Acute postoperative pain (APOP) project overview
It is well documented that there are a number of benefits to be gained through the optimisation of acute postoperative pain management.[1,2] Evidence from the literature suggests that patient satisfaction with pain control is varied, and patient expectation of experiencing postoperative pain is high. Australian data indicates that a significant number of postoperative patients are still in pain after discharge, with 86% of patients reporting pain after discharge and 41% reporting moderate to severe pain. The same study demonstrated that of all the patients reporting pain post-discharge, 36% were not given any analgesia at the time of discharge.
Consultation with state Therapeutic Advisory Groups (TAG)/Drug Use Evaluation (DUE) groups and pain experts in hospitals identified that acute postoperative pain is an area of interest for many health professionals. Concerns were raised about safety and efficacy of prescribed analgesia, timing and duration of therapy and adverse effects associated with analgesics, as well as the level of communication between health professionals, both within the hospital setting and at the hospital and community interface (i.e. at discharge).
Therefore the National Prescribing Service (NPS) funded and supported a national quality improvement initiative to improve the management of acute postoperative pain in Australian hospitals through the promotion and implementation of the principles outlined in the evidence-based literature.[1,2] The project engaged the expertise of state TAG/DUE groups from New South Wales, Tasmanian, Victoria, South Australia, and Queensland.
- the recording of preoperative pain history and analgesic use
- preoperative discussion of postoperative pain management with the patient
- prescribing of safe and effective postoperative analgesia, including opioids, tramadol, selective and non-selective NSAIDs and paracetamol
- regular review of analgesic adverse effects
- and implement a standardised approach to pain assessment (measurement and frequency) for surgical patients throughout hospitalisation, including on admission, during hospital stay and at discharge/in the community
- accurate communication of analgesic order(s)/management plans at discharge into the community following surgery.
In summary, the three key areas of focus were:
- pain assessment – pre and postoperative
- analgesic prescribing – promoting safe and effective use of analgesics
- communication of a pain management plan at the point of discharge – to the patient and the general practitioner (GP).
The APOP project promoted the best available evidence and recommendations in clinical practice drawing on the Australian and New Zealand College of Anaesthetists (ANZCA) and Faculty of Pain Medicine, Acute Pain Management: Scientific Evidence second edition and the Therapeutic Guidelines: Analgesic, version 4. ANZCA and the Faculty of Pain Medicine reviewed and provided advice on all educational materials for acute postoperative pain.
A prospective inpatient medical record review was used to measure changes in preoperative patient education and pre and postoperative pain assessment, as well as documentation of pain management plans at discharge. A structured patient telephone interview and GP postal survey were conducted one week after discharge for each patient to evaluate pain management and discharge communication, before and after education.
A hospital-based education intervention used a suite of intervention tools that included academic detailing (one-on-one education sessions with hospital staff), PowerPoint feedback presentations of hospital results together with comparative aggregate state and national data, point-of-prescribing prompts (e.g. reminder bookmark) and promotional material (e.g. wall posters).
The key messages for the APOP project were:
- Optimal postoperative pain management begins in the preoperative period
- Measure pain regularly using a validated pain assessment tool
- Ensure all postoperative patients receive safe and effective analgesia
- Monitor and manage adverse events
- Communicate ongoing pain management plan to both patients and primary healthcare providers at discharge.
Multifaceted interventions within hospitals led to moderate improvements in the quality of inpatient acute postoperative pain management and patients’ pain experiences. Continued educational strategies accompanied by iterative cycles of audit and feedback are likely to sustain improvements. Results will be available after publication.
- Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute pain management: Scientific evidence. Second edition. Melbourne: ANZCA, 2005. (NOW AVAILABLE – Acute pain management: Scientific evidence. Third edition, 2010.)
- Analgesic Writing Group. Therapeutic Guidelines: Analgesic. Version 4 ed. Melbourne: Therapeutic Guidelines, 2002.
- Whelan CT, Jin L, Meltzer D. Pain and satisfaction with pain control in hospitalized medical patients: No such thing as low risk. Arch Intern Med 2004;164:175-180.
- Warfield CA, Kahn CH. Acute pain management. Programs in U.S. hospitals and experiences and attitudes among U.S. adults. Anesthesiology 1995;83:1090-4.
- Kable A, Gibberd R, Spigelman A. Complications after discharge for surgical patients. ANZ J Surg 2004;74:92-97.
- Bloom B. Effects of continuing medical education on improving physician clinical care and patient health: A review of systematic reviews. International Journal of Technology Assessment in Health Care. 2005;21:380-85.