A survey of acute pain service structure and function in United States hospitals

A smart device application for acute pain service in surgical patients at a tertiary hospital in South Korea: a prospective observational feasibility study

BACKGROUND

Pain assessment and patient education are essential for successful postoperative pain management. However, the provision of personnel for performing these tasks is often insufficient. Recently, attempts have been made to implement smartphone applications for educating and monitoring surgical patients. We developed a smartphone application (app) for postoperative pain management, and conducted a feasibility study.

METHODS

This single-center prospective observational study included 60 patients aged < 70 years who underwent elective surgery. This study evaluated the SmartAPS application, which offers tools for postoperative pain assessment and educational materials for pain management. The primary outcome was the active usage rate, defined as responding at least twice daily on postoperative days (PODs) 1 and 2. Additionally, we investigated patient satisfaction with the app and educational videos as well as any challenges encountered during use.

RESULTS

Sixty patients were enrolled in the study and active app use was achieved in 56.7% of them. Response rates peaked at 85.0% for pain intensity and 83.3% for opioid-related side effects at 14:00 on POD 1 but dropped to 56.7% and 58.3%, respectively, at 18:00 on POD 2. Among the patients who responded to the survey regarding the app usage, 84.0% reported satisfaction with the app and 80% found it beneficial for managing postoperative pain. Furthermore, 92.0% did not encounter difficulties using the app, indicating a generally positive user experience.

CONCLUSIONS

Our findings support the utility of the SmartAPS application in acute pain services, highlighting its potential for improving postoperative pain management.

Immune Competence and Pain: A Narrative Review

PURPOSE OF REVIEW

This review aims to summarize current knowledge on the pathophysiology of pain and the role of neuro-immune crosstalk in the development of acute and chronic pain (CP). Specifically, the review focuses on the role of immune cells involved in the innate and acquired immune response, emphasizing their bidirectional interactions with the nervous systems and discussing the implications of this crosstalk on acute and CP management.

RECENT FINDINGS

In the last two decades, multiple studies have uncovered the important role of the immune system in initiating, maintaining, and resolving pain stimuli. Furthermore, researchers discovered that the immune system interacts tightly with the nervous system, creating a bidirectional crosstalk in which immune cells influence the response of peripheral and central nerve fibers while neurotransmitters and neuropeptides released by nociceptors directly and indirectly modulate the immune response. The neuro-immune crosstalk in acute and CP is a complex and not fully understood process that comprise the interactions of multiple diverse molecules, bidirectional interferences, and numerous redundant processes. Despite the complexity, important steps have been taken in recent years toward explaining the specific roles of each immune cell type and molecule in the initiation, maintenance and resolution of pain. These findings may set the basis for innovative therapeutic options that target the immune system, overcoming the limitations of current treatments in providing pain relief and the disadvantages associated with opioid therapy.

National review of acute pain service utilization, models of care, and clinical practices within the Veterans Health Administration

INTRODUCTION

The Veterans Health Administration (VHA) is the largest healthcare network in the USA and has been a national leader in opioid safety for acute pain management. However, detailed information on the availability and characteristics of acute pain services within its facilities is lacking. We designed this project to assess the current state of acute pain services within the VHA.

METHODS

A 50-question electronic survey developed by the VHA national acute pain medicine committee was emailed to anesthesiology service chiefs at 140 VHA surgical facilities within the USA. Data collected were analyzed by facility complexity level and service characteristics.

RESULTS

Of the 140 VHA surgical facilities contacted, 84 (60%) completed the survey. Thirty-nine (46%) responding facilities had an acute pain service. The presence of an acute pain service was associated with higher facility complexity level designation. The most common staffing model was 2.0 full-time equivalents, which typically included at least one physician. Services performed most by formal acute pain programs included peripheral nerve catheters, inpatient consult services, and ward ketamine infusions.

CONCLUSIONS

Despite widespread efforts to promote opioid safety and improve pain management, the availability of dedicated acute pain services within the VHA is not universal. Higher complexity programs are more likely to have acute pain services, which may reflect differential resource distribution, but the barriers to implementation have not yet been fully explored.

Prospective paired crossover evaluation of potential impact of investigator gender on perceived pain intensity early after acute or scheduled surgery

BACKGROUND

Postoperative pain is common but often difficult to assess, and there are many potential confounders. Over the last decades, the gender of investigator as well as participant has been found to influence pain perception in both preclinical and clinical studies. However, to our knowledge this has not been studied in various postoperative patients. Objectives of this study were to test the hypotheses that pain intensity levels early after acute or scheduled in- or out-hospital surgery are lower when evaluated by a female investigator, and higher when reported by a female patient.

METHODS

In this prospective observational paired crossover study, two investigators of opposite genders independently obtained individually reported pain intensity levels with a visual analogue scale in a mixed cohort of adult postoperative study patients at Skåne University Hospital in Malmö, Sweden.

RESULTS

In total, 245 (129 female) study patients were included and then one female excluded. The study patients rated their intensity of postoperative pain lower when evaluated by a female than by a male investigator (P = 0.006), where the male patients constituted the significant difference (P < 0.001). Pain intensity levels did not differ between female and male study patients (P = 0.210).

CONCLUSIONS

Main findings of lower pain intensity reported by males to a female than to a male investigator early after surgery in this paired crossover study in mixed postoperative patients, indicate that potential impact of investigator gender on pain perception should be considered and further evaluated in clinical bedside practice. Trial registration Retrospectively registered in the ClinicalTrials.gov research database on 24th June 2019 with TRN number NCT03968497.

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.

Analgesic effects of sufentanil in combination with flurbiprofen axetil and dexmedetomidine after open gastrointestinal tumor surgery: a retrospective study

Background

To investigated the effects of sufentanil in combination with flurbiprofen axetil and dexmedetomidine for patient-controlled intravenous analgesia (PCIA) on patients after open gastrointestinal tumor surgery, and compared this combination with traditional PCIA with pure opioids or epidural analgesia (PCEA).

Methods

Patients (n = 640) who underwent open gastrointestinal tumor surgery and received patient-controlled analgesia (PCA) were included. According to the type of PCA, patients were assigned to three groups: MPCIA (PCIA with sufentanil, flurbiprofen axetil, dexmedetomidine and metoclopramide), OPCIA (PCIA with sufentanil, tramadol and metoclopramide) and PCEA group (PCEA with sufentanil and ropivacaine). The characteristics of patients, intraoperative use of analgesics, postoperative visual analogue scale (VAS), postoperative adverse reactions and postoperative recovery were collected. The primary outcome was postoperative VAS score. One-way ANOVA, Kruskal-Wallis H test, Fisher exact probability method, and binary logistic regression analysis were used for analysis.

Results

There were no significant differences in the characteristics of patients, operation time, tumor site and the use of postoperative rescue analgesics among the groups. In the first two days after open gastrointestinal tumor surgery, the VAS (expressed by median and interquartile range) of MPCIA (24^th h, resting: 1,1; movement: 3,2. 48^th h, resting: 0,1; movement: 2,1.) and PCEA (24^th h, resting: 0,1; movement: 2,1. 48^th h, resting: 0,1; movement: 2,2.) groups were significantly lower than those of OPCIA group (24^th h, resting: 2.5,2; movement: 4,2. 48^th h, resting: 1.5,1.75; movement: 3,1.) (all p <  0.01). The incidence of postoperative nausea and vomiting in MPCIA group was 13.6% on the first day after surgery, which was significantly higher than that in PCEA group. There was no significant difference in the incidence of other postoperative adverse events. Higher intraoperative sufentanil dosage (OR (95%CI) = 1.017 (1.002–1.031), p = 0.021), lower body mass index (OR (95%CI) = 2.081 (1.059–4.089), p = 0.033), and tumor location above duodenum (OR (95%CI) = 2.280 (1.445–3.596), p <  0.001) were associated with poor postoperative analgesia.

Conclusions

The analgesic effects of PCIA with sufentanil in combination with flurbiprofen axetil and dexmedetomidine on postoperative analgesia was better than that of traditional pure opioids PCIA, and similar with that of PCEA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01670-0.

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.

Does an acute pain service improve the perception of postoperative pain management in patients undergoing lower limb surgery? A prospective controlled non-randomized study

Background and Aim:

An acute pain service (APS) has been running in our institute since April 2013 and is managed by the Department of Anesthesia and Intensive Care. However, it is not clear to what extent the patients feel benefited from the APS. The aim of the study was to compare the perception of postoperative pain management in patients receiving care under APS with those receiving routine postoperative pain relief following lower limb surgery.

Material and Methods:

This was a prospective, hospital-based, controlled non-randomized study. American Society of Anesthesiologists (ASA) grades I–III patients with age 18–75 years undergoing lower limb orthopedic surgery were prospectively recruited into APS (index group) or routine postoperative care (control group) (n = 55 each). Postoperatively, American Pain Society Patient Outcome Questionnaire-Revised (APS-POQ-R) and Short Form (SF-12) were used to evaluate the outcome of postoperative pain management at 24 h and health-related quality of life after 4 weeks respectively.

Results:

Both groups were comparable in terms of demographic data. Patients in the index group had statistically significant better perception of care than the control group. Index group scored significantly higher than control group on median patient satisfaction score (9; interquartile range [IQR] [7–10] vs. 5 [3–6]; P < 0.001). In index group, there was significant reduction of worst pain in first 24 h along with decreased frequency of severe pain.

Conclusion:

Implementation of acute pain service plays an important role in improving the quality of postoperative pain relief, perception of care, and patient satisfaction.

Quo Vadis PCA? A Review on Current Concepts, Economic Considerations, Patient-Related Aspects, and Future Development with respect to Patient-Controlled Analgesia

This review assesses four interrelating aspects of patient-controlled analgesia (PCA), a long-standing and still widely used concept for postoperative pain management. Over the years, anaesthesiologists and patients have appreciated the benefits of PCA alike. The market has seen new technologies leveraging noninvasive routes of administration and, thus, further increasing patient and staff satisfaction as well as promoting safety aspects. Pharmaceutical research focuses on the reduction or avoidance of opioids, side effects, and adverse events although influence of these aspects appears to be minor. The importance of education is still eminent, and new educational formats are tested to train healthcare professionals and patients likewise. New PCA technology can support the implementation of efficient processes to reduce workload and human errors; however, these new products come with a cost, which is not necessarily reflected through beneficial budget impact or significant improvements in patient outcome. Although first steps have been taken to better recognize the importance of postoperative pain management through the introduction of value-based reimbursement, in most western countries, PCA is not specifically compensated. PCA is still an effective and valued technique for postoperative pain management. Although there is identifiable potential for future developments in various aspects, this potential has not materialized in new products.

A survey of acute pain services in the UK

The organisational state of inpatient pain management in UK hospitals is difficult to determine. We sent an electronic questionnaire to 209 acute pain service leads throughout the UK. Questions were about staffing and service provision. We received 141 responses (67%); 47% of all UK hospitals. Each service was responsible for a median (IQR [range]) of 566 (400-839 [120-2800]) beds. Each acute pain specialist nurse was responsible for 299 (238-534 [70-1923]) beds. The mean (SD) number of consultant hours per week was 5.54 (4.62), delivered by a median of 1.0 (1.0-2.5 [0.2-7.0]) consultant. Overnight cover was provided by 20 (15%) acute pain services, and weekend cover by 39 (29%). Acute pain services commonly (in 50 (35%) hospitals) had roles in addition to acute pain management. Most teams (105, (77%)) reviewed medical patients and patients with chronic pain (in 131, (96%) teams). Half of the services (56, (49%)), reported that they were part of an integrated acute and chronic pain service, however, 83 (59%) did not have any members who work in chronic pain clinics. The majority (79, (70%)) were able to access a nominated chronic pain consultant for advice. Provision of acute pain services throughout the UK is highly variable. The majority do not meet core UK standards.

Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures

Objective

Each year, more than 150,000 patients with rib fractures are admitted to US trauma centers; as many as 10% die. Effective pain control is critical to survival. One way to manage pain is thoracic epidural analgesia. If this treatment reduces mortality, more frequent use may be indicated.

Methods

We analyzed the patient registry of a level II trauma center. All patients admitted with one or more rib fractures (N = 1,347) were considered. Patients who were not candidates for epidural analgesia (N = 382) were eliminated. Mortality was assessed with binary logistic regressions.

Results

Across the total population, mortality was 6.7%; incidence of pneumonia was 11.1%; mechanical ventilation was required in 23.8% of patients, for an average duration of 10.0 days; average stay in the hospital was 7.7 nights; and 49.7% of patients were admitted to the ICU for an average of 7.2 nights. Epidural analgesia was administered to 18.4% of patients. After matching samples for candidacy, patients who received epidurals were 3.7 years older, fractured 2.6 more ribs, had higher injury severity scores, and were more likely to present with bilateral fractures, flail segments, pulmonary contusions, hemothoraces, and pneumothoraces. Despite greater injury severity, mortality among these patients was lower (0.5%) than those who received alternative care (1.9%). Controlling for age, injury severity, and use of mechanical ventilation, epidural analgesia predicted a 97% reduction in mortality.

Conclusion

Thoracic epidural analgesia associates with reduced mortality in rib fracture patients. Better care of this population is likely to be facilitated by more frequent reliance on this treatment.

Effective pain management and improvements in patients' outcomes and satisfaction

Adequate pain management is a compelling and universal requirement in health care. Despite considerable advancements, the adverse physiological and psychological implications of unmanaged pain remain substantially unresolved. Ineffective pain management can lead to a marked decrease in desirable clinical and psychological outcomes and patients' overall quality of life. Effective management of acute pain results in improved patient outcomes and increased patient satisfaction. Although research and advanced treatments in improved practice protocols have documented progressive improvements in management of acute and postoperative pain, little awareness of the effectiveness of best practices persists. Improved interventions can enhance patients' attitudes to and perceptions of pain. What a patient believes and understands about pain is critical in influencing the patient's reaction to the pain therapy provided. Use of interdisciplinary pain teams can lead to improvements in patients' pain management, pain education, outcomes, and satisfaction.

No evidence of real progress in treatment of acute pain, 1993-2012: scientometric analysis

Over the past 2 decades, many new techniques and drugs for the treatment of acute pain have achieved widespread use. The main aim of this study was to assess the progress in their implementation using scientometric analysis. The following scientometric indices were used: 1) popularity index, representing the share of articles on a specific technique (or a drug) relative to all articles in the field of acute pain; 2) index of change, representing the degree of growth in publications on a topic compared to the previous period; and 3) index of expectations, representing the ratio of the number of articles on a topic in the top 20 journals relative to the number of articles in all (>5,000) biomedical journals covered by PubMed. Publications on specific topics (ten techniques and 21 drugs) were assessed during four time periods (1993–1997, 1998–2002, 2003–2007, and 2008–2012). In addition, to determine whether the status of routine acute pain management has improved over the past 20 years, we analyzed surveys designed to be representative of the national population that reflected direct responses of patients reporting pain scores. By the 2008–2012 period, popularity index had reached a substantial level (≥5%) only with techniques or drugs that were introduced 30–50 years ago or more (epidural analgesia, patient-controlled analgesia, nerve blocks, epidural analgesia for labor or delivery, bupivacaine, and acetaminophen). In 2008–2012, promising (although modest) changes of index of change and index of expectations were found only with dexamethasone. Six national surveys conducted for the past 20 years demonstrated an unacceptably high percentage of patients experiencing moderate or severe pain with not even a trend toward outcome improvement. Thus, techniques or drugs that were introduced and achieved widespread use for acute pain management within the past 20 years have produced no changes in scientometric indices that would indicate real progress and have failed to improve national outcomes for relief of acute pain. Two possible reasons for this are discussed: 1) the difference between the effectiveness of old and new techniques is not clinically meaningful; and 2) resources necessary for appropriate use of new techniques in routine pain management are not adequate.