Bardiau, Françoise M. RN, PhD*,; Taviaux, Nicole F. RN*,; Albert, Adelin PhD†,; Boogaerts, Jean G. MD, PhD‡,; Stadler, Michaela MD, MSc‡
According to Warfield and Kahn (1), 77% of adult patients experience pain after surgery. Among them, 80% express moderate to severe pain. Despite the introduction of novel drugs and analgesic techniques, the overall treatment of postoperative pain has not really improved (2–4). Clinical guidelines and quality programs are considered as essential tools to enhance postoperative pain management (5–7). Nurses play a major role in postoperative pain management, because drugs are prescribed by physicians but administered by nurses (4).
In 1990, the Royal College of Surgeons of England and the College of Anesthetists (8) recommended a more comprehensive approach to postoperative pain management. Later, in 1995, the American Pain Society (7) insisted that quality assurance and improvement programs be implemented to institutionalize pain management procedures. Many articles have dealt with quality improvement processes and implementation (9–11). However, few studies have actually assessed the effectiveness of strategies to improve the quality of pain management (4,12–16).
Wheatley et al. (15) observed patients after major surgery, where analgesic techniques such as patient-controlled analgesia and extradural infusion were applied within the first 24 h after surgery. A marked improvement in postoperative pain relief could have been demonstrated, but the study focused on relatively sophisticated methods of analgesia. Therefore, patients with minor surgery were a priori excluded from this survey.
Gould et al. (13) described the sequential introduction of an acute pain service (APS) in seven stages and the resulting improvement in the level of postoperative pain as assessed by a visual analog scale (VAS). The emphasis was on the policy for pain relief after surgery that would benefit every patient after any type of surgery. Nurses on the ward assessed VAS, respiratory rate, and sedation score by means of pain assessment charts. Guidelines for postoperative morphine analgesia were introduced on the wards. A baseline survey facilitated the comparison after successful implementation. No assessment was performed of nurses’ or doctors’ attitudes toward pain and pain relief. The efficacy of the program relied on the enthusiasm of the members of the acute pain team and was not ensured by a continuous quality assurance program.
Schug and Haridas (14) introduced an anesthesiologist-based APS that focused of the development of regional techniques and patient-controlled analgesia as the standard method of morphine administration. This service is headed by a staff anesthesiologist whose time commitments have increased significantly. Additionally, a senior nurse specialist worked with the service and established guidelines, nurse education, and continuing liaison with the nursing service. A baseline survey was not performed. No demographic data, pain score level, or information about the different analgesic techniques was available in this study.
Contrary to Schug and Haridas (14), Rawal and Berggren (17) introduced a low-cost model of an APS in 1994. This nurse-based, anesthesiologist-supervised model provides pain treatment for all surgical patients and served as a blueprint for the implementation of an APS in our hospital.
In 1998, Tighe et al. (12) evaluated the effect of introducing an APS, by means of a questionnaire. An audit of pain, emesis, sleep, and satisfaction before and after inception showed a significant improvement of patients’ perception. The authors estimated the first year costs at approximately £6.00 per patient and at £3.50 thereafter. Nurses’ attitudes and perceptions were not evaluated, and no further information about a quality program was given.
No study has dealt with the global approach to pain management as a continuous quality assurance program, as recently reported by Stamer et al. (18). Furthermore, Harmer (19) stated that standards for APS structure and better quality assurance programs are warranted. To provide improvement over time, regular audits and quality tools such as flowcharts, report cards, and quality manuals should be introduced in the field of postoperative pain relief.
In July 1996, a fatal incident occurred in our hospital. A 40-yr-old, ASA physical status I patient died because of oversedation and delayed respiratory depression 12 h after a spinal arthrodesis procedure. A peer-review meeting revealed overconsumption of medications prescribed by five different physicians to treat postoperative pain, partly ordered by telephone without a proper examination of the patient’s health state. At that time, no proper guidelines and responsibilities for nurses, anesthesiologists, and surgeons in the field of pain management had been defined or applied, and no regular assessment of pain intensity and drug efficacy was provided. This critical incident alerted the hospital manager and revealed the urgent need to improve pain management procedures.
This study describes the process of the implementation of an APS in a general hospital, the nature of the service provided, the staffing and facilities, the training and competence of those running the APS, and the effectiveness as Rawal (4) claimed recently. The purpose was to evaluate the results of a continuous quality improvement program by defining quality indicators and using quality tools. This program anticipated an enhancement of postoperative pain relief for all surgical inpatients and the maintenance of this service over time.
The study was conducted in a general hospital of 1005 beds, 240 among them located on surgical wards. The process of quality management was divided into 8 stages spanning a 3-yr period.
1. In September 1996, a pain management committee (PMC) was set up. It consisted of 5 anesthesiologists, 4 surgeons, 1 pharmacist, and 12 referent nurses, each responsible for the pain management in a surgical unit, and 1 “pain nurse.”
2. In November 1996, a survey of nurses’ attitudes and knowledge with regard to postoperative care was conducted. An anonymous 35-item questionnaire adapted from the work of Hunt (20) was distributed to 102 nurses.
3. In December 1996, a 10-cm VAS device was introduced to assess pain intensity routinely (0 = no pain at all and 10 = the worst imaginable pain).
4. From January to June 1997, a baseline survey (Survey I) by means of a prospective and observational study was designed to analyze the current practice of pain treatment. All surgical inpatients (n = 1304) older than 15 yr who were able to read and understand French, had normal mental health, and were hospitalized for elective surgery were included. Patients transferred directly to an intensive care unit, bypassing the postanesthesia care unit (PACU), those who received postoperative epidural analgesia, and those who had emergency or ambulatory procedures were excluded. During the preoperative visit, patients became familiar with the VAS device. No special instructions were given to the attending anesthesiologist regarding anesthesia and postoperative analgesia regimens. The current practice of pain treatment was characterized by a large variability and reflected the individual opinion of each anesthesiologist. The treatment consisted of systemic analgesics (i.e., paracetamol), nonsteroidal antiinflammatory drugs (NSAIDs), and morphine prescribed by anesthesiologists and surgeons and administered by ward nurses.On arrival in the PACU, patients were asked to rate their pain experience on the VAS device. This process was repeated every 2 h for the first 4 h, and when the patient moved to the surgical ward, it was continued every 4 h within 72 h. Medications given for pain control were carefully recorded for each patient (type of medication, dose, and frequency of injection). The demographic and clinical variables included the patient’s age, sex, type of surgery, and type of anesthesia.
5. In October 1997, an APS nurse-based, anesthesiologist-supervised model developed by Rawal and Berggren (17) was set up (16). This model is based on acute pain nurses (APNs) and pain representatives, namely, acute pain and section anesthesiologists, ward surgeons, and day or night nurses. Standardized treatment protocols, regular assessments of pain intensity by VAS every 4 h, recording of treatment efficacy on a bedside vital-sign chart, and APNs are the cornerstones of this model. The APNs make daily rounds on all surgical departments and register problems with analgesia, side effects of treatments, and patient satisfaction.Education of the nursing staff and nursing guidelines were elaborated, where the assessment of pain every 4 h and reassessment 45 min after rescue medication were defined. Lectures about the current practice of postoperative pain relief were provided to all physicians involved in the process. Both nurses and physicians became familiar with evidence-based guidelines concerning postoperative pain. Regular consensus meetings were organized by the Department of Anesthesia to establish a pain protocol accepted by all partners. A multimodal analgesic regimen was elaborated that combined different analgesic techniques. Every patient received paracetamol and NSAIDs regularly. This treatment was combined with either morphine in case of VAS >3 cm or different regional techniques in respect to the type of surgery. All patients leaving the PACU were dispensed an individual analgesic prescription sheet. Patient information pamphlets were given; patients were informed before surgery about the VAS device and told that every effort would be made to maintain their VAS below the previously defined threshold of 3 cm.The PMC developed a clinical pathway to create an optimal regimen of postoperative pain management. To document any simple item of the pathway, a flowchart was created. The analysis of flowcharts led to the definition of the most relevant quality indicators (Table 1) (21,22). A limited number of these indicators were graphed on report cards (patients’ preoperative information, VAS scores, analgesic consumption, and patient satisfaction). These report cards—produced monthly—enabled the PMC to identify problems and to introduce necessary corrections. Results were evaluated and compared with the predefined threshold.
6. Three months later, from February to April 1998, a second evaluation survey (Survey II) was conducted to assess the effect of the APS implementation. A total of 671 patients were included by using the same methodology as that described for the first survey. A model for interpreting, standardizing, and comparing VAS pain curves was defined and published (16).
7. In January 1999, after the results obtained by the first survey, a quality manual was published and distributed in the PACU and to surgical ward personnel, surgeons, and anesthesiologists (17,21–23). The goal of the quality manual was to precisely delineate the responsibilities and methods currently used, as well as to obtain a high degree of reliance on each hierarchical level for task coordination, control, and communications. This manual permitted the development of a monitoring system and clarification of the required improvements. The process of postoperative pain management was divided into three stages: pre-, peri-, and postoperative care. For each stage, the process was clearly defined (Table 2).
8. From October 1999 to December 1999, a third confirmation survey (Survey III) was conducted to investigate whether the initial improvements were maintained or possibly expanded by using the quality manual. The same methodology as in Surveys 1 and 2 was used.
Results were expressed as mean ± sd for quantitative variables and as frequencies for categorical findings. As described by Bardiau et al. (16), time-related VAS measurements were summarized with several pain indicators: AUC, area under the VAS-time curve (cm × h); mean VAS (cm); VAS max, peak of VAS (cm); time of VAS max (h); PVAS >3, the persistence of VAS >3 cm, i.e., the time period during which VAS was above the critical threshold (h); and pain duration, i.e., the time period during which the patient reported pain (VAS >0) during the 72 h (h). Mean values of quantitative variables (age, pain indicators, paracetamol, and morphine consumption) between studies were compared by one-way analysis of variance, whereas proportions (sex, NSAID use) were compared by use of the classic χ2 test. The numbers of patients included in the post-APS surveys were based on a power calculation assuming a 20% reduction in pain indicators: α = 0.05 and β = 0.20. All statistical calculations were performed with the SAS package (Version 6.12; SAS Institute, Cary, NC), always with all available data. Results were considered to be significant at the 5% critical level (P < 0.05).
Eighty six (84%) questionnaires of the survey on nurses’ attitudes about and knowledge of postoperative pain management were returned and analyzed (Table 3). This survey identified a lack of knowledge and skills among nurses in assessing and managing pain effectively because of the absence of nursing guidelines and pain treatment protocols. Furthermore, it revealed concerns and fears about side effects, tolerance, and addiction to morphine.
The three surveys included 2383 surgical inpatients. A total of 1304 patients with complete files were included in Survey I, 671 patients in Survey II, and 408 in Survey III. In Survey I, 482 patients were discharged after 48 h, as were 353 patients in Survey II and 166 in Survey III. The distribution of patients according to the type of surgery differed significantly between Surveys 1 and 2, but not between Surveys 2 and 3 (Table 4). A larger proportion of patients were operated on under regional anesthesia in Survey II (28% vs 24% in Survey I;P = 0.034).
Pain relief improved significantly after the implementation of the APS. Figure 1 shows the reduction in VAS pain scores (P < 0.001). The values of pain indicators (derived from the VAS score curves) observed in the three surveys are displayed in Table 5. A highly significant reduction of all pain indicators (P < 0.001) was observed after APS inception, except for the time of maximum VAS, which remained unchanged. The APS effect on pain indicators remained highly significant (P < 0.001) even when age, sex, surgical procedure, and type of anesthesia were adjusted for. Table 6 illustrates the reduction of AUC and PVAS >3 cm in the different surgical specialties.
The analgesic consumption changed after APS implementation. Paracetamol consumption increased significantly from 2.6 ± 2.0 g in the first survey to 4.8 ± 6.2 g in the second (P < 0.001) and 7.6 ± 3.7 g (P < 0.001) in the third. NSAID administration increased significantly from 20% in the first to 64% in the second and 99% in the third survey (P < 0.001). Morphine consumption decreased slightly in the second survey (11 ± 13 mg) in comparison with the first (14 ± 23 mg) (P < 0.001). In Survey III, morphine use remained stable (13.4 ± 31.2 mg) (P = 0.2232).
There is increasing recognition that inadequate treatment of pain continues to be a clinical problem in hospitalized patients (4). Physiological, psychological, ethical, and financial consequences result from badly managed pain in terms of delayed healing, patient suffering, and prolonged recovery. Clinical practice guidelines for acute pain management stated the goals as (a) reduction of the incidence and severity of patients’ acute postoperative pain, (b) education of patients about communication of unrelieved pain, and (c) enhancement of patient comfort and satisfaction, with a resultant decrease in postoperative complications and a reduced length of stay (24,25).
At the University Hospital Center of Charleroi, we began to manage acute pain on a case-by-case basis in 1997. Our approach to treating acute pain had become formalized, with a well defined structure throughout the institution, an APS. This service gave us the opportunity to treat large numbers of patients. We have developed an approach to acute pain management that includes the careful and systematic evaluation and documentation of our observations. This study followed the recommendations of the report of the working party of the Royal College of Surgeons of England and College of Anesthetists (8) on pain after surgery.
The results obtained from the nurse survey enabled the PMC to arrange for appropriate education of nurses and to describe a protocol for nursing practice. Education of the nursing staff with regard to pain assessment and treatment was started. Today, nurses increasingly assess patients for the presence and intensity of pain, as well as the consequences of its treatment. The fear of side effects from morphine administration decreased significantly. VAS pain scores have become a standard tool in the assessment of patients after surgery, similar to blood pressure or heart rate measurements.
Survey I focused on the importance of criteria that facilitate benchmarking. It uncovered a lack of standardized analgesic protocols and small analgesic consumption. Survey II showed a major improvement in pain scores in all surgical departments. The implementation of rigorous analgesic protocols and guidelines has led to appropriate drug prescription and administration in accordance with the clinical needs of a single patient. The obtained 4 hourly VAS data of all patients were analyzed by using five pain indicators. They were considered as outcome-based tools for evaluating current practices as compared with the desired outcome. AUC and PVAS >3 cm were sensitive enough to demonstrate the improvement in pain relief and appear clinically relevant as the most stringent criteria.
As Rawal and Berggren (17) stated, “the solution to the problem of inadequate postoperative pain relief does not lie so much in the development of new techniques, but rather in the establishment of a formal organization.” Therefore, the PMC defined a clinical pathway to create an optimal regimen of care for postoperative pain management. Clinical pathways, also known as “care pathways” or “critical pathways,” are an application of industrial quality management science to health care. Hospitals have begun introducing clinical pathways to cut costs and to reduce variation in care that does not influence outcome (25). A detailed description of pathway development has been previously reported (16,17). These pathways outline a recommended sequence and timing of interventions by anesthesiologists, nurses, surgeons, and other staff for the production of care for postoperative patients. To assess current practice in the pre-, peri-, and postoperative periods, a flowchart was drawn to describe the process and highlight weak points in the patient care process. By means of report cards, the predefined quality indicators were controlled and compared with the predefined threshold. Regular audits have provided feedback to all people involved and have ensured that the quality program is properly maintained.
A quality manual was created and distributed to all members of the nursing and medical staff. Survey III indicated that the process was correctly controlled. No significant change occurred after the application of the quality manual. Unfortunately, patient satisfaction was not assessed before the APS implementation, and, therefore, no conclusion in terms of increased satisfaction due to an APS could be drawn.
Regional techniques were restricted to selected patients not included in this survey. These patients were treated in the intensive care unit. However, at this time, regional techniques are managed appropriately on the surgical wards by means of formal protocols.
In conclusion, this study shows that standardization of pain treatment, stabilization of nursing practice, and regular feedback of performance are essential factors to improve the quality of pain relief. A significant reduction of postoperative pain scores in all surgical inpatients was observed. Setting up teams of surgeons, anesthesiologists, and nurses is the prerequisite for this improvement. In terms of scarce financial resources, cost-benefit analyses are warranted to assess the cost, consequences, and social implications of acute pain treatment.
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