|EVIDENCE BASED DATA
|Year : 2007 | Volume
| Issue : 5 | Page : 441
Postoperative Pain Management : Organisation and Audits
M.D, FICS, FAMS, Senior Prof. & Head, Department of Anaesthesiology, R.N.T.Medical College, Udaipur (Raj.), India
|Date of Web Publication||20-Mar-2010|
25, Polo Ground, Udaipur (Raj.)
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bajaj P. Postoperative Pain Management : Organisation and Audits. Indian J Anaesth 2007;51:441
Pain relief after surgical procedures continues to be a major medical challenge. The alleviation of pain is given a high priority by the medical profession and health authorities, who recognize that improvements in perioperative analgesia are not only desirable for humanitarian reasons, but essential for reducing postoperative morbidity and mortality , . The guidelines for acute pain management established by the Agency for Health Care Policy and Research highlight the fact that appropriate pain management in postoperative patients contributes to earlier mobilisation, shorter hospital stay and lower costs. Pain relief per se does not significantly improve the postoperative outcome, with the exception of patient satisfaction and pulmonary complications. Postoperative morbidity and the length of hospital stay are dependent on many factors, including preoperative information, quality of analgesia and existing programs for postoperative care and rehabilitation, including orders for mobilisation, oral nutrition and discharge criteria  . In recent years, the techniques for pain management in patients undergoing surgery have substantially improved. The choice of analgesic and the route and technique of administration can be tailored to individual need to optimize pain control and to avoid postoperative discomfort and suffering. However, although there is no reason why a patient should not receive appropriate analgesia, recent surveys have revealed that the incidence of moderate or even severe postoperative pain may be as high as 30-70% , . Most patients, physicians, surgeons and nurses still consider moderate-to-severe pain an acceptable consequence of surgical interventions. Undertreatment of pain has been determined to have a negative impact on short-term recovery and may even have a detrimental long-term effect on health. Three reasons for the undertreatment of pain relate to fear of narcotic addiction, poor communication among staff and perceptions by patients that medications for pain are neither necessary nor good. The recognition that unrelieved pain contributes to preoperative morbidity and mortality has inspired many institutions to develop an Acute Pain Service (APS) in an attempt to provide effective postoperative relief. Immediate and sustained formal support, as well as authoritative recommendations from various medical and health care organisations, have promoted the widespread introduction of APS ,,,,,, . This in turn has led to the successful and safe implementation of multimodal pain management strategies in surgical wards  . It has also led to an increase in the use of specialised pain relief methods, such as Patient Controlled Analgesia (PCA) and epidural infusions of local anaesthetics/opioid mixtures. Implementation of these methods may represent real advances both in improving patient wellbeing and in reducing postoperative morbidity  .
Studies have shown that pain is a particularly important determinant of patient satisfaction. It is now recognized that many patients have been greatly undertreated for their postoperative pain in the past. In spite of this fact, however, studies that include the assessment of patient satisfaction with postoperative pain management have repeatedly indicated that most patients seem satisfied with their postoperative care. Satisfaction is a subjective appraisal of personal care, and a number of factors seem to influence satisfaction with hospital care. Thorough information about the predictability and controllability of the painful stimulus is a major influence in pain expectation; however, most patients do not receive any information on pain and its possible methods of treatment. Providing patients with accurate preparatory information regarding the onset, duration, intensity and sensory qualities of the stressful events has been shown to minimise the distress of patients undergoing invasive medical procedures , . To ensure that patients have all the information they need, it is important to have annual audits of the postoperative pain unit; the audits should include an investigation of the quality of analgesia (the efficacy and safety of pain management), the amount and quality of patient information, patient satisfaction and the cost of treatment.
| Cost of pain management|| |
Studies of healthcare cost attempt to analyse the benefit of intervention and to provide well defined and relevant outcome measurements , . Cost analysis of acute pain management is impeded by the lack of a well defined baseline or outcome assessment. There is no valid method for assigning financial cost to differing levels of analgesia. Attempts at cost-benefit analyses that incorporate complication and outcome measures have been advocated, but a few studies involving APS have been conducted. It is important that cost-efficacy analyses consider the costs of analgesics, devices and nursing time, as well as the duration of stay in PACU/ICU/ surgical wards. The survival of APS may be threatened because of the present economic constraints in health-care and the requirements for cost-effective therapeutic interventions. This makes it especially important in the context of improved pain relief and outcome that there be well-defined quality criteria for provided service and an APS that is integrated in the multimodal rehabilitation program.
Pain relief after surgical procedures continues to be a major medical challenge. The introduction of the Acute Pain Services has led to a successful and safe implementation of multi-modal pain management strategies and an increase in the use of specialised pain relief methods. The APS has the responsibility for day-to-day postoperative pain, and it plays an important role in ensuring safe treatment and improving the knowledge and understanding of pain assessment in staff and patients. A key point in improving postoperative pain management is the regular assessment and documentation of pain. The 'golden rule' of pain assessment is : ' Do not forget to ask the patient!' Self-assessment, in fact, is the single most reliable indicator of the existence and the intensity of pain and the efficacy of pain treatment.
There has been growing interest in the assessment of patient satisfaction with healthcare. Studies have shown that pain is a particularly important determinant of patient satisfaction low pain intensity might be a good predictor of patient satisfaction. An awareness of the importance of controlling postoperative pain and the awareness of the options for effective postoperative pain relief (due to accurate preoperative information regarding the strategies presently available) should have a positive influence on patient satisfaction, despite postoperative experience with pain severity Good communication between APS staff and patients appears to be as important as analgesic efficacy in determining patient satisfaction. Furthermore, the exchange of information between patients and hospital staff members seems essential for a more individualised and optimal pain relief treatment plan. An APS in the hospital can improve both the knowledge of pain treatment and patient satisfaction; indeed, despite the fact that they may experience high levels of pain, most patients are satisfied with the efforts that nurses and physicians make to manage pain.
A satisfaction questionnaire provides useful baseline data for evaluating the quality of an institution's overall pain management program, and, furthermore, that the information it provides can be used to develop a plan for improving pain management. However, by itself, a satisfaction questionnaire is not the solution, even when repeated at regular intervals to determine APS progress. Indeed, if used in isolation from other data, satisfaction ratings can lead to the erroneous belief that pain management practices are optimal.
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