methods such as multivariate analyses of variance (MANOVA), discriminative and other parametric procedures and methods. Roy's test, Pearson's coefficient contingency (X), multiple correlation coefficient (R) were conducted amongst other univariant procedures.

RESULTS

The mean score for the individual items of SCQIPP questionnaire was between 2.0 and 4.7 (scale range 1-5) and the percentage of patients answers "strongly agree" ranged from 4.4 to 77%. The smallest number of positive answers were given by the patients for the item "In order to assess pain intensity, some of the staff asked me at least once in the morning, in the afternoon and in the evening to show the number from 0-10". Most of the patients (57%) evaluated severe pain during the previous 24 hours, as moderate pain, which represents significantly greater number of patients which complain of severe pain and mild pain (p < 0.001). The analysis of patients evaluation (MANOVA p < 0.05 and discriminative p < 0.05) indicates the existence of significant difference between the assessment of nursing care quality in managing acute postoperative pain as regards to clinics as the place for pain management, patient's sex and his expectations. Evaluation from "communication" subscale gives the greatest contribution (24.9%) to the difference between the observed clinics, and the greatest contribution (25.7%) to the difference in evaluation of nursing care quality as regards to patients' sex has the evaluations from "procedure" subscale.

CONCLUSION

The results of this study show a useful evidence and identify aspects of nursing care in postoperative management of acute pain which are still to be improved. According to the patients' answers the priority should be given to a regular assessment of the intensity of postoperative pain and evaluation of the effects of analgesic therapy.