Postoperative quality and safety using Efficacy Safety Score (ESS) and a wireless patient monitoring system at the ward: A randomised controlled study

BACKGROUND

Postoperative pain, side-effects and time to mobilisation are indicators for the quality of postoperative recovery. The aim of this randomised controlled study was to investigate if efficacy safety score (ESS) combined with a wireless patient monitoring system would improve these clinical outcomes for patients at a general surgical ward.

METHODS

The trial included 195 patients randomised to a standard care group (SC-Group) or intervention group (INT-Group) receiving continuous wireless monitoring of vital signs combined with ESS during the first 24 postoperative hours. The primary outcome was time to mobilisation. Secondary outcomes were average pain, doses of postoperative opioids, unscheduled interventions, side-effects, patient satisfaction and length of hospital stay (LOS).

RESULTS

Mean time to postoperative mobilisation was 10.1 hours for patients in the INT-Group compared to 14.2 hours in the SC-Group; this corresponds to an adjusted hazard ratio of 1.54 (95% confidence interval 1.04-2.28). INT-Group patients received a higher dose of oral morphine equivalents; 26 mg vs 15 mg, P < .001; reported lower intensity of pain on a 0-10 scale; 2.1 vs 3.3, P < .001; and had higher patient satisfaction on a 5-point scale; 4.9 vs 4.3, P < .001. The LOS was similar between the groups; 71 hours in INT-Group vs 77 hours in SC-Group, P = .58. No serious side-effects were registered in INT-Group, whereas two were registered in SC-Group.

CONCLUSIONS

Introducing ESS as a decision tool combined with a wireless monitoring system resulted in less pain, increased satisfaction and more rapid mobilisation for patients in this study.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03438578.

Pain and pain management in hospitalized patients before and after an intervention

Background and aim

Studies have shown that pain is common among hospitalized patients and that there is a lack of compliance with pain management guidelines. Improving pain management does not only involve developing new drugs or technology; even more important is an effective organisation that utilises existing expertise. The aim of this study was to investigate whether pain in hospitalized patients can be reduced by implementing evidence-based pain management guidelines, providing education for staff and an organisation that includes pain responsibility nurses.

Methods

A cross-sectional study was carried out between 2009 and 2010 at two hospitals in southwest Sweden, comprising a baseline survey followed by an intervention. The study involved 306 patients, who answered questions about pain intensity at rest and while moving, disturbed sleep due to pain and whether they had used a pain rating scale while in hospital. Medical records were scrutinised for analgesic prescriptions. An intervention then took place, involving implementation of evidence-based guidelines, staff education and the introduction of pain responsibility nurses. A follow-up survey was carried out in 2012, in which 293 patients answered the same questions and their medical records were also reviewed. The baseline results were then compared with those of the follow-up survey.

Results

When compared with the baseline survey, the follow-up survey revealed significant differences in the use of validated pain rating instruments as well as the prescription of more appropriate analgesics. Prescription of paracetamol increased significantly in the follow-up survey; 56% of the patients were prescribed paracetamol on a regular basis, compared with 42% at baseline. There was also a significant increase in the use of strong opioids, from 38% at baseline to 55% at follow-up. Prescriptions of weak opioids decreased from 16% at baseline to 4% at follow-up. No significant differences were observed in patient pain levels in the follow-up survey. At baseline, 29% of the patients reported moderate to severe pain at rest (NRS 4–10) and at follow-up that figure was 24% (NRS 4–10). In both surveys, 41% reported moderate to severe pain (NRS 5–10) during movement. Thirty-nine percent reported disturbed sleep at night at both baseline and follow-up.

Conclusions

This study demonstrates that evidence-based guidelines made accessible to all staff as a pocket size booklet and on the intranet, in combination with staff education, pain responsibility nurses who informed other staff on their own wards, improved the prescription of analgesics in the hospitals studied. In order to achieve a noticeable effect for patients, i.e., reduced pain levels, an intervention containing more components than those employed in the present study is required.

Implications

Nurses and physicians need greater knowledge about the importance of pain rating. A vital part of pain management at hospitals is continuous evaluation of treatment outcomes to prevent severe pain and disturbed sleep. The complexity of pain and pain management requires commitment, time and knowledge on the part of healthcare staff. Multi-professional pain teams that support ward staff in pain management are necessary in order to reduce suffering and unnecessary pain in hospitalized patients.

The Importance of Written and Verbal Information on Pain Treatment for Patients Undergoing Surgical Interventions

Patients who undergo a surgical intervention require information in the preoperative phase. Few qualitative studies are available that illuminate the importance of preoperative information for patients' experiences of postoperative pain management. The aim of this study was to examine patients' perceptions of preoperative information about pain treatment as well as its importance for the way pain was managed in the postoperative phase. A descriptive, qualitative study using individual interviews was performed. Content analysis was employed to analyze individual interviews with 18 patients who had undergone total hip or knee joint plastic surgery. Every second participant received verbal information on pain treatment in the standard way at the preoperative discussion, whereas the others were also provided with written information. The interviews took place in a public hospital, on the second or third postoperative day, between September and November 2010. The study revealed that a combination of written and verbal information on pain relief was perceived as valuable by the patients. Four main categories were identified: The form of information; the content of the information; the patients' experience of postoperative pain relief, and factors that influenced the patients' experience of pain relief. The theme "Participation" emerged from the latent content. Preoperative information on pain relief facilitated increased patient participation. Health care professionals often aim to ensure that patients participate in the care, but the latter sometimes lack the desire, strength, or ability to become involved.