Clinical approaches to the management of post-operative pain have changed considerably in recent years. Pain management modalities such as patient-controlled analgesia (PCA), epidural analgesia with opioids, and/or local anaesthetic drugs and regional blocks are being increasingly used. However, in general, the obstacles to bringing these techniques to surgical wards have not been overcome. Most surgical patients continue to receive pain treatments that have changed little in decades. This is one of the main conclusions of interdisciplinary expert committee reports by the National Health and Medical Research Council of Australia , the Royal College of Surgeons of England and the Royal College of Anaesthetists , the US Department of Health and Human Services  and the International Association for the Study of Pain (IASP) . The need for acute pain services (APS) based on a team approach was considered as one of the most important recommendations from these committees. Acute pain services have been established in the USA , Canada , New Zealand  and in some hospitals in Europe [8-12]. In general, there are very few data on APS in Europe. The present survey was undertaken with the following aims:
- to study the availability of APS in different European countries;
- to evaluate the use of techniques such as PCA and epidural analgesia on surgical wards; and
- to compare the nursing regulations with regard to pain assessment and documentation, and to the injection of opioids in epidural catheters and intravenous lines.
A questionnaire was mailed to anaesthesiologists in 105 European hospitals from 17 countries. Depending on the population, between five and ten hospitals were selected by a country coordinator from each participating country. The country coordinator for each country (names shown on title page) provided the names of hospitals and anaesthesiologists. It was emphasized to the country coordinator that the hospitals selected should be representative for the country in terms of geography and teaching vs. non-teaching. The survey was supported by EuroPain, a Brussels-based, non-profit European pain research group that aims to stimulate transnational studies.
In addition to demographic information, the respondents were questioned about the following: the total number of surgical procedures (in-patient and day surgery) over 1 year, the total number of beds, the availability of post-anaesthesia care units (PACUs) and the number of PACU beds, the availability of acute pain services (APS) and their organizational models, the role of the anaesthesiologist in pain management on surgical wards, the level of satisfaction/dissatisfaction with pain treatment on wards and the reasons for dissatisfaction, the use of techniques such as PCA or epidural opioids and/or local anaesthetics on wards and their economic implications, the routine use of pain assessment instruments and documentation, the government regulations regarding availability of opioids and the regulations for injection of drugs via epidural catheters, and suggestions for improvement of pain management on the wards.
A reminder was mailed to those who did not respond. The remaining non-responders were contacted by fax, telephone or via country coordinators. It was emphasized that, as far as possible, the answers should reflect hospital policies rather than the respondent's own opinions; however, for some questions, the respondent's opinion was requested. Three question formats were used: (1) yes or no boxes; (2) the selection of the best possible response out of three alternatives; and (3) fill in the blank. If exact data were not available, estimations were requested. Space for comments was provided for every question.
The respondents were requested to answer every question, and they were also encouraged to contact one of the authors (NR) for clarification if any question was unclear. Respondents were also informed that the questions could be answered in their own language if necessary. All data were collected and computerized with the help of a specially employed registered nurse. If answers were inadequate for questions considered particularly important, one of the authors (NR) contacted the respondents by telephone or fax. All data are for the year 1993.
Data are presented as numbers or percentages of respondents. Values are reported as means with range. Since the size of hospitals varied considerably, the data for a particular technique (e.g. epidural, PCR or regional blocks) are correlated where appropriate with demographic data (e.g. total number of surgical procedures, or total number of surgical beds or PACU beds) for that particular hospital.
A total of 101 (96.2%) completed questionnaires were returned; three questionnaires from Italy and one from Denmark were not returned. One questionnaire each from France, Germany and Italy and several comments on a questionnaire from Germany required translation from their national languages. Although the response to individual questions was generally good, answers to about 10% of questions were not provided or were inadequate. Differences between countries were noted in this respect. Nearly all hospitals could provide exact demographic information because of computerized record-keeping, but two respondents from the UK were not satisfied with their computer system and they provided estimates.
There were considerable differences in routines between countries and between hospitals from the same country. The total number of surgical procedures performed during 1 year in the participating hospitals was 1 087 971. For individual participating hospitals, the total number of surgical procedures ranged from 1115 (Sacavem, Portugal) to 53 392 (Vienna, Austria). For individual participating countries, the total number of surgical procedures ranged from 11 252 (Iceland) to 176 546 (UK). The average number of surgical procedures per hospital was 11 305.
Out of the hospitals surveyed, 89 (88%, 1% no response) were teaching institutions for nurses and 78 (77%) for anaesthesiologists.
Satisfaction with pain management
Table 1 shows that a majority (55%) of European anaesthesiologists were dissatisfied or very dissatisfied with post-operative pain management on surgical wards. As can be seen in Table 1, the situation was considered particularly unsatisfactory in Austria, Denmark, France, Germany, Iceland, Ireland, Italy, Norway, Spain, Sweden and the UK. Many reasons were provided for dissatisfaction and the commonest ones are shown in Table 2.
In general, respondents that had PACUs at their hospitals were satisfied with post-operative pain treatment. However, the percentage of dissatisfied respondents ranged from 10% to 33%. Over 20% of respondents from Spain were dissatisfied or very dissatisfied with pain management on PACUs. It should be emphasized that many hospitals in Europe do not have PACUs (Fig. 1).
Availability of acute pain services
Organized acute pain services for post-operative pain were not available in 62% of hospitals. In 37% (36) hospitals, there was some kind of organization, and the different organization models can be broadly divided into the groups shown in Table 3.
In general, management of post-operative pain was not formally organized, but anaesthesiologists 'on call' were usually available for consultation. However, there were a few exceptions, a formal organization was in place in the following countries: Belgium (one hospital), Germany (one hospital), Ireland (one hospital), the Netherlands (one hospital), Sweden (one hospital), Switzerland (two hospitals) and the UK (two hospitals). Most of these APS had been introduced during the last 3-4 years, while the earliest APS dated from 1985 in Kiel, Germany .
In hospitals where an organization existed, the two commonest APS models were: (1) specially trained nurses supervised by consultant anaesthesiologists responsible for the APS; and (2) junior anaesthesiologists responsible for the APS and senior anaesthesiologists available for consultation. When available, the nurse-based model was reported from France, Norway, Sweden, Switzerland and the UK. In one Norwegian hospital, the PACU took an active interest in pain management on wards. The survey showed that about 60% of the hospitals surveyed had pain centres for management of chronic and cancer pain, and specialists from these centres were consulted for acute pain problems when necessary. In two hospitals in Austria, a 'Pain Ambulance' had a similar function. The American model, consisting of an anaesthesiologist, nurse, pharmacist and physiotherapist, for a 24-h APS  was not available at any of the participating hospitals.
Reasons for inability to introduce new techniques
A majority of respondents would have liked to introduce analgesic techniques such as epidural opioids, PCA and regional analgesia onto surgical wards, but could not do so because of organizational and economic problems (Table 4). About 50% of respondents were unable to introduce PCA for similar reasons. There was much greater interest (49%) (47 hospitals) in introducing PCA than in introducing epidural techniques (22%) (20 hospitals) on to the wards. This was partly because an epidural technique was already established at several hospitals. The percentage of respondents who were unable to introduce other analgesic techniques on surgical wards were 17% (peripheral nerve and paravertebral blocks), 5.9% (intrathecal opioids), 3.0% (interpleural block), 1.0% (cryoanalgesia, hypnosis) and 1% [transcutaneous electrical nerve stimulation (TENS)]. Two frequent suggestions for the introduction of PCA on to the wards were: (1) the need for less complicated and cheaper PCA pumps (including cassettes); and (2) the involvement of the pump manufacturing companies in the teaching and training of personnel (i.e. nurses, surgeons and also anaesthesiologists).
Anaesthesiologists' role in pain management on wards
Table 5 shows that almost all anaesthesiologists had the main responsibility or an advisory role in pain management on surgical wards; only 8% anaesthesiologists had no role. In Austria, Greece, Iceland, Italy and Portugal, the anaesthesiologists only had responsibility for special techniques such as epidural analgesia and PCA. In some hospitals in Switzerland and the UK, anaesthesiologists were only responsible for the first 24 h after surgery, after which they had an advisory role.
Regular assessment and documentation of pain intensity on wards
Only 39 (38.6%) hospitals used an instrument to assess pain intensity. The visual analogue scale (VAS) was the predominant instrument and was used in 31 (79.5%) hospitals that assessed pain. Other methods of assessment were the verbal rating score in 15.4% hospitals, and the CHEOPS, SDS, descriptive scale and nursing score. At several hospitals, the VAS was only used with epidural or PCA techniques.
In some hospitals, the VAS was only used when clinical studies were performed. One centre each in Belgium and the UK used the VAS on PACU, but not on surgical wards. Although pain intensity was assessed in few hospitals (one in Switzerland and one in the UK), there seemed to be only one hospital (in Sweden) where pain was assessed routinely in every surgical patient on the ward. Documentation of pain intensity at the bedside or nurse station, and vital sign charts were even more uncommon. Italy, Sweden, Switzerland and the UK had one hospital each where pain intensity was documented. Again, this was more frequent on PACUs when epidural analgesia or PCA were used and for clinical research projects. In one hospital (UK), a special chart had been devised, but implementation of routine pain intensity assessment and documentation was proving difficult. In general, anaesthesiologists were dissatisfied with pain assessment and documentation procedures at their hospitals; they acknowledged the need for such measures but were unable to introduce them with current levels of staffing. Some typical comments were 'nursing staff barely adequate for regular service' (UK), 'even BP and heart rate recording every 2-4 h are difficult or impossible, how can we make nurses check and chart VAS frequently?' (Belgium) and 'we need APS' (most countries).
Several respondents noted that improvements were possible only if anaesthesiologists were made responsible. Interestingly, a few respondents commented that receiving and answering the questionnaire had stimulated them to take steps to improve the organization of pain management on surgical wards.
Next to the lack of organized APS, economic factors were considered to be the most important reason for inadequate pain relief on surgical wards. A mean of 72.3% respondents considered economic costs important or very important. Table 4 shows that 32% of physicians consider economic costs to be the main reason for their inability to provide the analgesic treatment of their choice. In general, it was the cost of equipment such as PCA pumps rather than analgesic drugs that were considered important. Many respondents, particularly those from Belgium, Ireland, Finland, Germany, Greece, Sweden and the UK, complained about lack of PCA pumps; respondents from the latter two countries also commented about lack of staff. Most respondents commented that economic issues were becoming increasingly important.
Nursing regulations and the availability of opioids
Figure 2 shows nurse regulations for permission to inject drugs into epidural catheters. Nurses were not allowed to inject drugs into the following types of catheters: intrathecal (82% hospitals), peripheral nerve block (54% hospitals), epidural (50% hospitals) and intravenous lines (19% hospitals).
In a majority of hospitals [49 (48.5%)], opioids were prescribed individually for patients; however, in 40 (40.6%) hospitals, opioids were prescribed on the basis of standard orders. In one hospital in the UK, an algorithm was used for i.m. or PCA opioid administration; a protocol was available for PCA but not i.m. opioids. In one Swedish hospital, pain management was based on standard orders and protocols for i.m., PCA and epidural techniques. Pain management based on standard orders was particularly common in Austria and Sweden. The availability of protocols for special analgesia techniques such as epidural analgesia and PCA are shown in Table 6.
In general, opioids were freely available in most countries for the management of post-operative pain; however, 25% (range 10-67%) of respondents considered the laws regarding the use of opioids to be restrictive. Over 40% of respondents from Austria, Germany, Greece, Italy and Spain were dissatisfied or very dissatisfied with regulations regarding the use of opioids; the greatest number of dissatisfied respondents were from Greece and Spain (67%).
The registration of the use of opioids and special documentation procedures were required in 87 (86.1%) hospitals; such procedures were not necessary in 13 (12.9%). Denmark (75%), Belgium (60%) and Spain (50%) had the most liberal regulations in this regard.
In some countries, there were laws that recommend maximum daily doses for opioids; however, it was unclear how these laws were implemented (the question was not asked) or if they had any significance in the practical management of pain. Although maximum daily doses of opioids did not appear to be a major practical problem, it should be emphasized that 12% of respondents commented that they were not allowed to administer opioid analgesics beyond a certain limit: for morphine, this daily limit ranged from 30 mg (Greece) to 180 mg (Belgium).
Suggestions for the improvement of post-operative analgesia on wards
This question elicited a very high response: over 65 suggestions were received. The recommendations could be broadly grouped into the following categories: (1) more emphasis on teaching of pain during training; (2) mandatory courses on pain as part of examinations; and (3) practical courses and bedside teaching programmes. These recommendations were for training programmes for anaesthesiologists, surgeons and nurses.
In a majority of hospitals, in-service teaching programmes for pain management were available; however, 30-40% of hospitals did not have such programmes. Anaesthesiologists were responsible for teaching in almost all hospitals except two in Sweden and one hospital in Denmark in which nurses had this function.
This survey was not a scientific study, but an attempt to review European trends, the availability of APS, the use of newer techniques such as PCA and epidural analgesia on surgical wards, and the nursing regulations regarding such techniques in different countries. Although the number of hospitals surveyed in individual countries was small, it is presumed that the hospitals selected by the country coordinators were representative for that country. This is supported by the similarity of the present data for the UK with the results of a nationwide survey on APS based on data from 354 hospitals from that country . During 1993, a total of 1087 971 surgical procedures were performed in the participating hospitals; out of these procedures, 835 986 (77%) were performed on inpatients and 251 985 (23%) on day stay surgery patients.
This present survey shows that post-operative pain is managed adequately on most PACUs but the situation on surgical wards is generally unsatisfactory. A majority of the European anaesthesiologists surveyed (53%) were dissatisfied or very dissatisfied with the management of post-operative pain on surgical wards. There were clear differences not only between different countries but also between different hospitals. Many hospitals (27%) did not have PACUs and this situation was particularly common in Italy (86%).
The Royal College of Surgeons and the Royal College of Anaesthetists report from the UK , and similar reports from Australia , Canada , New Zealand , the USA  and from organizations such as the International Association for the Study of Pain , all emphasize the importance of establishing APS as an important tool for the improved management of post-operative pain on surgical wards. The present survey showed that only one-third of the participating hospitals had some kind of an organization to provide acute pain services. Generally, this consisted of the availability of anaesthesiologists for consultation and teaching. Formally organized APS which included daily rounds of surgical wards, the use of techniques such as PCA and epidural analgesia on surgical wards, ongoing nurse teaching programmes and the development of protocols were available in very few centres in Belgium, Germany, Ireland, the Netherlands, Sweden, Switzerland and the UK. Most of these APS were introduced in 1990 or later; the earliest European APS was introduced in 1985 in Kiel, Germany . These organized APS were run either by junior anaesthesiologists or by nurses, and were supervised by consultant anaesthesiologists who were formally responsible for such APS. There is a lack of consensus regarding the essential components of an APS. The recent UK survey showed that there is a large degree of variation in what is thought to constitute an APS in the UK . Even in the USA, where the role of APS seems to be better defined, the staffing, services and components of APS can vary considerably from hospital to hospital [14,15]. Notably, 24-h obstetric pain services were available in most hospitals, suggesting that priority is given to treating obstetric pain over acute post-operative pain.
The role of anaesthesiologists also varied considerably between countries. Almost 10% of respondents did not have any role in post-operative pain management. In several hospitals in Austria, Greece, Iceland, Italy and Portugal, anaesthesiologists were formally responsible only for special techniques such as epidural and PCA. Similar findings have also been reported from the USA [14,15].
Although almost 40% of respondents reported using the VAS (most common) or some other pain score in special situations, routine assessment of pain intensity was rare on PACUs and even rarer on surgical wards. Frequent pain assessment, assessment before and after treatment, and its documentation on vital sign charts have been recommended as a quality assurance measure for every patient who undergoes surgery [3,4]. Only one hospital in Sweden had such hospital-wide routines. Departmental protocols for different analgesic modalities were available in most (60%), but not all, hospitals. Although anaesthesiologists generally acknowledged the need for frequent pain assessment, many respondents were unable to introduce such routines because of the lack of extra funding for nursing staff. The implementation of such routines for frequent assessment and documentation of pain intensity appears to be difficult. In a USA survey of 300 hospitals, VAS or verbal scores were used in only 24-26% of hospitals; it is unclear if this pain grading was used for every patient undergoing surgery or, as is more likely, for the selected patients treated by the APS .
Over 70% of the respondents considered economic factors to be a major reason for their inability to introduce the analgesic techniques of their choice on surgical wards; this was mainly because of the high cost of equipment and the need for trained personnel. A similar conclusion was reached by the authors of a UK survey of 354 hospitals . Considerably more respondents were interested in introducing PCA rather than the epidural technique on surgical wards, presumably because the epidural technique was already established in many hospitals.
Opioids were prescribed individually for patients in 49% of the participating hospitals, while in 41%, these were prescribed on the basis of standard orders. Even registration and documentation procedures for opioid use were not uniform: in 13% of participating hospitals, such procedures were not considered necessary (several hospitals in Belgium and Denmark had the most liberal regulations). Nurses were not permitted to inject drugs into intravenous lines in 20% of hospitals, into epidural catheters in 50% of hospitals and into subarachnoid catheters in 82% of hospitals. In general, nurses were allowed to inject drugs via these routes quite frequently in the Scandinavian countries, France, Portugal and Spain, while more restrictive policies applied for nurses in Belgium, the Netherlands and the UK. Opioids were freely available for post-operative pain management in most countries. However, 25% of respondents considered opioid laws too restrictive. The greatest number of dissatisfied respondents were from Greece and Spain.
Most respondents provided suggestions for the improvement of post-operative analgesia on surgical wards. The recurring features were: (1) undergraduate teaching for physicians and nurses; (2) mandatory courses as part of examinations; (3) practical courses and bedside teaching programmes for junior doctors and nurses; and (4) the establishment of organized APS with the involvement of anaesthesiologists, surgeons and ward nurses.
In conclusion, this 17-nation, 105-hospital survey reports that a majority of respondents were dissatisfied with the management of post-operative pain on surgical wards. Only one-third of the participating hospitals had some kind of organization to provide APS. Less than 10% of participating hospitals had a formal organization that would meet the requirements of a good APS. Quality assurance measures such as frequent pain assessment and its documentation were rarely practised. A majority of respondents were unable to introduce newer techniques such as PCA because of the lack of funds. Nursing regulations regarding the documentation of opioid use, and permission to inject drugs into intravenous lines and epidural catheters varied considerably between European countries. There is a need for the implementation of quality assurance measures such as routine assessment and charting of pain within the framework of organized APS. There is also a need for a clearer definition of the role of anaesthesiologists in such APS.
The authors wish to acknowledge the excellent help provided by all the respondents from the 17 participating countries. The authors also wish to thank Ing-Marie Dimgren for secretarial assistance. The following medical companies supported this project: Abbott (USA), Astra (Sweden), B. Braun (Germany), Lundbeck (Sweden), Pharmacia (European section) and Syntex (Sweden).