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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