Audit of an Acute Pain Service in a Tertiary Care Hospital in a developing country

Authors:

Muhammad Qamarul Hoda

MBBS, FCPS, FFARCS

Associate Professor & Clinical Director, Intensive Care Unit

Department of Anaesthesia, Aga Khan University, Karachi, Pakistan

Mohammad Hamid

MBBS, Diplomate American Board

Assistant Professor

Department of Anaesthesia, Aga Khan University, Karachi, Pakistan.

Fauzia Anis Khan

MBBS, FCPS, FRCA

Professor

Department of Anaesthesia, Aga Khan University, Karachi, Pakistan.

Dr. Mohammad Hamid

Assistant Professor

Department of Anaesthesia, Aga Khan University Hospital

P.O. Box No. 3500, Stadium Road

Karachi 74800

Pakistan.

E-mail: mohammad.hamid@aku.edu

Tel: (92-21) 486-4378

Fax: (92-21) 493-2095

Reprint request

Same as corresponding author

Short running head:

Acute pain audit

Word count:

Words 1246
ABSTRACT

The first anaesthesia based acute pain service (APS) was introduced in Pakistan

at Aga khan university hospital in July 2001, with the aim of patient safety and

satisfaction. American Society of Anesthesiologist task force guidelines were

used for the introduction of APS.

APS has managed 6810 patients during four and half years period. Common

analgesic techniques used, were Intravenous infusion (50 %), Patient controlled

intravenous analgesia (18 %) and Epidural infusions (30 %). Common reported

side effects were nausea and vomiting with intravenous infusion (10 %) and

PCIA (10%) while motor block noticed with epidural infusion (29%).

In this article we are going to share our experience with the initial setup of APS,

difficulties faced after establishment of APS and an audit to show overall APS

performance.
Introduction

The goal of adequate pain control after surgery is still underachieved and several steps

need to be taken to reach this target. 1 Introduction of an acute pain service (APS) is an

important step in postoperative pain management. In addition to controlling postoperative

pain and reducing morbidity and mortality, acute pain services can also help in early

recovery and discharge from the hospital.

Need for acute pain service was realized several decades ago but the real impetus was

provided by the development of acute pain services in 1985 in USA and Germany which

was followed by a joint report from Royal college of Surgeons of England and College of

Anaesthetist recommending the development of APS in all hospitals under taking acute

surgery.2,3

APS is now responsible for clinical research, training of medical and nursing staff, 4,5

development of guidelines, organization of seminars, audits and evaluation of new and

existing methods of postoperative pain management. 6 In addition after introduction of

APS in several hospitals there was an increase use of specialized methods of pain relief

such as patient controlled intravenous analgesia (PCIA), patient controlled epidural

analgesia (PCEA), and epidural infusions on surgical wards. 7 Anaesthetist can provide

proactive leadership in this multidisciplinary 8

management of postoperative pain. 9

The first anaesthesia based APS was introduced in Pakistan in July 2001 at our

University Hospital, with the aim of patient safety and satisfaction. In this article we

would like to share the experience of setting up of an APS in a developing country, the
difficulties encountered and the nature of service provided over four and half years

period.
Methods and Results

Initially AP team comprised of two anaesthesia consultants and a resident/medical

officer. Acute pain consultants provided continuous coverage over 24 hours and spend

one session of dedicated time every week. While resident was involved in daily morning

and evening rounds on all acute pain patients and discussed with the consultant. During

the second year, on the request of APS a nurse was induced into the team.

APS realized the importance of education of health personnel involved in the care of

surgical patients. Educational methods used were lecture sessions for nurses and

residents, hands on teaching of residents and daily discussions with pain nurse and

resident who was rotating in APS. We have also designed booklets on PCA and Epidural

infusions for medical staff. Recently we have also published two booklets on PCA and

epidurals infusion for patient’s education in English and local language.

In the first year of APS pharmacy department agreed to provide premixed bags of

Bupivacaine with Fentanyl in three different concentrations, which are being infused by

using I-med Gemini PC-1 infusion pump. Patient controlled analgesia was never used

before anywhere in our country. We introduced PCA in the first year of establishing APS

and choose Graseby 3400 PCIA pumps based on the previous experience of APS

consultants during their training in UK and USA.

In the second year of service an ongoing education and training program for nurses and

residents was started to minimize the complications and improve quality of care. At the

same time regular audits and patient satisfaction surveys were initiated to identify

deficiencies in APS.
We also realized the importance of multidisciplinary nature of pain service. In order to

achieve this, nursing policies were developed in collaboration with the nursing

department. With the help of pharmacy department we managed to get premixed infusion

bags for epidural infusions in three standard concentrations of Bupivacaine 0.125%, 0.1%

and 0.0625% with Fentanyl 2 microgram/ml. Assessment and recording of pain as fifth

vital sign is recognized recently by joint commission on accreditation of healthcare

organizations. 10 Prior to APS there were no standardized prescriptions, assessment tools

and protocols for pain management on the surgical floors. We have designed assessment

and monitoring forms for PCIA and Epidural infusion, which are being utilized since

June 2002, by nursing staff in recovery room and surgical wards.

postoperative patients received pain relief treatment which was supervised by the acute

pain service. This audit was conducted on all the patients managed by acute pain service

and included postoperative surgical patients, medical consults and trauma patients.

Chronic pain patients were excluded from this audit. A proforma was developed for this

purpose which was filled by acute pain nurse in the form of monthly report and later

annual report.

Different surgical specialties covered by APS during this period included General surgery

(20%), Orthopedics (25.8%), Obstetric/gynaecology (35.2%), urology (5.9%) and

miscellaneous group (12.9%). Higher percentage of Obstetric and Gynae patients were

managed by acute pain service in the last two years period while orthopedics group was

dominant in first eighteen months.

The methods of analgesia administered during study period are shown in Table I.

Modalities of Epidural (30.2%), PCIA (17.9%) and intravenous infusions (49.8%) were

commonly used for postoperative pain management. The decrease in the use of

intravenous infusion over the years, correspond with the increase in the use of PCIA,

which gradually increased from 0.3% in 2001 to 30.7% in the year 2005.

Reported incidence of complication has increased during the last two years period

(31.2%), which was very low in first eighteen months (4.27%). Overall incidence of

nausea and vomiting was (10.4%). Further breakdown shows the higher incidence of

nausea and vomiting in I/V infusion (10.3%) and PCIA group (14.9 %) than epidural

infusion group (6.0 %). Sedation was also common in I/V infusion (8.7%) and PCA
groups (13.3%) when compared with epidural group (0.14%). None of these patient

required active management to treat sedation, which was mild and not associated with

respiratory depression. Low incidence of nausea, vomiting and hypotension as reported,

may be a considerable underestimate due to inconsistent methods in reporting.

A breakdown of epidural complication is also presented in Table II. Motor block was

noticed in 29.4% patients either unilaterally or bilaterally. Majority of these patients

responded to either change in position or by reducing the bupivacaine concentration.

For an acute pain service to function smoothly it is fundamental that nursing staff,

surgical staff, primary anesthetist and APS works as a team towards the same goal.

Several problems were noticed at the start of acute pain service, some of which were

specific to our country. It included Lack of awareness and realization of importance for

adequate pain control. In addition, there was no established APS setup in the country to

follow and absence of trained AP nurses in the country.

Due to non availability of APS in the country, we had to rely on published articles and

recommendations which were mostly from the developed countries, for the development

of APS. High incidence of technical problems during pain management and errors in

documentation were counteracted by nurse’s education. Since lack of awareness and

inexperienced hospital staff is an important associated factor, continuing programs for

nursing and anesthesia staff have been introduced to facilitate staff familiarity with new

acute pain therapy equipment and techniques. Documentation has increased during the

last two years period but the accurate assessment is still lacking particularly by ward

nurses, despite the availability of key for assessment on assessment forms, presence of

educational material on each ward and several teaching classes.

It is concluded that careful planning, dedicated team and multidisciplinary

approaches are mandatory for introduction of APS. Established APS not only

improve documentation, assessment and quality of care but also patient safety.
Acknowledgements

The authors thank Ms. Riffat Aamir (Acute Pain Nurse) for technical support in data

collection and maintenance.

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2001 2002 2003 2004 2005 Total

Modality n= (%) n= (%) n= (%) n= (%) n= (%) n= (%)

188 502 441 465 488 2048

2 58 195 363 604 1222

Intravenous 488 960 552 574 824 3398

Infusion (72%) (63%) (45%) (40%) (41.9%) (49.8%)

Para Vertebral/ 21 25 46 92
_ _
Extra Pleural (1.8%) (1.8%) (2.3%) (1.3%)

Brachial Plexus 5 1 6
_ _ _
Block (0.4%) (0.06%) (0.08%)

2 4 2 8
Caudal Infusion _ _
(0.3%) (0.3%) (0.13%) (0.11%)
 Table II. Modality and Associated Complications

Complication Epidural Intravenous Infusion PCIA

Number (%) Number (%) Number (%)

Nausea/vomiting 124 (6.0) 351 (10.3) 183 (14.9)

Sedation 03 (0.14) 297 (8.7) 163 (13.3)

Itching __ __ 3 (0.24)

Rashes __ __ 2 (0.16)

Hallucination __ __ 1 (0.08)

Combination of symptoms __ 23 (0.67) __

Hypotension 16 (0.7) 01 (0.02) __

Motor block 604 (29.4) __ __

Ineffective epidural 16 (0.7) __ __

Urinary retention 09 (0.43) __ __

Catheter migration __ __ __

Catheter pull out 77 (3.7) __ __

Kinking/leakage 11 (0.4) __ __