The relief of postoperative pain continues to be an area of great interest and study, not only for physicians but also for the Health Government Authorities. Inadequate control of postoperative pain has been evident for decades and the importance of implementing organised units dedicated to the control of pain has been described for more than 50 years.1 In Portugal, postoperative pain was considered an important national issue in 2001, when governmental policies implemented the ‘National Plan to Combat Pain’. The goal was to create an Acute Pain Service in 75% of the Hospitals of the National Health System.2 In 2008, new policies dictated the need to reduce the prevalence of undertreated postoperative pain and organisational guidelines for Acute Pain Services were reviewed.3 But the mandatory existence of an Acute Pain Service in ‘all the hospitals with surgical activity in National Health System’ has only become a National Guidance in 2012.4 In order to understand the true situation in Portugal regarding Acute Pain Services and their establishment according to governmental guidelines, we conducted a questionnaire survey in every Portuguese National Health Service Hospital.
We identified every hospital with National Health Service surgical activity in Portugal, according to the government's official records (www.acss.min-saude.pt/%C3%81reaseUnidades/InvestimentosInstalEquipamentos/Destaques/SistNacionalIdentifInstititui%C3%A7%C3%B5esSistSa%C3%BAde/RedeHospitalardoSNS/tabid/318/language/pt-PT/Default.aspx [Accessed 27 February 2013]). We contacted every Head of Anaesthesiology Department, in order to obtain an E-mail contact to send a questionnaire about the existence of Acute Pain Services (or not), and how they functioned.
We sent 51 questionnaires to National Public Hospitals, 44 (86.3%) of which were returned fully completed. Of those 44 Institutions, 24 represented hospital centres (which include several hospitals) and 20 represented individual hospitals. Of the 44 institutions, 21 (47.7%) had an Acute Pain Service (14 were in centres and seven in individual hospitals).
In institutions with Acute Pain Services, 57.1% of the teams were composed of members from different areas (anaesthesia, nursing and pharmacy being the most frequent). In all of the 21 institutions, Anaesthesia assumed the leadership of the Acute Pain Services. A ‘nurse-based’ Acute Pain Service was adopted in nine institutions. The ‘nurse-based’ model involves specialised nurses in the provision of better analgesia, regardless of the techniques used, under the supervision of an anaesthetist.5 This model has significant advantages in terms of cost. An ‘anaesthetist-based’ acute pain service was implemented in the remaining 12 institutions. Nevertheless, the daily visits of the Acute Pain Team included an anaesthetist (either alone, or with a nurse, or with the patient's physician assistant) in 17 Acute Pain Services when patients had some kind of ‘nonconventional’ analgesia. In 19 of the institutions with an Acute Pain Service, the ability to assist patients with acute pain, 24 h a day, 7 days a week, was confirmed. The majority of the institutions with Acute Pain Services answered positively to the existence of analgesic protocols, either for ‘conventional’ or ‘nonconventional’ analgesia (19 out of 21 Acute Pain Services). In addition, 20 institutions with an Acute Pain Service had surveillance protocols to detect and manage complications assigned to analgesic plans (Table 1). All Acute Pain Services commonly used differentiated analgesic techniques and devices. According to the answers obtained from our questionnaire, training programmes and updating sessions regarding acute pain treatment were regularly undertaken by the team members in 17 of the 21 Institutions with an Acute Pain Service. Patient satisfaction surveys about their acute pain management were absent in 12 Institutions but were conducted in the remaining nine.
Of the 23 institutions that denied the existence of an Acute Pain Service, the majority of the Institutions (52,17%) answered positively to the existence of ‘analgesic protocols’ (either for ‘conventional’ or ‘nonconventional’ analgesia) and 18 (78.3%) confirmed they had surveillance protocols for complications that might occur with the analgesic treatments. Apart from the absence of an Acute Pain Service, the institutions confirmed the use of differentiated analgesic techniques and devices. In the majority of the institutions, the daily visits were conducted by the anaesthetist. Concern with the lack of professional knowledge and skills to provide an adequate pain treatment in hospitals without an Acute Pain Service existed, considering that 16 (69.6%) institutions assumed they had updating sessions in this theme, although just occasionally, and only two (8.7%) had them regularly.
In reality, Portugal is a long way from its goal of having an Acute Pain Service in every National Health Service hospital with surgical activity. Some specific requirements in the Acute Pain Service functioning, dictated by governmental policies, such as the existence of analgesic and surveillance protocols, and the availability of assistance 24 h a day, 7 days a week, were adequately implemented in most of the institutions with an Acute Pain Service.4 The promotion of updating sessions for professionals involved in pain management was a concern in the majority of the Acute Pain Services, fulfilling one of the governmental guidelines. Other items, such as providing information to the public about acute pain treatment, and surveys of patient satisfaction with this acute pain treatment, are clearly neglected in most of the institutions with an Acute Pain Service (Table 1). In Institutions without an Acute Pain Service, the goal of the questionnaire was to understand whether, despite the absence of an organisational structure, some of the governmental guidelines were achieved. Approximately half of the institutions confirmed they had analgesic protocols and the majority had surveillance protocols to detect and manage analgesic side effects (Table 1), which represents a true effort to achieve real pain management. Concern with the patient's recovery in the postoperative period, and with adequate pain treatment, is reflected in the high incidence of patients who are visited by anaesthetists, even in the absence of an Acute Pain Service.
In a context of an economical crisis, the policies of financial restraint, the incitement of higher productivity with lower resources available and lower funds allocated to the health system, Portugal has not yet achieved the goal outlined by recent governmental guidelines, the existence of an Acute Pain Service in every hospital with surgical activity of the national health system, with a structured organisational model.4
Acknowledgements relating to this article
Assistance with the letter: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
1. Werner MU, Soholm L, Rotboll P, et al. Does an acute pain service improve postoperative outcome? Anesth Analg
4. Organização das Unidades Funcionais de Dor Aguda. Lisbon: Direção Geral da Saúde; 2012. www.dgs.pt/directrizes-da-dgs/normas-e-circulares-normativas/norma-n-0032012-de-19102012.aspx
[Accessed 5 October 2014].
5. Rawal N. 10 years of acute pain services – achievements and challenges. Reg Anesth Pain Med