Acute Pain Services and Postsurgical Pain Management in the Netherlands: A Survey

Acute Pain Services and pain-related patient-reported outcomes in Hungarian hospitals

BACKGROUND

Postoperative pain management is an important part of surgical care, where Acute Pain Service offers added value in terms of patient outcomes and costs. The technology, however, has hardly been adopted in Hungary, with only two hospitals operating Acute Pain Service and whose performance has not been evaluated yet. This research compared pain management outcomes of surgical, orthopedic, and traumatology patients in Hungarian hospitals with and without Acute Pain Service.

METHODS

We recruited 348 patients, 120 in the APS group and 228 in the control group, whose experience was surveyed with an adapted version of the American Pain Society Patient Outcome Questionnaire. The questionnaire covered pain intensity, pain interference with physical and emotional functions, side effects, patient satisfaction, information received, and participation in treatment decisions. The differences were analyzed by Fisher's exact test and Mann-Whitney U test.

RESULTS

The APS group showed better results with lower pain intensity scores regarding worst postoperative pain (χ2 = 18.919, p = 0.0043). They reported less pain interference with activities in bed (χ2 = 21.978, p = 0.0006) and out of bed (χ2 = 14.341, p = 0.0129). Furthermore, patients in the APS group experienced fewer pain-management-related side effects, like nausea (χ2 = 15.240, p = 0.0101), drowsiness (χ2 = 26.965, p = 0.0001), and dizziness (χ2 = 13.980, p = 0.0124). However, patient information (χ2 = 3.480, p = 0.0945) and patient satisfaction (χ2 = 5.781, p = 0.2127) did not differ significantly between the two groups.

CONCLUSIONS

Our findings confirm earlier international evidence on the benefits of Acute Pain Service in postoperative pain management and support the wider adoption of the technology in Hungarian hospitals. Nevertheless, close attention should be paid to patient information and involvement as better outcomes alone do not necessarily increase patient satisfaction.

Perioperative pain management models in four European countries: A narrative review of differences, similarities and future directions

There is general agreement that acute pain management is an important component of perioperative medicine. However, there is no consensus on the best model of care for perioperative pain management, mainly because evidence is missing in many aspects. Comparing the similarities and differences between countries might reveal some insights into different organisational models and how they work. Here, we performed a narrative review to describe and compare the structures, processes and outcomes of perioperative pain management in the healthcare systems of four European countries using Donabedian's framework as a guide. Our comparison revealed many similarities, differences and gaps. Different structures of acute pain services in the four countries with no common definition and standards of care were found. Protocols have been implemented in all countries and guidelines in some. If outcome is assessed, it is mainly pain intensity, and many patients experiencing more intense pain than others have common risk factors (e.g. preoperative pain, preoperative opioid intake, female sex and young age). Outcome assessment beyond pain intensity (such as pain-related physical function, which is important for early rehabilitation and recovery) is currently not well implemented. Developing common quality indicators, a European guideline for perioperative pain management (e.g. for patients at high risk for experiencing severe pain and other outcome parameters) and common criteria for acute pain services might pave the way forward for improving acute pain management in Europe. Finally, the education of general and specialist staff should be aligned in Europe, for example, by using the curricula of the European Pain Federation (EFIC).

Responsiveness of multiple patient-reported outcome measures for acute postsurgical pain: primary results from the international multi-centre PROMPT NIT-1 study

BACKGROUND

Postsurgical outcome measures are crucial to define the efficacy of perioperative pain management; however, it is unclear which are most appropriate. We conducted a prospective study aiming to assess sensitivity-to-change of patient-reported outcome measures assessing the core outcome set of domains pain intensity (at rest/during activity), physical function, adverse events, and self-efficacy.

METHODS

Patient-reported outcome measures were assessed preoperatively, on day 1 (d1), d3, and d7 after four surgical procedures (total knee replacement, breast surgery, endometriosis-related surgery, and sternotomy). Primary outcomes were sensitivity-to-change of patient-reported outcome measures analysed by correlating their changes (d1-d3) with patients' global impression of change and patients' specific impression of change items as anchor criteria. Secondary outcomes included identification of baseline and patient characteristic variables explaining variance in change for each of the scales and descriptive analysis of various patient-reported outcome measures from different domains and after different surgeries.

RESULTS

Of 3322 patients included (18 hospitals, 10 countries), data from 2661 patients were analysed. All patient-reported outcome measures improved on average over time; the median calculated sensitivity-to-change for all patient-reported outcome measures (overall surgeries) was 0.22 (range: 0.07-0.31, scale: 0-10); all changes were independent of baseline data or patient characteristics and similar between different procedures.

CONCLUSIONS

Pain-related patient-reported outcome measures have low to moderate sensitivity-to-change; those showing higher sensitivity-to-change from the same domain should be considered for inclusion in a core outcome set of patient-reported outcome measures to assess the effectiveness and efficacy of perioperative pain management.

Evaluating clinical pharmacists' involvement in postoperative acute pain services: a multicenter survey in Guangdong Province, China

Objective: Postoperative pain management is an important part of surgical pharmacy. Postoperative acute pain services in China are in their initial stages. This survey aimed to investigate the attitudes, involvement, and knowledge of clinical pharmacists in China regarding postoperative acute pain services. The results can provide valuable information to guide clinical pharmacists in developing targeted strategies to improve their postoperative acute pain service capabilities. Methods: A questionnaire was distributed to the pharmacy departments of 133 grade A tertiary hospitals in Guangdong province, and the responses were collected electronically. Results: 123 completed questionnaires were collected from clinical pharmacists. Although 95.93% of clinical pharmacists believed they should participate in postoperative pain services, only 62.6% reported substantial involvement. Overall satisfaction with the postoperative pain service was 93.5%. Understanding of non-steroidal anti-inflammatory drugs and opioid analgesics by clinical pharmacists was comparable (p > 0.05). Furthermore, 98.37% of clinical pharmacists desired systematic learning in postoperative pain management, and 40.65% expressed a strong need. Conclusion: Clinical pharmacists in China demonstrate a positive attitude toward participating in postoperative acute pain services. However, the actual level of involvement was concerning, and the lack of systematic training and well-established work protocols may be contributing factors. Efforts should be made to establish comprehensive and standardized processes and work protocols for postoperative acute pain services and provide systematic and hierarchical professional training to enhance clinical pharmacists' capabilities in postoperative acute pain services.

The First Comprehensive Survey of the Practice of Postoperative Pain Management in Hungarian Hospitals - a Descriptive Study

BACKGROUND

Pain management is a key issue in health care. Providers adopt promising technological developments, like Acute Pain Service, at differing speeds, with countries, such as the USA and Germany taking the lead. Where Hungary stands is unknown, as the practice of pain management has not yet been comprehensively reviewed in that country.

AIM

To explore the practice of postoperative pain management in Hungarian hospitals by addressing the questions of who is responsible for it, who measures pain and how, what kind of pain relief technologies are used, and who takes care of patients during duty hours.

METHODS

We carried out a survey covering Hungarian hospitals with operational license for surgery, traumatology, orthopedics and anesthesiology between December 2019 and March 2020. The response rate was 72%, and we analyzed 135 questionnaires.

RESULTS

We identified only 2 hospitals with an Acute Pain Service. In the majority of hospitals, the attending physician orders pain relief therapy. During duty hours the surgeon on duty takes care of pain management in 52.1% of the cases. Among pain relief therapies, intravenous infusions (74.1%) and oral medication (67.4%) are the most frequent. Ward nurses measure postoperative pain (77.8%) with unidimensional scales. According to 59.7% of the respondents, pain is not measured and documented at rest. Written protocols are available in 34.4% of the departments.

CONCLUSIONS

Compared with other countries, pain management in Hungary lags behind with significant room for improvement. Development and implementation of pain management protocols with appropriate education is the key intervention point.

Acute Pain Service in Hungarian hospitals

Background

Surgical procedures play an increasing role among health technologies to treat diseases. Pain often accompanies such diseases, both as a result of their pathology, but also as the side-effect of the intervention itself, and it is not only a burdensome subjective feeling, but adversely affects the recovery process, can induce complications and increases treatment costs. Acute Pain Service Teams are becoming increasingly widespread in hospitals to address post-operative pain, yet we have so far no data on how many hospitals have actually adopted this technology in Hungary.

Objectives

The main objectives of our study were to assess the prevalence of Acute Pain Service Teams, map their structure and operation, as well as to understand the barriers and conducive factors of their establishment in Hungarian hospitals.

Methods

We carried out a survey among the 72 hospitals with surgical departments. The questionnaire was filled in by 52 providers, which gave us a response rate of 72.2%.

Results

Our results show, that only two of the responding hospitals have Acute Pain Service Teams albeit their structure and operation are in line with the literature. In the 50 hospitals without such teams, financing difficulties and human resources shortages are mentioned to be the most important obstacles of their establishment, but the lack of initiative and interest on the part of the specialities concerned are also an important barrier.

Conclusions

Lagging behind the more affluent EU member states, but similarly to other Central and Eastern European countries, Acute Pain Service has been hardly adopted by Hungarian hospitals. Hungarian health professionals know the technology and would support its wider introduction, if the technical feasibility barriers could be overcome. Health policy should play a more active role to facilitate change in this area, the investment in which promises a substantial return in terms of health gains and cost savings.

A survey of acute pain service in Canadian teaching hospitals

BACKGROUND

The first national survey to ascertain the prevalence, structure, and functioning of the APS in Canadian university affiliated hospitals was conducted in 1991. This is a follow-up survey to assess the current status of the APS in Canada.

METHODS

We requested completion of a 26-question survey from lead personnel of the APS teams or Anesthesia departments of Canadian teaching hospitals.

RESULTS

Among the 32 centers that were contacted, 21 (65.6%) responded. Of these respondents, 18 (85.7%) indicated that they have a structured APS (72.22% adults, 5.56% pediatrics, 22.22% mixed). Among the 18 centers with an APS, 16 of the services are led by an anesthesiologist. Eight centers (44.44%) have a regional anesthesia group, of which five (27.75%) have a regional anesthesia group that is distinct from the APS team. Nine centers (50%) offer ambulatory nerve catheter analgesia after discharge home. Fifteen centers (83.33%) use standardized order sets, and 13 centers (72.22%) use an electronic record for APS. More than 50% of the centers use intravenous lidocaine and ketamine as a part of their multimodal analgesia.

CONCLUSION

Most Canadian teaching hospitals do have a functioning APS. This survey has the potential to generate research questions about the availability of standardized and advanced acute pain management in Canada's teaching hospitals.

An Update on Resources, Procedures and Healthcare Provision in Pain Units: A Survey of Spanish Practitioners

Multidisciplinary pain treatment units are recommended to provide comprehensive diagnosis and treatment of chronic pain, a complex clinical syndrome and one of the leading causes of disability worldwide. The objective of this study was to provide updated results on the situation of pain treatment units in Spain and to determine compliance with recommendations proposed by de Spanish Ministry of Health (SMH). A cross-sectional, prospective, multicenter survey was performed, collecting data on resources, procedures and healthcare provision. Between March and May 2019, the Spanish Pain Society sent an invitation letter to 183 pain units with a link to the questionnaire. Sixty-nine units from 13 regions agreed to participate. According to the International Association for the Study of Pain criteria, only 12 units were classified as multidisciplinary pain centers. Most (95.7%) were in hospitals, 82.6% from the public sector, and 46.4% had protocols to coordinate with primary care. Interviewees rated the adequacy of facilities at 6.3 (from 0 to 10). Moreover, 67% of interviewees found that there were insufficient staff, with no mental health professionals, physical therapists or social workers in 49.3%, 87.0% and 97.1% units, respectively. Only 24 pain units had a day hospital, 44.9% offered psychological interventions, and 79.7% supported teaching and research activities. Results suggest that a small proportion of Spanish pain units meet the national standards for multidisciplinary pain units proposed by the SMH.

Prevalence and Risk Factors for Acute Postoperative Pain After Elective Orthopedic and General Surgery at a Tertiary Referral Hospital in Tanzania

Background

In Africa, postoperative pain management is still a major problem with a prevalence of postoperative pain in up to 95.2% of the patients. There are little data on the prevalence and potential risk factors for postoperative pain in Tanzania. Therefore, we aimed to investigate these at Kilimanjaro Christian Medical Centre in Northern Tanzania. Our goal is to optimize pain management.

Methods

A prospective cohort study was carried out from December 2016 to April 2017. Patients ≥18 years admitted for elective general or orthopedic surgery were included in the study. Demographic data were collected during a pre-operative visit, and pain was assessed with a numerical rating scale (NRS 0–10) at 4, 24, 36 and 48 hours postoperatively. A NRS >3 was considered as moderate to severe postoperative pain. Potential risk factors for postoperative pain were identified using univariate and multivariable binary logistic regression analyses.

Results

A total of 281 patients were included in the study. The prevalence of postoperative pain was 61%, 73%, 67% and 58% at 4, 24, 36 and 48 hours after surgery, respectively. Pethidine was the most frequently prescribed analgesic for postoperative pain management (85.1%) in the first 24 hours postoperatively; only 1% received paracetamol or diclofenac, and 13% received tramadol. In the multivariable model, general anesthesia and intra-operative analgesia (OR = 3.70, 95% CI 1.70–8.04) were significant risk factors for postoperative pain.

Conclusion

Pain is still inadequately managed at Kilimanjaro Christian Medical Centre leading to a high prevalence (73% on the first day after surgery) of reported postoperative pain in this study. It reflects the need for adequate postoperative analgesia, especially in low- and middle-income countries. Further research identifying risk factors in larger cohorts can be performed if adequate analgesia is given.

The Effectiveness of Using a Nurse-Led Pain Relief Model for Pain Management among Abdominal Surgical Patients: A Single-Center, Controlled before-after Study in China

BACKGROUND

Effective pain management is closely related to the prognosis of patients after surgery. Setting up acute pain service is among the effective strategies to control pain. The operation of acute pain service is mostly dominated by anesthesiologists; however, control of postsurgical pain is still unsatisfactory. Nurses are the main force for providing postoperative care of patients, and their role in acute pain service is crucial. Therefore, in the current study, we have developed a nurse-led pain relief model that emphasizes the central role of nurses during the entire surgical procedure. However, the effect of using this model for pain management among abdominal surgical patients remains unknown.

AIMS

The current study was conducted to investigate the effect of using a nurse-led pain relief model for pain management among abdominal surgical patients.

DESIGN

A single-center, propensity score-matched, controlled before-after study.

METHODS

The patients, hospitalized for abdominal surgery in a university-affiliated hospital from January 2015 to December 2017, were enrolled and divided into group A (hospitalized before nurse-led pain relief model implementation, from January, 2015 to October, 2016) and group B (hospitalized after nurse-led pain relief model implementation, from October, 2016, to December, 2017) using propensity score match assay. The researchers compared the quality of acute pain management, the main side effects of pain management, and nurses' pain knowledge and attitude between group A and group B.

RESULTS

A total of 2851 patients undergoing nonemergency abdominal surgery were enrolled in the current study and were propensity matched 1:1 into two groups with 1,127 subjects in each group. The quality of acute pain management postsurgery was better after implementation of the nurse-led pain relief model. More patients received higher numerical rating scales cores (≥4 points) at indicated time points after surgery in group A compared with group B (14.20% vs. 12.24% 6 hours postsurgery, p = .001; 12.33% vs. 8.52% 12 hours postsurgery, p = .004; 12.95% vs. 3.99% 24 hours postsurgery, p = .036; 16.06% vs. 7.19% 48 hours postsurgery, p = .001). Furthermore, the occurrence of nausea and vomiting during pain management were significantly decreased in patients from group B (nausea: X² = 38.926, p < .05; vomit: X² = 39.302, p < .05). Additionally, after using the nurse-led pain relief model, nurses were more open to improving their knowledge and attitudes to pain management (p < .05).

CONCLUSION

Our study demonstrated that a nurse-led pain relief model can enhance the quality of acute pain management among post-abdominal surgical patients, suggesting that such a model can be an effective intervention for providing a better pain control among postsurgical patients.

A survey of postoperative pain treatments and unmet needs

More than 300 million patients undergo surgery worldwide each year. Pain associated with these procedures is associated with short- and long-term negative sequelae for patients, healthcare providers, and healthcare systems. The following chapter is a review of the reality of postoperative pain management in everyday clinical routine based on survey- and registry-derived data with a focus on care in adults. Between 30% and up to 80% of patients report moderate to severe pain in the days after surgery. Structures, processes, and outcomes vary widely between hospitals and indicate gaps between evidence-based findings and practice. Pain assessment is not effectively implemented in many hospitals and should consider cultural differences. Few data exist on the situation of pain management in low- and middle-income countries, indicating lack of resources and available medication in many of these areas. Certain types of surgery as well as demographic and clinical factors are associated with increased risk of severe postoperative pain.

A Patient-Based National Survey and Prospective Evaluation of Postoperative Pain Management in Spain: Prevalent but Possibly Preventable

Objective

To evaluate the national general prevalence of postoperative pain and the associated organizational/structural factors related to the provision of health care services.

Design and Setting

Observational prospective cohort study performed in 46 tertiary hospitals that were randomly selected from the Spanish National Inventory of Hospitals through a two-stage balanced and stratified procedure.

Subjects and Methods

Nine-hundred surgical patients representing a wide spectrum of surgical procedures and anesthetic methods were recruited. Those suffering moderate or worse pain while in the postanesthesia care unit/surgery ward (PACU/SW) were followed for 72 hours. Site characteristics were also surveyed. Multilevel models were used to evaluate center- and patient-level factors associated with pain and quality of recovery (QoR). Weighted generalized estimating equations were used to analyze the evolution of pain intensity.

Results

The prevalence while in and at discharge from the PACU/SW was 48.7% (cluster-adjusted 95% confidence interval [CI] = 38.1–59.2%) and 21.6% (95% CI = 15.4–27.8%), respectively. Pain intensity decreased significantly over time. Less than 20% of the patients received systemic patient-controlled analgesia (PCA) or regional analgesic techniques. Age, preexisting pain, type of surgery, use of general anesthesia, and postoperative potent opioids were associated with pain risk and intensity, as were center-level factors such as patient information, protocol availability, and coordination of care. In turn, QoR was related to pain intensity and patient satisfaction with analgesia and side effects.

Conclusions

Compared with previous reports, the prevalence of moderate/severe postoperative pain has decreased but remains excessive. Organizational improvements to deploy procedure-specific, opioid-sparing analgesic strategies including regional techniques are recommended.

Cross-Cultural Comparison of Postoperative Discharge Opioid Prescribing After Orthopaedic Trauma Surgery

BACKGROUND

The extent of variation in analgesic prescribing following musculoskeletal injury among countries and cultural contexts is poorly understood. Such an understanding can inform both domestic prescribing and future policy. The aim of our survey study was to evaluate how opioid prescribing by orthopaedic residents varies by geographic context.

METHODS

Orthopaedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions in the surveys by conversion to morphine milligram equivalents (MMEs). We then constructed multivariable regressions with generalized estimating equations to describe differences in opiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases.

RESULTS

U.S. residents prescribed significantly more total MMEs per case (mean [95% confidence interval] = 383 [331 to 435]) compared with residents from the Netherlands (229 [160 to 297]) and from Haiti (101 [52 to 150]) both overall (p < 0.0001) and for patients treated for injuries of the femur (452 [385 to 520], 315 [216 to 414], and 103 [37 to 169] in the U.S., the Netherlands, and Haiti, respectively), tibial plateau (459 [388 to 531], 280 [196 to 365], and 114 [46 to 183]), tibial shaft (440 [380 to 500], 294 [205 to 383], and 141 [44 to 239]), wrist (239 [194 to 284], 78 [36 to 119], and 63 [30 to 95]), and ankle (331 [270 to 393], 190 [100 to 280], and 85 [42 to 128]) (p = 0.0272). U.S. residents prescribed significantly more MMEs for patients <40 years old (432 [374 to 490]) than for those >70 years old (327 [270 to 384]) (p = 0.0019).

CONCLUSIONS

Our results demonstrate greater prescribing of postoperative opioids at discharge in the U.S. compared with 2 other countries, 1 low-income and 1 high-income. Our findings highlight the high U.S. reliance on opioid prescribing for postoperative pain control after orthopaedic trauma.

CLINICAL RELEVANCE

Our findings point toward a need for careful reassessment of current opioid prescribing habits in the U.S. and demand reflection on how we can maximize effectiveness in pain management protocols and reduce provider contributions to the ongoing opioid crisis.

Understanding Innovation in Homeless Service Provision: A Study of Frontline Providers' Values-Readiness for Change

Service innovation for adults experiencing mental illness and homelessness typically involves shifting from treatment-led, staircase models toward recovery-oriented, Housing-First models. Aligning frontline service providers' values to those embedded within newer models is an important, but under-investigated, influence on the innovation process. To assess values alignment in this context, we conducted semi-structured qualitative interviews with frontline providers in staircase services in Ireland (n = 50). Data showed that, while their values mostly aligned to the treatment-led model, there was meaningful evidence of more recovery-oriented values, too. Strategies to enhance innovation through values-alignment are discussed.

Acute Pain Service: A 10-Year Experience

BACKGROUND

Pain management after surgery is crucial to decrease perioperative morbidity and mortality. Acute pain services (APS) are multidisciplinary teams that represent a modern strategy to address pain inside hospitals. The APS defines and applies pain treatment protocols specific for each surgery. To evaluate the performance of the APS at our institute, we performed a large retrospective cohort study focusing on complications of epidural analgesia and IV opiates.

METHODS

Data from the 10 years of activity of the APS were collected. Pain was assessed using the VAS at rest (VASr) and during movement (VASm) at each daily visit; the presence of side effects and complications was also assessed.

RESULTS

A total of 17,913 adult patients were followed by APS during the study period. Epidural analgesia was used in 7,776 cases (43%), while 9,239 (52%) patients used IV patient-controlled analgesia (PCA). A combination of the 2 was used in 87 patients (0.5%). A total of 456 perineural catheters (2.6%) were placed, while 442 patients(2.5%) used other analgesic techniques. We recorded 163 dural punctures during catheter placement, with no epidural hematoma, epidural abscess, or meningitis, and no permanent modification in sensitive or motor functions.

CONCLUSIONS

In our large case series, APS was confirmed safe and effective in treating postoperative pain, using both epidural analgesia and IV PCA with morphine.

Pain management in hospitals: patients' satisfaction and related barriers

Background:

Suboptimal pain control has been frequently reported in healthcare settings and documented to negatively impact patients’ health. Patients’ perception regarding pain management may influence their satisfaction regarding treatment.

Objectives:

This study focuses on the assessment of patients’ satisfaction regarding pain therapy and defining patient-related barriers for its implication.

Methods:

A cross-sectional study was conducted in two tertiary care hospitals from April till July 2017. A face-to face interview questionnaire was filled regarding pain scores and patients’ attitudes regarding pain management. Both medical and post-surgical adult patients with all types of pain were eligible to participate. A descriptive analysis of patient satisfaction and perceptions regarding pain management was done.

Results:

Results from 183 participants with a mean age of 49 (SD=17.33) revealed that pain was their main reason for hospitalization (71.6% of the cases). Numeric pain scores were recorded only in 14.2% of the patient medical files. Pain intensity documentation by healthcare professionals was found in 41.5% of the cases, and 7.7% of the patients had to wait for more than 30 minutes before getting the pain medication. Around 85% of the patients were satisfied with their pain management. Patients’ barriers to effective pain therapy were mainly fear of adverse effects, addiction, and additional costs (p<0.05).

Conclusions:

Pain remains a prevalent problem that requires more efforts for improvement. Our study can effectively serve as a start for larger studies where barriers to pain management can be assessed as an independent variable affecting pain management practice.

Non-invasive patient-controlled analgesia in the management of acute postoperative pain in the hospital setting

OBJECTIVE

Acute postoperative pain is experienced by the majority of hospitalized patients undergoing surgical procedures, with many reporting inadequate pain relief and/or high levels of dissatisfaction with their pain management. Patient-controlled analgesia (PCA) ensures patient involvement in acute pain control, a key component for implementing a quality management system. This narrative article overviews the clinical evidence for conventional PCA and briefly discusses new, non-invasive PCA systems, namely the sufentanil sublingual tablet system (SSTS) and the fentanyl iontophoretic transdermal system (FITS).

METHODS

A Medline literature search ("patient-controlled analgesia" and "acute postoperative pain") was conducted to 1 April 2017; results from the main clinical trials are discussed. Additional literature was identified from the reference lists of cited publications.

RESULTS

Moderate to low quality evidence supports opioid-based intravenous PCA as an efficacious alternative to non-patient-controlled systemic analgesia for postoperative pain. However, despite the benefits of PCA, conventional intravenous PCA is limited by system-, drug- and human-related issues. The non-invasive SSTS and FITS have demonstrated good efficacy and safety in placebo- and intravenous morphine PCA-controlled trials, and are associated with high patient/healthcare practitioner satisfaction/ease of care ratings and offer early patient mobilization.

CONCLUSIONS

Evidence-based guidelines for acute postoperative pain management support the use of multimodal regimens in many situations. As effective and safe alternatives to conventional PCA, and with the added benefits of being non-invasive, easy to use and allowing early patient mobilization, the newer PCA systems may complement multimodal approaches, or potentially replace certain regimens, in hospitalized patients with acute postoperative pain.

Pain Assessment Discrepancies: A Cross-Sectional Study Highlights the Amount of Underrated Pain

BACKGROUND

Inadequately treated postoperative pain can lead to longer healing processes, longer hospital stays, and the development of chronic pain. In a 900-bed university hospital in Switzerland, pain scores were assessed systematically. The study's primary aim was to define whether the routine pain assessment on the ward is accurate and reproducible. Subsequently the obtained data were used for a benchmark analysis to determine the hospital's performance in pain assessment quality compared with similar centers.

METHODS

During a 3-month period, PAIN OUT questionnaires were used for patients' interviews. Patients were included randomly according to the daily surgical schedule. Pain scores were assessed routinely by nursing staff on the wards and compared to PAIN OUT data. The ascertained data were analyzed by descriptive statistics as well as the Wilcoxon test for nonparametric values using IBM SPSS.

RESULTS

658 patients were included in the study. Comparing routine pain measurements with PAIN OUT results revealed that within the first 24 hours on the ward, pain scores were significantly lower than measured with PAIN OUT questionnaires. This difference increased with increasing pain scores. The quality of pain management of the hospital in which this study was performed ranged around the 50th percentile when compared to similar centers.

CONCLUSION

The cross-sectional data comparison of pain assessment by the ward staff and by interviews with the PAIN OUT questionnaire showed a large gap of underrated pain. The benchmark analysis with the method of PAIN OUT suggests a decent pain management among reference groups.

Management of postoperative pain in Spain: a nationwide survey of practice

BACKGROUND

Although the need for structured assessment and management of acute postoperative pain has been recognized, practices and responsibilities vary between and within hospitals and countries. We sought to determine current pain management practices in Spanish hospitals with and without acute pain services (APSs) or acute pain management programmes (APMPs) and compare them to practices reported for 1997-1998.

METHODS

Members of the Spanish Pain Society and APS/APMP heads were asked to respond to a survey. Responses were stratified by hospital size (< 200 or ≥ 200 beds) and APS/APMP presence or not. Categorical variables were described by percentages and the 95% confidence interval and continuous ones by the median and interquartile range.

RESULTS

Responses were received from 42.4% of hospitals with ≥ 200 beds (vs. 9.6% of the smaller ones). We fully analysed only data for the larger hospitals, 57.7% of which had an APS or APMP. Full-time pain physicians were on staff in 28.6% of large hospitals; 25% had full-time nurses. Patients received written information about postoperative pain in 34.8% of APS/APMP hospitals, and 72% of them recorded pain assessments routinely. Protocols reflected interdepartmental consensus in 80.8%; training in postoperative pain was organised in 54%. Respondents thought pain was well or very well managed in 46.4%. In APS/APMP hospitals the following results had improved: provision of written information for patients (58.5% vs. 0%), the recording of pain assessments (93% vs. 43.8%), consensus on a pain scale (92.5% vs. 41.9%), use of protocols (99.7% vs. 55.2%), analysis of quality indicators (52.8% vs. 15.4%), training (73% vs. 26.9%), and respondents' satisfaction with pain management in their hospital (68.6% vs. 9.5%).

CONCLUSIONS

The presence of an APS or APMP is associated with better results on indicators of quality of acute postoperative pain management.

Patient Perception of Acute Pain Management: Data from Three Tertiary Care Hospitals

Introduction. The primary objectives of this study were to assess patients' description of their acute pain intensity; patients' attitude towards their pain management during hospitalization; and their overall satisfaction with pain treatment. Methodology. A cross-sectional questionnaire-based study was conducted between October 2014 and March 2015 in three medical centers in Lebanon. All participants' responses were reported using descriptive statistics. The association between categorical variables was evaluated using Pearson χ² test or Fisher's exact test where the expected cell count was < 5. Results. A total of 119 women on the maternity services and 177 patients on the orthopedic services were surveyed. Around 50% of obstetric and 37% of orthopedic patients reported pain to be severe at its highest intensity. In maternity and orthopedic patients, respectively, unfavorable practices included pain not being assessed prior to pain medication administration (19.3% and 30.5%), having to wait for ≥30 minutes before getting the pain medication (14.2% and 11.3%), and pain score not being documented on medical chart (95% and 93.2%). Surprisingly, 94.1% of the maternity and 89.2% of orthopedic patients were satisfied to strongly satisfied with their pain management. Conclusion. Pre- and postoperative pain remain a prevalent problem that requires a consensus and joint efforts for improvement.

Management of Postoperative Pain in Medical Institutions in Shandong Province in China

The aim of the study was to investigate current situation of postoperative pain management in medical institutions in Shandong Province.A questionnaire was developed on the basis of guidelines of acute pain and pain quality assessment scale. The questionnaire was used to obtain information regarding the nature and scale of the medical institution, structure of pain management organization, implementation of pain assessment, and analgesic techniques and processes used in clinical practice. A multistage stratified and cluster sampling method was employed to investigate the current situation of postoperative pain management in 168 medical institutions in Shandong Province.For acute pain service (APS), 32% of the hospitals established postoperative pain management organizations similar to APS. For pain evaluation, 57.1% of the hospitals evaluated pain as the fifth vital sign, and 47.0% of the hospitals evaluated pain at rest and during activity. Furthermore, 43.0% of the surveyed hospitals employed patient-controlled analgesia mode, of which hospitals employing brachial plexus block, lumbar plexus block, and femoral nerve block analgesia accounted for 5.0%, 1.0%, and 4.0%, respectively. The survey revealed that 51.0% of the hospitals educated patients about pain and pain management, of which patients were postoperatively educated by ward nurses in 5.0% and patients were educated by APS during ward rounds in 2.0%.There is a lack of standardized postoperative pain management, the involvement of nurses in pain management is scarce, and the pain assessment and education and application of advanced analgesic management techniques were found to be inadequate in medical institutions in Shandong Province.

A follow-up on Acute Pain Services in Germany compared to international survey data

BACKGROUND

After the introduction of instruments for benchmarking, certification and a national guideline for acute pain management, the aim of this study was to describe the current structure, processes and quality of German acute pain services (APS).

METHODS

All directors of German departments of anaesthesiology were invited to complete a postal questionnaire on structures und processes of acute pain management. The survey asked for staff, techniques and quality criteria, which enabled a comparison to previous data from 1999 and surveys from other countries.

RESULTS

Four hundred and eight (46%) questionnaires were returned. APS have increased considerably and are now available in 81% of the hospitals, mainly anaesthesia based. However, only 45% fulfilled the minimum quality criteria, such as the assignment of personnel, the organization of patient care during nights and weekends, written protocols for postoperative pain management, regular assessments and documenting pain scores. Staff resources varied considerably, but increased compared to 1999. Two daily rounds were performed in 71%, either by physicians and nurses (42%), by physicians only (25%) or by supervised nurses (31%). Most personnel assigned to the APS shared this work along with other duties. Only 53% of the hospitals had an integrated rotation for training their specialty trainees.

CONCLUSIONS

The availability of APS in Germany and other countries has increased over the last decade; however, the quality of nearly half of the APS is questionable. Against the disillusioning background of recently reported unfavourable pain-related patient outcomes, the structures, organization and quality of APS should be revisited.