| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
From the Department of Anesthesiology, Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada.
Address correspondence to: Dr. David H. Goldstein, Department of Anesthesiology, Kingston General Hospital, 76 Stuart St., Kingston Ontario K7L 2V7, Canada. Phone: 613-549-6666, ext. 3399; Fax: 613-548-1375; E-mail: goldsted{at}kgh.kari.net
 |
Abstract |
|---|
 TOP Abstract IntroductionMethodsResultsDiscussionConclusionReferences |
|---|
Methods: Between June 2000 and January 2001, 62 Canadian hospitals affiliated with the 16 Canadian university anesthesiology departments were sent a postal questionnaire.
Results: Fifty of the 62 respondents returned a completed questionnaire representing a response rate of 81%. Eighty percent of the hospitals surveyed had at least 200 beds, 90% (45) had implemented an APMS. Anesthesiology was primarily responsible in all 45 hospitals with an APMS. The results presented are based on the 45 centres with an APMS.
Conclusion: Since the early 1990s the percent of Canadian academic hospitals with an APMS has increased from 53% to 92%. These figures are comparable to the United States. Greater collaboration from nursing and pharmacy, mandatory training for medical and nursing students and residents, and a standardized approach to continuous quality improvement remain necessary.
|
Introduction |
|---|
|
TOPAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
|
Methods |
|---|
|
TOPAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
|
Results |
|---|
|
TOPAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
Anesthesiology was primarily responsible for the APMS in all 45 hospitals. Approximately 18% of APMSs were initiated between 1995 to 2000 and 49% had over 20 patients per day on the service. Forty percent had an APMS committee in place and in 89% of centres the committee was multidisciplinary. The structure of the APMS clinical team consisted of an anesthesiologist (100%), a designated nurse (56%) and a designated pharmacist (33%). Additional demographic and staffing details (Table I) are presented as Additional Material at www.cja-jca.org.
Consultation requests to the APMS in the perioperative period were made by the operating room anesthesiologist in consultation with the surgeon in 96% of hospitals. Patients with epidurals were admitted to the ward in 98% of hospitals and critical care areas in 82% of hospitals. The average length of stay on the APMS was greater than 48 hr in the majority of hospitals. Additional details regarding operational aspects of an APMS (Table II) are available as Additional Material at www.cja-jca.org.
All 45 centres prescribed morphine via iv patient controlled analgesia (IVPCA). Ninety-six percent of centres provided continuous epidural infusions, 80% used single shot blocks, and 73% provided continuous infusion nerve blocks. Additional information regarding analgesic types and modes of delivery (Table III) are available as Additional Material at www.cja-jca.org.
Transitional analgesia refers to the initiation of oral analgesics in an effort to acquire therapeutic serum levels prior to discontinuing an existing modality. Co-analgesia refers to the use of a non-steroidal anti-inflammatory drug (NSAID) or acetaminophen with an IVPCA, epidural opiates or a peripheral block to minimize the dose and side effects of opiates. Over half of the centres provided NSAIDs as the primary transitional and co-analgesic. Naproxen, ketoralac and indomethacin were the primary NSAIDs used. Ketaprofen was used in only five (11%) centres. Additional responses to questions related to the use of transitional and co-analgesia (Table IV) are presented as Additional Material at www.cja-jca.org.
Thirty-two percent of centres provided formal education in the management of acute pain to anesthesiology residents and 60% provided formal education to medical students (Table V, available as Additional Material at www.cja-jca.org). Of the 14 centres with residency education in acute pain only half had a formal curriculum with written goals and objectives, and an assessment process.
Sixty percent of centres used specific APMS data collection tools for charting, while 29% had data available in an electronic format. Seventy-five percent reported collecting data on pain scores using the visual analogue scale and at least 80% reported collecting data on sedation, nausea, vomiting, pruritus, sensory and motor block, and hypotension. Twenty-nine percent reported having ongoing data collection for the purposes of an APMS outcomes database. Additional details regarding data management (Table VI) are available as Additional Material at www.cja-jca.org).
|
Discussion |
|---|
|
TOPAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
Given the findings of this survey, it appears that Canadian academic hospitals have made varying attempts to achieve Ready’s four goals when developing and implementing an APMS.1 The following section will review the progress of Canadian academic APMSs with respect to these four goals.
1) To improve postoperative analgesia
Ninety percent of Canadian academic hospitals have implemented an APMS. This is up from 53% in 1993.8 These figures are comparable to the United States10 and possibly higher than the United Kingdom, where 44% of non-academic hospitals had an APMS in 1995.11 Consistent with Zimmerman’s findings,8 the average number of patients on the APMS exceeded 20 per day and in 65% of centres the length of stay on the APMS was greater than 48 hr. Success of an APMS is dependent upon a multidisciplinary clinical team.1,2 While anesthesiology was involved in all centres, much lower representation was reported for nursing (55%) and pharmacy (33%). These findings are only slightly higher than those reported by Zimmerman in 1993.8 Growing clinical demands and reduced numbers12,13 of anesthesiologists may explain why anesthesiology providing sole coverage to the APMS has decreased from 36% in 19939 to 22% in 2001. The literature suggests that a designated group of anesthesiologists will contribute to continuity of care while providing input into policies, procedures, continuous quality improvement initiatives and the advancement of APMS research,11,14,15 yet in this study only 44% of centres reported having a designated group of APMS physicians. Issues related to the importance of appropriate and adequate nursing involvement on the APMS team have been addressed in recent publications.16,17 Consistent with the literature, only one-third of centres had pharmacy represented on the clinical team.8 In spite of increasing numbers of centres with an APMS and mandates by professional organizations,18,19 there is still a lack of resources to treat pain adequately. However, resources may be more effectively utilized in treating acute pain in the perioperative setting than managing chronic postsurgical pain in the future.20
2) To apply and advance new analgesic methods
Our study found IVPCA, epidural analgesia and peripheral nerve blocks to be the mainstays of therapy on the wards. Baker,21 Rawal22 and Klein23 report a trend towards discharging patients with indwelling nerve block catheters. These initiatives along with improved management of postoperative pain in hospitals may address the high rates of moderate to severe pain being reported by patients after discharge from hospital24,25 and may ultimately facilitate earlier discharge from hospital and reduce readmission rates in both postsurgical and palliative patients.
The use of transitional and co-analgesia has been shown to improve pain scores, reduce side effects and facilitate ambulation,26,27 however fewer than two-thirds of centres reported prescribing transitional analgesia when weaning patients from IVPCA, epidurals or peripheral blocks.
3) To train anesthesiology residents
The findings of this study support the need for a more comprehensive, formalized approach to the preparation of anesthesiologists regarding the management of postoperative pain. This initiative should be targeted at both the undergraduate and postgraduate level. In addition, currently in Canada there are only approximately 18 training fellowships in acute pain or regional anesthesia offered per year28 and the exact number of practicing Canadian anesthesiologists with fellowship training in these specialties is unknown.
4) To carry out clinical research
Access to well defined, consensus based data is a prerequisite to research and continuous quality improvement in the management of acute pain,2,29,30 yet only 29% of centres reported having an ongoing prospective data collection system. Pain and side effect indices are collected in varying degrees among the centres, and only a minority collect information on the treatment and success of treatment of side effect therapy.
Data are essential for the development of a strategy for the clinical management of APMSs in both academic and community hospitals.2,15,31 Having prospective consensus based data available in an electronic format would improve access to data at the point-of-care for clinical purposes, while allowing for easy access to data for the purposes of audit, research and administrative reports.
A major weakness of this study is the limited ability to apply the results to a broader population. Only academic institutions with an APMS were included in the study and therefore results cannot be generalized to all Canadian hospitals. In addition, no information was obtained about the management of acute pain in patients not followed by an APMS, which represents the vast majority of postoperative patients. Twenty percent (n = 12) of academic institutions did not respond to the survey. If non-responders were less likely to have an APMS in place than responding institutions, than the proportion of academic centres with an APMS may be as low as 73%. Recall bias is an inherent weakness of survey research. Respondents were asked to report on aspects of the APMS not directly related to anesthesiology (e.g., nursing and pharmacy), therefore results should be interpreted with caution as perceptions and responses to these questions may differ from those of other health care professions, educators and administrators.
Strengths of the study include the comprehensiveness of the questionnaire, which provides a snapshot of the current status of APMSs in Canadian academic centres. An additional strength of the study is its ability to identify centres with an APMS thereby providing necessary information to aid in the development of a national acute pain network.16
|
Conclusion |
|---|
|
TOPAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
|
Acknowledgments |
|---|
|
Footnotes |
|---|
Accepted for publication May 12, 2003. Revision accepted November 14, 2003.
|
References |
|---|
|
TOPAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
2 Ready LB. Acute pain services: an academic asset. Clin J Pain 1989; 5(Suppl 1): S28–33.
3 Canadian Anesthesiologists’ Society. Consensus-Based Guidelines for Acute Pain Management using Neuraxial Analgesia, 2000. Available from: URL: http://www.cas.ca/guidelines/neuraxial.asp.
4 Anonymous. Practice guidelines for acute pain management in the perioperative setting. A report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology 1995; 82: 1071–81.[Medline]
5 U.S. Department of Health and Human Services. Acute pain management in adults: operative procedures, AHCPR Pub. No. 92-0019. 1992. Rockville, MD, Agency for Health Care Policy and Research.
6 Australia National Health and Medical Research Counsel. Acute Pain Management: Scientific Evidence. Canberra: Ampersand Editorial Design; 1998.
7 Carr DB. Pain Control: the New "Whys" and "Hows". Seattle: International Association for the Study of Pain; Report No.: 1. 1993; 1–5.
8 Zimmermann DL, Stewart J. Postoperative pain management and acute pain service activity in Canada. Can J Anaesth 1993; 40: 568–75.
9 Ashburn MA. Anesthesia-based acute pain services: past, present, and future. Problems in Anesthesia 1998; 10: 1–7.
10 Ready LB. How many acute pain services are there in the United States, and who is managing patient-controlled analgesia? (Letter). Anesthesiology 1995; 82: 322.[Medline]
11 Harmer M, Davies KA, Lunn JN. A survey of acute pain services in the United Kingdom (Letter). BMJ 1995; 311: 360–1.
12 Byrick RJ, Craig D, Carli F. A physician workforce planning model applied to Canadian anesthesiology: assessment of needs. Can J Anesth 2002; 49: 663–70.
13 Byrick R, Craig D, Carli F. A physician workforce planning model applied to Canadian anesthesiology: planning the future supply of anesthesiologists. Can J Anesth 2002; 49: 671–7.
14 Rawal N, Allvin R. Acute pain services in Europe: a 17-nation survey of 105 hospitals. The EuroPain acute pain working party. Eur J Anaesthesiol 1998; 15: 354–63.[Medline]
15 Rawal N. Organization of acute pain services–a low-cost model. Acta Anaesthesiol Scand 1997; 111: 188–90.
16 VanDenKerkhof EG, Goldstein DH, Wilson R. A survey of directors of Canadian academic acute pain management services: the nursing team members role - a brief report. Can J Anesth 2002; 49: 579–82.
17 Musclow SL, Sawhney M, Watt-Watson J. The emerging role of advanced nursing practice in acute pain management throughout Canada. Clin Nurse Spec 2002; 16: 63–7.[Medline]
18 Canadian Pain Society. Patient Pain Manifesto. Canadian Pain Society. 2001. URL: http://www.canadianpainsociety.ca/cont-ang/4nouvelles-manifeste.htm.
19 Registered Nurses’ Association of Ontario. Assessment and Management of Pain. RNAO. 2003. URL: http://www.mao.org/bestpractices/PDF/BPG_Assessment_of_Pain.pdf.
20 Macrae WA, Davies HT. Chronic postsurgical pain. In: Crombie IK (Ed.). Epidemiology of Pain. Seattle: IASP Press; 1999: 125–42.
21 Baker CJ, Rennie W, Brown R, Kenny S. Home plexus catheters after major limb surgery. Can J Anesth 2003; 50: A20 (abstract).
22 Rawal N, Allvin R, Axelsson K, et al. Patient-controlled regional analgesia (PCRA) at home. Controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia. Anesthesiology 2002; 96: 1290–6.[Medline]
23 Klein SM. Beyond the hospital: continuous peripheral nerve blocks at home (Editorial). Anesthesiology 2002; 96: 1283–5.[Medline]
24 Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery 1997; 85: 986. Anesth Analg 1997; 85: 808–16; Erratum 1997; 85: 986.[Abstract]
25 Collins M, MacDonald V. Managing postoperative pain at home. Canadian Nurse 2000; 96: 26–9.
26 Katz J, Clairoux M, Redahan C, et al. High dose alfentanil pre-empts pain after abdominal hysterectomy. Pain 1996; 68: 109–18.[Medline]
27 Kehlet H, Dahl JB. The value of "multimodal" or "balanced analgesia" in postoperative pain treatment. Anesth Analg 1993; 77: 1048–56.
28 Association of Canadian University Departments of Anesthesia. Postgraduate Fellowships in Anesthesia. Can J Anesth 2001; 48: xxxvi–vii.
29 Goldstein DH, VanDenKerkhof EG, Rimmer MJ. A model for real time information at the patient’s side using portable computers on an acute pain service. Can J Anesth 2002; 49: 749–54.
30 Rawal N. 10 years of acute pain services–achievements and challenges. Reg Anesth Pain Med 1999; 24: 68–73.[Medline]
31 Goldstein DH, VanDenKerkhof EG, Sherlock R, Sherlock J, Harper S. How an audit of epidural patients in a community hospital setting resulted in the development of a formal acute pain management service. Pain Res Manage 2001; 6: 16–20.
This article has been cited by other articles:
 |
|
 |
|
  A. Sinha and K. Brecht 44610 - ACUTE PAIN MANAGEMENT SERVICE (APMS) IN-HOUSE CLINICAL LIST - IF YOU HAVEN'T GOT A DATABASE YET Can J Anesth, August 1, 2007; 54(suppl_1): 44610 - 44610. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Beaulieu Non-opioid strategies for acute pain management Can J Anesth, June 1, 2007; 54(6): 481 - 485. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
