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Management of perioperative pain in hospitalized patients: A national survey
ELSEVIER
SPecial
Article
Management of Perioperative Pain in Hospitalized Patients: A National Survey Daniel B. Carr, MD,* Christine Miaskowski, RN, PhD,? Stephen C. Dedrick, RPh, MS,1 G. Rhys Williams, MS5 Department of Anesthesia, New England Medical Center and Tufts University School of Medicine, Boston, MA; Department of Physiological Nursing, University of California, San Francisco, CA, Department of Pharmacy, Duke University, Durham, NC; Janssen Research Foundation, Titusville, NJ
“Saltonstall Professor of Pain Research and Professor of Anesthesia, Tufts University School of Medicine tprofessor and Chairman, Department of Physiological Nursing, University of California, San Francisco IAssociate Director, Department macy, Duke University Hospital $4ssistant Director, Janssen Foundation
Outcomes
of PharResearch,
data on current practices of A survey was carried out to provide “benchmark” in-hospital perioperative pain management. The 59-item survey questionnaire incorporated all key points contained in the Agency for Health Care Policy and Research and the American Society of Anesthesiologists published guidelines concerning institutional policies as well as practice patterns. The questionnaire was mailed to designated pain specialists in a sample of 400 hospitals that were systematically stratified by bed size and geographic region. Of the 400 questionnaires mailed, 223 (56%) were returned. Of the 223 respondents, 85% were board-certified anesthesiologists. There was good to excellent overall adherence to most of the guideline recommendations; significant exceptions were the infrequent use of nonpharmacologic techniques for pain control and the relatively high frequency of intramuscular opioid use. In general, large hospitals have a greater adherence to the recommendations of the guidelines than do smaller hospitals. No noteworthy variations in institutional policies or practice patterns were evident. These results provide comprehensive baseline data against which future developments in the field of perioperative pain management can be assessed. 0 1998 by Elsevier Science Inc.
Address correspondence to Dr. Carr at the Department of Anesthesia, Tufts University School of Medicine, 750 Washington St., NEMC #298, Boston, MA 02111, USA.
Keywords: Analgesia:
Supported by a grant from Janssen Research Foundation, Titusville, NJ. The survey was carried out by Winters Associates, Inc., Mendham, NJ.
Introduction
Received for publication April 11, 1997; revised manuscript accepted for publication September 4, 1997.
management:
epidural, nonpharmacologic,
opioid, patient-controlled, perioperative; pain management guidelines.
pain
Changes occurring in the delivery of health care and the responses by governmental agencies and by professional groups have prompted the development of clinical practice guidelines designed to enhance patient outcomes. It is clear that efficient management of perioperative analgesic requirements can improve patients’ outcomes as well as their quality of life. Because the most influential practice guidelines have appeared during a time when practice patterns were
Journal of Clinical Anesthesia 10:77-85, 1998 0 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
095%8180/98,‘$19.00 PI1 SO952-8180(97)00227-4
Special Article
evolving rapidly, it has not been possible to assess the specific impact of any particular guideline recommendation on the management of perioperative pain. Nonetheless, the definition of “benchmark survey data” focusing on current perioperative pain management provides a starting point for future systematic trials and interventions. This report summarizes the results of a large, comprehensive survey of current practice patterns in the management of acute perioperative pain in hospitalized patients. The survey assessed the degree of compliance with specific recommendations that were made in two published guidelines for the management of postoperative pain: (1) the 1992 Clinical Practice Guideline Report of the Agency for Health Care Policy and Research (AHCPR) on Acute Pain Management’ and (2) the 1995 Practice Guidelines for Acute Pain Management in the Perioperative Setting of the Task Force on Pain Management of the American Society of Anesthesiologists.’ Both sets of guidelines were developed by expert panels, and both made a number of similar recommendations. These recommendations formed the basis for the development of the survey instrument used in the present study. During the completion of this survey, the American Pain Society3 issued a guideline on the management of acute or cancer-related pain, and it also made similar recommendations. Although each of these guidelines dealt with other more specific issues, such as postoperative pain management in pediatric, geriatric, and ambulatory surgery patients, and the use of regional anesthesia techniques and others, these issues were excluded from the present study in order to make our survey instrument more targeted. Our survey addressed the following areas: (1) general institutional issues (e.g., development of formal policies for perioperative pain management, establishment of a pain service, establishment of quality improvement programs); (2) the specialized training of the personnel involved in the management of patients with acute perioperative pain; (3) the use of advanced planning as part of perioperative pain control programs; (4) the education and training of the patient; (5) the analgesia-anesthesia programs used in the intraoperative period and in the postanesthesia care unit (PACU); (6) the types of analgesic programs used in the postoperative period; (7) the monitoring, assessment, and documentation of postoperative pain and its relief; (8) trends in postoperative pain management and related reimbursement issues; (9) the use of nonpharmacologic measures for the relief of postoperative pain; and (10) the methods used to monitor patient satisfaction. Respondents were also asked for a self-assessment of the overall quality of perioperative pain management in their respective institutions.
Materials and Methods Development of the Sample The sample was designed to accurately represent acute, nonfederal hospitals with respect to the frequency of surgical procedures performed, the size of the hospital, 78
J. Clin.
Anesth.,
vol.
10, February
1998
and its geographic location. A sample size of 400 was selected in order to achieve an expected response rate of 250, a number that represents approximately 5% of all acute care hospitals in the United States. Using this baseline figure, the number of surgical procedures performed by hospitals of varying bed size and geographic location was determined using data published by the American Hospital Association (AHA) for six separate bed size categories over the nine U.S. Census Regions. Although these figures include both outpatient and inpatient operations, we assumed that the ratio of inpatient procedures to outpatient procedures would be constant throughout the sample. The sample design is illustrated by the following example. Of the nearly 24 million operations performed by all hospitals nationwide during 1994, approximately 2.4 million were performed in hospitals having fewer than 100 beds; furthermore, 134,662 operations, corresponding to 0.56% of the total, were performed in hospitals of this size that are located in U.S. Census Region 1. Thus, two hospitals (i.e., 0.56% of 400 rounded) of this size within this geographic region were selected for the sample. A similar approach was used for hospitals in the nine U.S. Census Regions and the six AHA bed-size groups, viz., less than 100 beds, 100 to 199 beds, 200 to 299 beds, 300 to 399 beds, 400 to 499 beds, and more than 500 beds. Once the number of representative hospitals to be polled in each bed-size group and in each geographic region was determined, the individual institutions were selected at random from the American Hospital Association Guide.’
Identification of Key Physicians The individual physician most responsible for the perioperative pain management program in each of the 400 targeted hospitals was identified by telephone contact with each hospital’s anesthesiology department and the PACU.
Development of the Suruey Qustionnaire An initial test version of the survey questionnaire was drafted by a panel of experts and mailed to 39 physicians selected as outlined above; the questionnaires were mailed via USPS Priority Mail, with an offer of a $100 honorarium and an assurance of confidentiality. Of the 39 questionnaires mailed, 23 responses (59%) were received. A revised survey instrument consisting of 59 questions was then mailed in a similar fashion to the 400 designated physicians in the targeted sample hospitals; four were returned “addressee unknown” and 223 (56%) were returned complete. The data on the various subgroups were consolidated as follows: (1) by bed size into three groups (i.e., less than 200 beds, 200 to 399 beds, and greater than 400 beds) and (2) by geographic groups [i.e., East (U.S. Census Regions 1 and 2)) South (Regions 3 & 5)) Midwest (Regions 4 SC6)) and Far West (Regions 7, S, and 9)].
Survey
Table
Number of Questionnaires
1.
~200 Bed Size
No.
Region: East South Midwest Far West Totals
Sent
19
No.
Sent
No.
Returned
No.
Returned
Sent
Returned
13 12 21 16
85 99 102
47 39 68
42
33 34 33 25
110
69
122
83
149
78
125
62
396
The responses to each question were summarized by subgroups. Because of the exploratory nature of this survey involving a large number of questions, the results of which were broken down by hospital size and by geographic location, and because no prior hypotheses were stipulated, no statistical tests of significance were performed, and no p-values are reported. Rather, the data for the various subgroups are presented in terms of their 95% confidence intervals, calculated by the normal approximation to the binomial theorem. These results, therefore, represent purely descriptive “benchmark data.” of Responses
Table1 shows the number of responses received compared with the number of questionnaires sent. The data are divided by bed size group and by geographic region. Total response rates (i.e., encompassing all hospitals regardless of size in any one geographic area) of 55% or more were seen in the East, Midwest, and Far West, but responses from the hospitals in the South averaged only 39%. Smaller hospitals (those with less than 200 beds) had a response rate of 68%, while those in the 200 to 399 bed size range had a 52% response rate, and for those with over 400 beds, the rate was 50%. Results of
Sent
16 16 21 25
Data Reduction and Analysis
Profile
No.
33 35 38 43
31
Respondents
Of the 223 respondents, 189 (85%) self-reported certification by the American Board of Anesthesiology (Table 2). Respondents from hospitals having fewer than 200 beds were less frequently certified (74%) than those from the two other groups (90% and 94%, respectively). There were no differences between the geographic groups in the certification of respondents ( Table2).
Pain Service and Pain
Carr
et al.
Totals
Beds
18 11 26 28
30
Distribution
>400
200 to 399 Beds
Returned
management:
Sent and Number Returned
Beds No.
pain
of pwioperatiue
Committee
Of the 223 respondents, 140 (63%) indicated that their institution had an organized pain management service or pain team (Table2). There appears to be a difference with respect to bed size, in that 38% of hospitals with fewer
223
Total Responses
(%)
55% 39% 67% 63% 56%
than 200 beds have a pain service compared with ‘74% and 84% of the hospitals in the two larger bed size categories. A formal pain management service or team is more prevalent in hospitals in the East (84%) than in other regions of the country, which varied from 55% to 61%. Only 29% of all respondents indicated that their institutions have a formal pain management committee, with 15% in the smaller hospitals and 36% and 40% in the intermediate and larger groups; there is no evident variation in geographic region. The survey queried the nonmutually exclusive sources that have influenced the pain management practices of the respondents. The standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) influenced 40% of respondents, while somewhat smaller percentages were assigned to effects of the AHCPR (35%) and the ASA guidelines (33%).
Education
of
Personnel
Seventy-seven percent of respondents indicated that the personnel involved in the management of acute postoperative pain receive special education, with no obvious differences with respect to bed size or geographic location (Table 2). The principal groups who receive such education are surgical staff nurses (85%) and obstetric-gynecologic staff nurses (50%). Pharmacists and house officers receive education in fewer than 15% of the institutions surveyed. Over 60% of the respondents indicated that in-house educational sessions are given less than twice a year, while 16% indicated that such sessions are given two to four times per year, and 22% indicated a frequency of four or more such sessions per year. Over 80% of respondents indicated that the main topics of the training sessions are pain assessment and techniques of epidural intravenous patient-controlled analgesia (IV PCA) administration, with lesser percentages devoted to the topics of IV opioids, use of nonsteroidal anti-inflammatory drugs (NSAIDs) , and nonpharmacologic pain management techniques. Manufacturers of PCA pumps provide formal training sessions for the use of pumps in 68% of hospitals surveyed, but they offer formal general education in pain management in only 12% of the hospitals (Table 2). J. Clin. Anesth., vol.
10,
February 1998
79
Special Article Table
2.
Institutional
Considerations
Consideration Grand
Geographic
Total
of Responses
Is respondent
respondent’s
47 41 (87%)
(%) institution
No. of responses No. of “yes” answers 95% CI Does
institution
No. of responses No. of “yes” answers 95% CI
(%)
institution
No. of responses No. of “yes” answers 95% CI
(%)
Do pump
No.
offer
Does
(%)
manufacturers
offer
responses of “yes” answers respondent’s
(%)* institution
No. of responses No. of “yes” answers 95% CI *95%
confidence
Quality
(%)
interval
Improvement
a pain
Midwest,
Far West,
69
<200,
83
Bed Size
Total
200 to 400, 78
>400,
62
223
have
39 26 (67%) (48,78%)
a pain
offer
pain
62 22 (36%) (24,48%)
management
education
40 30 (75%) (64,86%)
68 49 (72%) (61,83%)
(CI)
24 fit%) (52,82%)
25 17 (68%) (50,86%)
training
on general
2 (7%) 28
4 (17%) 26
have
a QI program
Preoperative
Practice
pumps
Anesth.,
29 ;A%) (53,81%) pain
management
3 (12%) 26 for postoperative
g%) 25 (41,71%)
33 13 (39%) (22,56%)
too wide
to be meaningful.
61 26 (43%) (31,55%)
Issues
1998
189 161 (85%)
60 32 (55%) (39,65%)
83 33 (38%) (28,48%)
78 58 (74%) (64,84%)
58 49 (84%) (76,92%)
223 140 (63%) (57,69%)
56 14 (25%) (14,36%)
76 11 (15%) (7,23%)
68 24 (36%) (25,47%)
21 ;iY,, (27,53%)
197 57 (29%) (23,35%)
83 62 (71%) (61,81%)
78 39 (76%) (66,86%)
58 51 (88%) (81,95%)
223 172 (77%) 71,83%
60 41 (68%) (56,80%)
49 30 (61%) (47,75%)
40 31 (78%) (65,91%)
149 101 (68%) 61,75%
5 (:;a)
30 5 (17%)
109 13 (12%)
49 30 (61%) (47,75%)
194 85 (44%) (37,51%)
of personnel?
50 E%) (74,92%) institution?
45 32 (71%) (58,84%) in respondent’s
3 (12%) 29 pain
institution?
3 (9%) 33
management?
55 21 (38%) (25,51%)
IV PCA = intravenous
Programs
vol. 10, February
58 55 (94%)
in respondent’s
The survey evaluated a number of preoperative practice issues that are presented in all acute pain guidelines. The first of these is the frequency with which an individualized pain management plan is developed during the preoperative period for those patients likely to have moderate or severe pain in the postoperative period. Almost half of the respondents indicated that such planning is done “freJ. Clin.
69 62 (90%)
committee?
33 10 (30%) (14,46%)
on IV PC4
62 46 (74%)
68 42 (62%) (42,69%)
management
training
47 37 (78%)
team?
Quality improvement (QI) programs for the evaluation of perioperative pain management are recognized as an important feature of good current pain management practice. An average of 44% of the respondents’ institutions have such evaluative programs in place, although only 33% of the smaller hospitals have such programs, compared with 61% of the larger ones. No differences with respect to geographic region are evident (Table 2).
80
68
59 51 (87%)
service/pain
43 15758%) (67,89%)
manufacturers
No. of responses No. of “yes” answers 95% CI
have
10 E%) (10,34%)
respondent’s
Do pump
39
35 31 (88%)
47 40 (84%) (74,94%)
(%)
respondent’s
Does
South,
Hospital
board-certified?
No. of responses No. of “yes” answers Does
East, 47
Location
76 25 (33%) (22,440/o)
69 30 (43%) (31,55%)
patient-controlled
analgesia;
QI = quality
improvement.
quently” or “nearly always” (see Table 3for definitions and data). The average frequency of such planning is lower in the smallest hospital group (41%) compared with the two larger groups (50% and 54%, respectively). In addition, such planning is more frequently done in the East (56%) and Midwest (54%) than in hospitals in the South (43%) and Far West (38%). Educating the patient as to the details of a perioperative pain management program is most often (86%) given by the anesthesiologist, followed by the surgeon (41%), and/or the staff nurse (42%). Because most of the survey respondents were anesthesiologists, these results may be somewhat biased. In addition to discussions with the patient, 41% of respondents use text and visual materials, and cific technique(s)
49% to
perform demonstrations be used. Audio or
used by 26%, and the hospital 19% of respondents postoperative pain
to provide management.
television patient
of video
the tapes
speare
system is used by education
about
Survey
Table
3.
Preoperative
of perioperaliue
pain
management:
Cam et al.
Considerations Geographic East
Consideration
south
Percent of the time that a postoperative No. of Responses Percent of the time 95% CI
47 56%
Percent of the time that anesthesiologist No. responses Anesthesiologist 95% CI Surgeon 95% CI
47 74%
(67,81%) 19% (12,26%)
Midwest
Far West
pain control plan is made preoperatively: 53 54% (45,63%)
34 43% (33,53%)
(4765%)
Hospital
Location
54 38% (28,47%)
or surgeon makes intraoperative 39 72% (63,810/o)
18%
(1125%)
63 73% (66,80%) 22%
54 79% (73,X5%) 17%
(15,29%)
(I&24%)
x200
Bed
200to
“frequently” 68 41% (33,490/o)
Size >400
400
Grand Total
or “nearly always”*: 66 50%
56 54%
(42,58%)
(46,62%)
71 77% (71,83%) 21%
54 75% (68,82%)
(13,29%)
(12,26%)
190 48% (43,53%)
anesthesia decision: 78 73% (67,79%) 18% (14,22%)
19%
203 75%
(71,79%) 19% (15,23%/o)
CT = confidence interval. Intruoperative
and PACU
Periods
Specific decisions as to the choice of intraoperative anesthesia are made primarily by the anesthesiologist (75%), while the surgeon makes this decision in 19% of cases; in 6%, the decision is made jointly by surgeon and anesthesiologist. No obvious differences with respect to hospital size or geographic location were noted (Tuble 3). In the PACU, the decision as to the type of analgesia is made by the anesthesiologist 81% of the time and by the surgeon only 16% of the time. Data on the various analgesic programs used in the PACU are presented in Table
4.
Postanesthesia Care Unit (PACU) Considerations Geographic
Consideration
East
No. responses Anesthesiologist Surgeon How often are No. responses IV Opioids % of the time 95% CI IVPCA % of the time 95% CI Epidural % of the time 95% CI
46 83%
CT
Hospital
Midwest
Far West
c200
Bed
Size
200 to 400
>400
Grand Total
or surgeon makes the PACU analgesia decision:
34 93% 8%
9%
57 80% 18%
50 75% 25%
73 84% 24%
63 86% 12%
51 73%
10%
81% 16%
39
39
50
43
38
131
54%
187
used in PACU pain management? 29
24
59% (47,71%)
(59,75%)
22% (14,30%)
(12,26%)
18% (13,23%)
(11,17%)
How often is intraoperative % of the time
Location
South
Percent of the time that the anesthesiologist
95%
Table 4. IV opioids are used by 55% of respondents; an additional average of 7% use only intramuscular (IM) opioids. IV PCA is used by 21%, and continuation of intraoperative epidural analgesia occurs in 16%. If epidural analgesia is started preoperatively, it is continued “frequently” or “nearly always” in both the PAW and in the postoperative period by 65% of respondents (Table 4). There are no differences with respect to geographic region, although in the smallest bed size group, continuing epidural occurs less frequently (55%) than in the intermediate and large hospital groups (70% and 73%, respectively).
66% (58,74%)
67%
19%
14%
epidural
55% (45,65%)
68% (59,77%)
27% (19,35%)
(11,25%)
18%
65%
22%
(15,29%)
14%
(1323%)
anesthesia continued
(5674%)
18%
69% (61,770/o)
(11,17%) in the PACU?
65% (58,72%)
IV = intravenous; CI = confidence interval; PCA = patient-controlled
64% (56,72%)
(7,?%)
55% (48,62%)
60%
(51,69%)
(44&X%)
55% (50,60%)
20% (14,26%)
23% (16,30%)
21% (17,25%)
20%
(1624%)
23% (18,28%)
16% (14,18%)
70% (64,76%)
73% (67,79%)
65% (61,69%)
analgesia. J. Clin. Anesth.,
vol.
10, February 1998
81
Table
Postoperative Considerations
5.
Geographic Consideration
East
South
Percent of the time that the anesthesiologist No. responses Anesthesiologist 95% CI Surgeon 95% CI
47 55% (45,65%)
39% (29,49%)
No. For For For For For For
of responses IV PCA epidural IV opioids IM opioids parenteral NSAIDs oral NSAIDs
Midwest
Hospital Far West
or surgeon makes the postoperative
34 52% (41,63%) 36% (24,48%)
Percentage of the time that anesthesiologist
Location
57 37% (29,45%) 49% (41,57%)
51 50% (40,60%) 52% (42,620/o)
writes various postoperative
Bed Size
200 to 400
s-400
Grand Total
51
189
analgesia decision: 74 50% (43,57%) 45% (37,53%)
64 43% (35,51%) 47% (37,57%)
(42,60%) 42% (32,52%)
51%
48% (43,53%) 45% (40,50%)
analgesic orders:
47 36%
39 40%
61 24%
65 14%
75 24%
77 28%
60 31%
100%
97%
97%
100%
96%
100%
100%
99%
46%
39% 6% 31% 6%
29% 2% 29% 2%
16% 2% 12% 2%
35% 4% 22% 4%
29%
30% 2% 35% 5%
31% 3% 29% 3%
6% 44% 6%
CI = confidence interval; IV PCA = intravenous patient-controlled drugs.
Posto@rative Decision-Making The specific type of postoperative analgesic program to be used is selected by the anesthesiologist 48% of the time, with no noticeable differences with respect to hospital size group. However, a lower percentage (37%) is seen in Midwestern hospitals than in those in other regions of the country, which ranged from 50% to 55% (Table 5). The surgeon makes this decision in 45% of the cases surveyed, with no evident differences occurring between various bed size or geographic groups. The physician who writes orders for analgesia varies according to the pain management modality being used. If IV PC4 is to be used, the anesthesiologist writes the orders in 27% of cases, while if epidural analgesia is to be used, he or she writes the orders in virtually all cases. The anesthesiologist writes 31% of the orders for IV opioids, but only 3% of the IM opioid orders. If parenteral or oral NSAIDs are used, the percentages of orders written by the anesthesiologist are 29% and 3%, respectively. In all of the above instances, those orders not written by the anesthesiologist are written by the surgeon. The use of preprinted orders for postoperative pain management programs is nearly universal in all hospitals (97%).
1% 31%
1%
analgesia; IM = intramuscular; NSAIDs = nonsteroidal
189 27%
antiinflammatory
The use of a numeric rating scale to assess the degree of postoperative pain is widely recommended, and 72% of respondents indicate that their institutions have implemented such a practice. However, patient complaints are used to assess pain “very frequently” in 70% of the cases, while the numeric pain scale is used “very frequently” in only 40% of the cases (Fig-ure 1). The percentages of respondents using other possible indicators of pain or analgesia, such as physical signs, the number of PCA boluses used, and number of IM opioid doses given, are depicted in Fig-ure 1.
Nonphawnacologic Techniques The use of nonpharmacologic techniques for managing postoperative pain was repeatedly stressed in the published guidelines. However, in this survey, measures such as relaxation, guided imagery, hypnosis, and transcutaneous electrical nerve stimulation (TENS) are used by less than 5% of respondents. Patient education was cited by 52% as a nonpharmacologic method for managing postoperative pain.
Postoperative Pain Relief Documentation PostoperativePain Therapy Regimens used for patients with moderate or severe postoperative pain vary according to specific therapy, but not with hospital size and/or geographic region (Table 6). IV PCA is used by 29% and epidural by 15% of respondents. Opioids, given IV or IM, account for an additional 15% and 19% of postoperative pain therapy, respectively, while parenteral and oral NSAIDs are used by 13% and 9%, respectively. There are no differences in these practice patterns with respect to either hospital bed size or location. 82
J.
Gin. Anesth., vol. 10, February 1998
Pain therapy and pain relief are documented in the nurse’s notes in 85% of respondents, and 50% stated that documentation is noted in the physician’s notes. A pain management flowsheet is used by 39% of respondents, while therapy records, graphic sheets, and pain team notes are used less than 30% of the time. Pain intensity is assessed by staff nurses on the day of operation on an average (i SD) of 9.0 2 5.2 times with epidural analgesia, 7.6 ? 4.7 times with IV PCA, and 6.8 * 4.4 times with IV or IM opioids. On the first postoperative day, the comparable figures are 7.6 t 4.7 for epidural
Surv~
Table
6.
Postoperative
Pain
Consideration often
East is each
No. responses IVPCA Percent of the 95% CI Epidural Percent of the 95% CI IV opioids Percent of the 95% CI IM Opioids Percent of the 95% CI Parenteral NSAIDs Percent of the 95% CI Oral NSAIDs Percent of the 95% CI IV PCA drugs.
SO&b
of the following
therapies
used
Hospital
Location Midwest
Far West
in postoperative
et
200 to 400
>400
Grand Total
pain management?
61
65
75
77
60
212
time
24% (21,27%)
27% (22,42%)
32% (29,35%)
31% (27,35%)
29% (25,33%)
28% (25,31%)
30% (27,33%)
29% (27,31%)
time
17% (14,20%)
15% (11,19%)
15% (12,18%)
13% (10,16%)
12% (10,14%)
17% (14,20%)
17% (14,20%)
15% (13,17%)
time
16% (13,19%)
18% (13,23%)
11% (9,13%)
17% (13,21%)
18% (15,21%)
16% (13,19%)
12% (9,15%)
15% (13,17%)
time
23% (l&28%)
22% (17,27%)
17% (14,20%)
16% (12,20%)
20% (16,24%)
17% (14,20%)
20% (16,24%)
19% (17,21%)
time
11% (9,13%)
11% (9,13%)
14% (12,16%)
14% (12,16%)
12% (10,14%)
13% (11,150/o)
13% (11,15%)
13% (12,14%)
(7,?%)
(5,K$)
11% (9,13%)
(7;::)
10% (8,12%)
(7,Z)
(7,;:)
9% (S,lO%)
time
IV or
patient-controlled
IM
al.
Bed Size
39
analgesia;
CI = confidence
analgesia, 6.0 ? 3.7 for IV PCA, and 5.2 + 2.7 for IV or IM opioids. The responsible physician assesses pain intensity on the day of operation on average 2.2 t 1.6 times for epidural analgesia, 1.7 2 1.2 times for IV PCA, and 1.6 t for
Carr
47
= intravenous
1.2 times the first
management:
Regimens Geographic
How
ofperioperatiue pain
opioids.
The
respective
figures
for
postoperative day are 1.6 2 1.1 for epidural analgesia, 1.4 t 1.0 for IV PCA, and 1.3 + 1.1 for IV or IM opioids.
interval;
IM
= intramuscular;
= nonsteroidal
antiinflammatory
Trends in PostoperativePain Management Two-thirds of respondents report declining reimbursement for IV PCA over the past year or two (Table 7)) and 29% believed that this trend will lead to a decrease in IV PCA use in the future; 54% expect use to remain unchanged, in the belief that the attending surgeon will take over its management Declining reimbursement for epidural analgesia was reported by 73% of respondents, and 56% believed a continuation of this trend would decrease its future
i ElFrequently (30 - 90 %)
NSAIDs
use.
Regional anesthetic techniques were considered costeffective by 89% of respondents. In addition, 45% believed that use of regional anesthetic techniques would remain unchanged, while 38% believed that use of this technique would increase.
60%
Other Issues Patient
satisfaction with their postoperative pain managemost often measured by spontaneous comments (69%), but specific questions relative to satisfaction are asked by 35% of respondents. Written questionnaires to assess satisfaction are used by 44% of respondents, and post-discharge telephone surveys are employed by 29% of respondents. A final question in the survey requested an assessment of the overall efficacy of postoperative pain management programs by respondents in their own institutions: 52% of respondents rated their institution’s program as “very ment
Patient Complaints Figure 1. Frequency No. - number; PCA muscular.
Pain Scale
Physical Signs
of use of various - patient-controlled
No. PCA Boluses
No. IM Opioids
methods to assess pain. analgesia; IM - intra-
is
J. Clin.
Anesth.,
vol. 10, February
1998
83
Special
Article
Table
7.
Trends
in Postoperative
Pain
Management
Reimbursement
Geographic Consideration
East
Has the respondent No. responses No. of yes answers 95% CI
experienced
Has the respondent No. responses No. of yes answers 95% CI Does
experienced
(%)
a decline
consider
patient-controlled
good” or “excellent” “good”.
in reimbursement
anesthesia
45 41 (91%) (83,99%)
(%)
IV PCA = intravenous
regional
analgesia;
their
for
62 56 (90%) (83,99%) CI = confidence
84
J, Clin. Anesth.,
of pain especially
vol. 10, February
control when
1998
anesthesia
epidural
the
Grand Total
48 34 (71%) (64,78%)
181 119 (66%) (61,71%)
212 155 (73%) (67,79%)
196 174 (89%) (8593%)
past 2 year,+
69 40 (58%)
64 46 (72%)
(4670%)
(61,83%)
anesthesia
>400
200 to 400
over
49 26 (53%) (39,67%)
Size
over
the past 2 years?
58 42 (72%) (60,84%)
78 50 (64%) (53,75%)
73 57 (78%)
(68,87%)
61 47 (77%) (66,88%)
48 ;i%) (75,940/o)
77 68 (88%) (81,95%)
69 62 (90%) (839%)
50 44 (88%) (19,97%)
institution
interval.
as
Numerous studies of perioperative pain management have addressed such matters as specific outcomes, various physiologic measures, length of hospital stay, incidence of complications, patient satisfaction,6-11 the benefits of “preemptive” analgesia’*-l4 and of regional anesthesia,r’-r7 and/or the costs associated with such care.r’-*’ To a large extent, these previous studies have been limited to one or a few institutions and/or to a relatively narrow group of interests. While our study was in progress, a more comprehensive overview of certain aspects of the current state of practice related to postoperative pain management was published by War-field and Kahn.‘l Their paper presented results of a 300-hospital telephone survey that dealt primarily with such matters as the establishment of a formal pain program; the goals, components, and types of services offered; the staffing of such programs; and the familiarity of the institutions with the AHCPR guidelines. In general, our results are in agreement with their findings in the few areas in which direct comparisons can be made. Our survey was specifically designed to obtain detailed, comprehensive information on institutional issues and practice patterns in a large number of institutions of varying bed size and geographic region. Two guidelines that influenced our survey were those prepared by the AHCPR’ in 1992 and the ASA in 1995.’ These and other guidelines3,22-24 share many common, widely endorsed recommendations, including the establishment of institutional policies and the implementation of these policies within the framework of quality improvement; individualplanning involved,
c200
Bed
to be cost-effective?
Discussion
ized preoperative cation of all staff
IV PCA
66 47 (71%) (60,82%)
33 29 (88%) (77,99%)
and 39% rated
for
54 31 (57%) (44,0%)
39 30 (77%) (64,90%)
36 (4793%)
Far West
in reimbursement 34 25 (74%) (69,89%)
(61,85%)
the respondent
No. responses No. of yes answers 95% CI
a decline
Hospital
Midwest
SOUth
44 38 (86%) (76,96%)
(%)
Location
options; “high
edutech”
nodes
of pain
relief
delivery
are
employed;
assessment
and
documentation of pain intensity and the effectiveness of its control; and the use of nonpharmacologic modalities. Excerpts from the AHCPR and ASA guidelines describing each of these key points are shown in Table 8, along with a summary of the findings from the present survey. Although a high percentage of institutions follow many of the guidelines’ recommendations, some shortfalls still exist, particularly concerning the use of nonpharmacologic pain control measures and the use of postoperative IM opioids on an “as needed” basis. The cost-effectiveness of modern pain therapies is of great importance today. 25-27 Our participants seem concerned that the failure of appropriate reimbursement for their services may well result in the decreased use of modern pain control measures by the very teams that are
Table 8. Comparison and ASA Guidelines
General
Guideline
of General with Findings
Recommendations of Current Study
Affirmative Responses in Cm-rent Survey
Recommendations
Pain management team/service Formal pain management committee Formal QI program Education of personnel Proactive planning Documentation of pain and pain relief Systematic solicitation of patient satisfaction Systematic patient education/training Use of numeric pain scale Postoperative use of IM opioids AHCPR = Agency for Health Care American Society of Anesthesiologists; = intramuscular.
of AHCPR
63% 29% 44% 77% 48% >85% >69% >86% 72% 19%
Policy and Research; ASA = QI = quality improvement; IM
Survey
most qualified to provide them. Another important finding in our survey is the nearly uniformly greater adherence to guideline recommendations in the larger compared with the smaller hospitals, a finding that in our opinion indicates that advanced technological procedures have better outcomes in institutions that perform these procedures more frequently and that are, therefore, more likely to occur in larger hospitals. The analysis of responses according to geographic location revealed no obvious regional differences in the approaches to perioperative pain management. We have no ready explanation for the lower overall response rate from institutions in the South compared with those of the other regions. Another limitation of our study is the focus on anesthesiologists as respondents who were identified by their institutions as the physician most responsible for perioperative pain management. Independent confirmation of our findings from an outside source or by a non-anesthesiologist (such as a pain management nurse within each institution) would be desirable. While our survey was not intended to test any particular hypothesis, it does provide broad descriptive findings that may guide in developing future studies, targeting future resources, and providing “benchmark data” against which the evolution of clinical practice can be compared. Major changes in future practice are to be anticipated. For example, the replacement of board-certified anesthesiologists by less highly trained health care professionals in providing pain control services may occur. In addition, as the trend toward decreasing invasiveness of many major surgical techniques continues, the severity of postoperative pain and, therefore, the therapy for its relief is diminished. The increasing emphasis on ambulatory surgery suggests that a detailed survey of perioperative pain management in that setting would be welcome.
References 1. Carr
DB, Jacox AJ, Chapman CR, et al: Acute Pain Management: OT Medical Procedures and Trauma. Clinical Practice Guideline. Rockville MD: Public Health Service, U.S. Department of Health and Human Services. Agency for Health Care Policy and Research, Pub. No. 92-0032, Feb. 1992. 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. AnesthesioZogy 1995;82:1071-81. American Pain Society: Principals of Analgesic Use in the Treatment oj Acute Pain and Chronic Cancer Pain, 3d ed. Skokie, IL: American Pain Society, 1992. American Hospital Association: Hospital Statistics. Chicago: American Hospital Association, 199495. American Hospital Association: Guide to the Health Care Field. Chicago: American Hospital Association, 1994. Sinatra RS, Hord AH, Ginsberg B, Preble M: Acute Pain: Mechunisms and Management. St. Louis: Mosby Yearbook, 1992. Operative
2.
3.
4. 5. 6.
of pioperative
pain management:
Carr et al.
7. Ferrante
FM, Ostheimer GW, Covino BG (eds): Patient-Controlled Chicago: Blackwell, 1990. 8. Ballantyne JC, Carr DB, Chalmers TC, Dear KB, Angelillo IF, Mosteller F: Postoperative patient-controlled analgesia: metaanalysis of initial randomized control trials. J Clin Anessth 1993;5: 182-93. 9. Liu S, Carpenter RL, Neal JM: Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 1995;82:1474506. 10. Liu SS, Carpenter RL, Mackey DC, et al: Effects of perioperative analgesic technique on rate of recovery after colon surgery. Analgesia.
Anesthesiology
1995;83:757-65.
11. Ballantyne JC, Carr DB, Berkey CS, Chalmers TC, Mosteller F: Comparative effects of postoperative analgesic therapies upon respiratory function: meta-analyses of randomized controlled trials. Anesth Analg (in press). 12. Katz J, Clairoux M, Kavanagh BP, et al: Pre-emptive lumbar epidural anaesthesia reduces postoperative pain and patientcontrolled morphine consumption after lower abdominal surgery. Pain 1994;59:395-403. 13. Kissin I: Preemptive analgesia. Why its effect is not always obvious. Anesthesiology 1996;84:1015-9. 14. Niv D: Intraoperative treatment of postoperative pain. Pain, 1996: an updated review. Seattle: IASP Press, 1996;173-87. 15. Cousins MJ, Bridenbaugh PO (eds): i%ural Blockade in, Clinical Anesthesia and Management of Pain, 2d ed. Philadelphia: J.B. Lippincott, 1987. 16. Atanassoff PG: Effect of regional anesthesia on perioperative outcome. J Clin Anesth 1996;8:446-55. 17. Kehlet H: 1993 John J. Bonica Lecture. Postoperative pain relief. A look from the other side. Reg An&h 1994;369-77. 18. Gouveia WA (ed): Applying patient outcomes and pharmacoeconomics in patient care. Am J Health-System Phawn 1995;52(Suppl 3) :Sl-s35. 19. Carr DB: Economics of patient-controlled analgesia: an annotated bibliography. Pain, 1996: an updated r&ew. Seattle: IASP Press, 1996;437-9. 20. Bootman L, Townsend RJ, McGhan MTF: Principles of Pharmaceconomics, 2d ed. Cincinnati: Whitney Books, 1996. 21. Warfield CA, Kahn CH: Acute pain management. Programs in U.S. hospitals and experiences and attitudes among U.S. adults. Anesthesialog)’ 1995;83:1090-4. 22. Ready LB, Edwards WT: Management ofAcute Pain. Seattle: IASP, 1992. 23. Royal College of Surgeons of England, the College of Anesthetists. Report Of The Working Pa?%y on Pain after Surgey. London: Royal College of Surgeons, 1990. 24. National Health and Medical Research Council (Australia): IZiIalzagement of Severe Pain. Canberra, Australia. 25. Russell LB, Gold MR, Siegel JE, Daniels N, Weinstein MC: The role of cost-effectiveness analysis in health and medicine. Panel on Cost-Effectiveness in Health and Medicine. JAMA 1996;276: 1172-7. 26. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB: Recommendations of the Panel on Cost-Effectiveness in Health and Medicine. JAM.4 1996;276:1253-8. 27. Siegel JE, Weinstein MC, Russell LB, Gold MR: Recommendations for reporting cost-effectiveness analyses. Panel on CostEffectiveness in Health and Medicine. JAMA 1996;276:1339-41.
J. Clin. Anesth.,
vol. 10, Februav
1998
85
SPecial
Article
Management of Perioperative Pain in Hospitalized Patients: A National Survey Daniel B. Carr, MD,* Christine Miaskowski, RN, PhD,? Stephen C. Dedrick, RPh, MS,1 G. Rhys Williams, MS5 Department of Anesthesia, New England Medical Center and Tufts University School of Medicine, Boston, MA; Department of Physiological Nursing, University of California, San Francisco, CA, Department of Pharmacy, Duke University, Durham, NC; Janssen Research Foundation, Titusville, NJ
“Saltonstall Professor of Pain Research and Professor of Anesthesia, Tufts University School of Medicine tprofessor and Chairman, Department of Physiological Nursing, University of California, San Francisco IAssociate Director, Department macy, Duke University Hospital $4ssistant Director, Janssen Foundation
Outcomes
of PharResearch,
data on current practices of A survey was carried out to provide “benchmark” in-hospital perioperative pain management. The 59-item survey questionnaire incorporated all key points contained in the Agency for Health Care Policy and Research and the American Society of Anesthesiologists published guidelines concerning institutional policies as well as practice patterns. The questionnaire was mailed to designated pain specialists in a sample of 400 hospitals that were systematically stratified by bed size and geographic region. Of the 400 questionnaires mailed, 223 (56%) were returned. Of the 223 respondents, 85% were board-certified anesthesiologists. There was good to excellent overall adherence to most of the guideline recommendations; significant exceptions were the infrequent use of nonpharmacologic techniques for pain control and the relatively high frequency of intramuscular opioid use. In general, large hospitals have a greater adherence to the recommendations of the guidelines than do smaller hospitals. No noteworthy variations in institutional policies or practice patterns were evident. These results provide comprehensive baseline data against which future developments in the field of perioperative pain management can be assessed. 0 1998 by Elsevier Science Inc.
Address correspondence to Dr. Carr at the Department of Anesthesia, Tufts University School of Medicine, 750 Washington St., NEMC #298, Boston, MA 02111, USA.
Keywords: Analgesia:
Supported by a grant from Janssen Research Foundation, Titusville, NJ. The survey was carried out by Winters Associates, Inc., Mendham, NJ.
Introduction
Received for publication April 11, 1997; revised manuscript accepted for publication September 4, 1997.
management:
epidural, nonpharmacologic,
opioid, patient-controlled, perioperative; pain management guidelines.
pain
Changes occurring in the delivery of health care and the responses by governmental agencies and by professional groups have prompted the development of clinical practice guidelines designed to enhance patient outcomes. It is clear that efficient management of perioperative analgesic requirements can improve patients’ outcomes as well as their quality of life. Because the most influential practice guidelines have appeared during a time when practice patterns were
Journal of Clinical Anesthesia 10:77-85, 1998 0 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
095%8180/98,‘$19.00 PI1 SO952-8180(97)00227-4
Special Article
evolving rapidly, it has not been possible to assess the specific impact of any particular guideline recommendation on the management of perioperative pain. Nonetheless, the definition of “benchmark survey data” focusing on current perioperative pain management provides a starting point for future systematic trials and interventions. This report summarizes the results of a large, comprehensive survey of current practice patterns in the management of acute perioperative pain in hospitalized patients. The survey assessed the degree of compliance with specific recommendations that were made in two published guidelines for the management of postoperative pain: (1) the 1992 Clinical Practice Guideline Report of the Agency for Health Care Policy and Research (AHCPR) on Acute Pain Management’ and (2) the 1995 Practice Guidelines for Acute Pain Management in the Perioperative Setting of the Task Force on Pain Management of the American Society of Anesthesiologists.’ Both sets of guidelines were developed by expert panels, and both made a number of similar recommendations. These recommendations formed the basis for the development of the survey instrument used in the present study. During the completion of this survey, the American Pain Society3 issued a guideline on the management of acute or cancer-related pain, and it also made similar recommendations. Although each of these guidelines dealt with other more specific issues, such as postoperative pain management in pediatric, geriatric, and ambulatory surgery patients, and the use of regional anesthesia techniques and others, these issues were excluded from the present study in order to make our survey instrument more targeted. Our survey addressed the following areas: (1) general institutional issues (e.g., development of formal policies for perioperative pain management, establishment of a pain service, establishment of quality improvement programs); (2) the specialized training of the personnel involved in the management of patients with acute perioperative pain; (3) the use of advanced planning as part of perioperative pain control programs; (4) the education and training of the patient; (5) the analgesia-anesthesia programs used in the intraoperative period and in the postanesthesia care unit (PACU); (6) the types of analgesic programs used in the postoperative period; (7) the monitoring, assessment, and documentation of postoperative pain and its relief; (8) trends in postoperative pain management and related reimbursement issues; (9) the use of nonpharmacologic measures for the relief of postoperative pain; and (10) the methods used to monitor patient satisfaction. Respondents were also asked for a self-assessment of the overall quality of perioperative pain management in their respective institutions.
Materials and Methods Development of the Sample The sample was designed to accurately represent acute, nonfederal hospitals with respect to the frequency of surgical procedures performed, the size of the hospital, 78
J. Clin.
Anesth.,
vol.
10, February
1998
and its geographic location. A sample size of 400 was selected in order to achieve an expected response rate of 250, a number that represents approximately 5% of all acute care hospitals in the United States. Using this baseline figure, the number of surgical procedures performed by hospitals of varying bed size and geographic location was determined using data published by the American Hospital Association (AHA) for six separate bed size categories over the nine U.S. Census Regions. Although these figures include both outpatient and inpatient operations, we assumed that the ratio of inpatient procedures to outpatient procedures would be constant throughout the sample. The sample design is illustrated by the following example. Of the nearly 24 million operations performed by all hospitals nationwide during 1994, approximately 2.4 million were performed in hospitals having fewer than 100 beds; furthermore, 134,662 operations, corresponding to 0.56% of the total, were performed in hospitals of this size that are located in U.S. Census Region 1. Thus, two hospitals (i.e., 0.56% of 400 rounded) of this size within this geographic region were selected for the sample. A similar approach was used for hospitals in the nine U.S. Census Regions and the six AHA bed-size groups, viz., less than 100 beds, 100 to 199 beds, 200 to 299 beds, 300 to 399 beds, 400 to 499 beds, and more than 500 beds. Once the number of representative hospitals to be polled in each bed-size group and in each geographic region was determined, the individual institutions were selected at random from the American Hospital Association Guide.’
Identification of Key Physicians The individual physician most responsible for the perioperative pain management program in each of the 400 targeted hospitals was identified by telephone contact with each hospital’s anesthesiology department and the PACU.
Development of the Suruey Qustionnaire An initial test version of the survey questionnaire was drafted by a panel of experts and mailed to 39 physicians selected as outlined above; the questionnaires were mailed via USPS Priority Mail, with an offer of a $100 honorarium and an assurance of confidentiality. Of the 39 questionnaires mailed, 23 responses (59%) were received. A revised survey instrument consisting of 59 questions was then mailed in a similar fashion to the 400 designated physicians in the targeted sample hospitals; four were returned “addressee unknown” and 223 (56%) were returned complete. The data on the various subgroups were consolidated as follows: (1) by bed size into three groups (i.e., less than 200 beds, 200 to 399 beds, and greater than 400 beds) and (2) by geographic groups [i.e., East (U.S. Census Regions 1 and 2)) South (Regions 3 & 5)) Midwest (Regions 4 SC6)) and Far West (Regions 7, S, and 9)].
Survey
Table
Number of Questionnaires
1.
~200 Bed Size
No.
Region: East South Midwest Far West Totals
Sent
19
No.
Sent
No.
Returned
No.
Returned
Sent
Returned
13 12 21 16
85 99 102
47 39 68
42
33 34 33 25
110
69
122
83
149
78
125
62
396
The responses to each question were summarized by subgroups. Because of the exploratory nature of this survey involving a large number of questions, the results of which were broken down by hospital size and by geographic location, and because no prior hypotheses were stipulated, no statistical tests of significance were performed, and no p-values are reported. Rather, the data for the various subgroups are presented in terms of their 95% confidence intervals, calculated by the normal approximation to the binomial theorem. These results, therefore, represent purely descriptive “benchmark data.” of Responses
Table1 shows the number of responses received compared with the number of questionnaires sent. The data are divided by bed size group and by geographic region. Total response rates (i.e., encompassing all hospitals regardless of size in any one geographic area) of 55% or more were seen in the East, Midwest, and Far West, but responses from the hospitals in the South averaged only 39%. Smaller hospitals (those with less than 200 beds) had a response rate of 68%, while those in the 200 to 399 bed size range had a 52% response rate, and for those with over 400 beds, the rate was 50%. Results of
Sent
16 16 21 25
Data Reduction and Analysis
Profile
No.
33 35 38 43
31
Respondents
Of the 223 respondents, 189 (85%) self-reported certification by the American Board of Anesthesiology (Table 2). Respondents from hospitals having fewer than 200 beds were less frequently certified (74%) than those from the two other groups (90% and 94%, respectively). There were no differences between the geographic groups in the certification of respondents ( Table2).
Pain Service and Pain
Carr
et al.
Totals
Beds
18 11 26 28
30
Distribution
>400
200 to 399 Beds
Returned
management:
Sent and Number Returned
Beds No.
pain
of pwioperatiue
Committee
Of the 223 respondents, 140 (63%) indicated that their institution had an organized pain management service or pain team (Table2). There appears to be a difference with respect to bed size, in that 38% of hospitals with fewer
223
Total Responses
(%)
55% 39% 67% 63% 56%
than 200 beds have a pain service compared with ‘74% and 84% of the hospitals in the two larger bed size categories. A formal pain management service or team is more prevalent in hospitals in the East (84%) than in other regions of the country, which varied from 55% to 61%. Only 29% of all respondents indicated that their institutions have a formal pain management committee, with 15% in the smaller hospitals and 36% and 40% in the intermediate and larger groups; there is no evident variation in geographic region. The survey queried the nonmutually exclusive sources that have influenced the pain management practices of the respondents. The standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) influenced 40% of respondents, while somewhat smaller percentages were assigned to effects of the AHCPR (35%) and the ASA guidelines (33%).
Education
of
Personnel
Seventy-seven percent of respondents indicated that the personnel involved in the management of acute postoperative pain receive special education, with no obvious differences with respect to bed size or geographic location (Table 2). The principal groups who receive such education are surgical staff nurses (85%) and obstetric-gynecologic staff nurses (50%). Pharmacists and house officers receive education in fewer than 15% of the institutions surveyed. Over 60% of the respondents indicated that in-house educational sessions are given less than twice a year, while 16% indicated that such sessions are given two to four times per year, and 22% indicated a frequency of four or more such sessions per year. Over 80% of respondents indicated that the main topics of the training sessions are pain assessment and techniques of epidural intravenous patient-controlled analgesia (IV PCA) administration, with lesser percentages devoted to the topics of IV opioids, use of nonsteroidal anti-inflammatory drugs (NSAIDs) , and nonpharmacologic pain management techniques. Manufacturers of PCA pumps provide formal training sessions for the use of pumps in 68% of hospitals surveyed, but they offer formal general education in pain management in only 12% of the hospitals (Table 2). J. Clin. Anesth., vol.
10,
February 1998
79
Special Article Table
2.
Institutional
Considerations
Consideration Grand
Geographic
Total
of Responses
Is respondent
respondent’s
47 41 (87%)
(%) institution
No. of responses No. of “yes” answers 95% CI Does
institution
No. of responses No. of “yes” answers 95% CI
(%)
institution
No. of responses No. of “yes” answers 95% CI
(%)
Do pump
No.
offer
Does
(%)
manufacturers
offer
responses of “yes” answers respondent’s
(%)* institution
No. of responses No. of “yes” answers 95% CI *95%
confidence
Quality
(%)
interval
Improvement
a pain
Midwest,
Far West,
69
<200,
83
Bed Size
Total
200 to 400, 78
>400,
62
223
have
39 26 (67%) (48,78%)
a pain
offer
pain
62 22 (36%) (24,48%)
management
education
40 30 (75%) (64,86%)
68 49 (72%) (61,83%)
(CI)
24 fit%) (52,82%)
25 17 (68%) (50,86%)
training
on general
2 (7%) 28
4 (17%) 26
have
a QI program
Preoperative
Practice
pumps
Anesth.,
29 ;A%) (53,81%) pain
management
3 (12%) 26 for postoperative
g%) 25 (41,71%)
33 13 (39%) (22,56%)
too wide
to be meaningful.
61 26 (43%) (31,55%)
Issues
1998
189 161 (85%)
60 32 (55%) (39,65%)
83 33 (38%) (28,48%)
78 58 (74%) (64,84%)
58 49 (84%) (76,92%)
223 140 (63%) (57,69%)
56 14 (25%) (14,36%)
76 11 (15%) (7,23%)
68 24 (36%) (25,47%)
21 ;iY,, (27,53%)
197 57 (29%) (23,35%)
83 62 (71%) (61,81%)
78 39 (76%) (66,86%)
58 51 (88%) (81,95%)
223 172 (77%) 71,83%
60 41 (68%) (56,80%)
49 30 (61%) (47,75%)
40 31 (78%) (65,91%)
149 101 (68%) 61,75%
5 (:;a)
30 5 (17%)
109 13 (12%)
49 30 (61%) (47,75%)
194 85 (44%) (37,51%)
of personnel?
50 E%) (74,92%) institution?
45 32 (71%) (58,84%) in respondent’s
3 (12%) 29 pain
institution?
3 (9%) 33
management?
55 21 (38%) (25,51%)
IV PCA = intravenous
Programs
vol. 10, February
58 55 (94%)
in respondent’s
The survey evaluated a number of preoperative practice issues that are presented in all acute pain guidelines. The first of these is the frequency with which an individualized pain management plan is developed during the preoperative period for those patients likely to have moderate or severe pain in the postoperative period. Almost half of the respondents indicated that such planning is done “freJ. Clin.
69 62 (90%)
committee?
33 10 (30%) (14,46%)
on IV PC4
62 46 (74%)
68 42 (62%) (42,69%)
management
training
47 37 (78%)
team?
Quality improvement (QI) programs for the evaluation of perioperative pain management are recognized as an important feature of good current pain management practice. An average of 44% of the respondents’ institutions have such evaluative programs in place, although only 33% of the smaller hospitals have such programs, compared with 61% of the larger ones. No differences with respect to geographic region are evident (Table 2).
80
68
59 51 (87%)
service/pain
43 15758%) (67,89%)
manufacturers
No. of responses No. of “yes” answers 95% CI
have
10 E%) (10,34%)
respondent’s
Do pump
39
35 31 (88%)
47 40 (84%) (74,94%)
(%)
respondent’s
Does
South,
Hospital
board-certified?
No. of responses No. of “yes” answers Does
East, 47
Location
76 25 (33%) (22,440/o)
69 30 (43%) (31,55%)
patient-controlled
analgesia;
QI = quality
improvement.
quently” or “nearly always” (see Table 3for definitions and data). The average frequency of such planning is lower in the smallest hospital group (41%) compared with the two larger groups (50% and 54%, respectively). In addition, such planning is more frequently done in the East (56%) and Midwest (54%) than in hospitals in the South (43%) and Far West (38%). Educating the patient as to the details of a perioperative pain management program is most often (86%) given by the anesthesiologist, followed by the surgeon (41%), and/or the staff nurse (42%). Because most of the survey respondents were anesthesiologists, these results may be somewhat biased. In addition to discussions with the patient, 41% of respondents use text and visual materials, and cific technique(s)
49% to
perform demonstrations be used. Audio or
used by 26%, and the hospital 19% of respondents postoperative pain
to provide management.
television patient
of video
the tapes
speare
system is used by education
about
Survey
Table
3.
Preoperative
of perioperaliue
pain
management:
Cam et al.
Considerations Geographic East
Consideration
south
Percent of the time that a postoperative No. of Responses Percent of the time 95% CI
47 56%
Percent of the time that anesthesiologist No. responses Anesthesiologist 95% CI Surgeon 95% CI
47 74%
(67,81%) 19% (12,26%)
Midwest
Far West
pain control plan is made preoperatively: 53 54% (45,63%)
34 43% (33,53%)
(4765%)
Hospital
Location
54 38% (28,47%)
or surgeon makes intraoperative 39 72% (63,810/o)
18%
(1125%)
63 73% (66,80%) 22%
54 79% (73,X5%) 17%
(15,29%)
(I&24%)
x200
Bed
200to
“frequently” 68 41% (33,490/o)
Size >400
400
Grand Total
or “nearly always”*: 66 50%
56 54%
(42,58%)
(46,62%)
71 77% (71,83%) 21%
54 75% (68,82%)
(13,29%)
(12,26%)
190 48% (43,53%)
anesthesia decision: 78 73% (67,79%) 18% (14,22%)
19%
203 75%
(71,79%) 19% (15,23%/o)
CT = confidence interval. Intruoperative
and PACU
Periods
Specific decisions as to the choice of intraoperative anesthesia are made primarily by the anesthesiologist (75%), while the surgeon makes this decision in 19% of cases; in 6%, the decision is made jointly by surgeon and anesthesiologist. No obvious differences with respect to hospital size or geographic location were noted (Tuble 3). In the PACU, the decision as to the type of analgesia is made by the anesthesiologist 81% of the time and by the surgeon only 16% of the time. Data on the various analgesic programs used in the PACU are presented in Table
4.
Postanesthesia Care Unit (PACU) Considerations Geographic
Consideration
East
No. responses Anesthesiologist Surgeon How often are No. responses IV Opioids % of the time 95% CI IVPCA % of the time 95% CI Epidural % of the time 95% CI
46 83%
CT
Hospital
Midwest
Far West
c200
Bed
Size
200 to 400
>400
Grand Total
or surgeon makes the PACU analgesia decision:
34 93% 8%
9%
57 80% 18%
50 75% 25%
73 84% 24%
63 86% 12%
51 73%
10%
81% 16%
39
39
50
43
38
131
54%
187
used in PACU pain management? 29
24
59% (47,71%)
(59,75%)
22% (14,30%)
(12,26%)
18% (13,23%)
(11,17%)
How often is intraoperative % of the time
Location
South
Percent of the time that the anesthesiologist
95%
Table 4. IV opioids are used by 55% of respondents; an additional average of 7% use only intramuscular (IM) opioids. IV PCA is used by 21%, and continuation of intraoperative epidural analgesia occurs in 16%. If epidural analgesia is started preoperatively, it is continued “frequently” or “nearly always” in both the PAW and in the postoperative period by 65% of respondents (Table 4). There are no differences with respect to geographic region, although in the smallest bed size group, continuing epidural occurs less frequently (55%) than in the intermediate and large hospital groups (70% and 73%, respectively).
66% (58,74%)
67%
19%
14%
epidural
55% (45,65%)
68% (59,77%)
27% (19,35%)
(11,25%)
18%
65%
22%
(15,29%)
14%
(1323%)
anesthesia continued
(5674%)
18%
69% (61,770/o)
(11,17%) in the PACU?
65% (58,72%)
IV = intravenous; CI = confidence interval; PCA = patient-controlled
64% (56,72%)
(7,?%)
55% (48,62%)
60%
(51,69%)
(44&X%)
55% (50,60%)
20% (14,26%)
23% (16,30%)
21% (17,25%)
20%
(1624%)
23% (18,28%)
16% (14,18%)
70% (64,76%)
73% (67,79%)
65% (61,69%)
analgesia. J. Clin. Anesth.,
vol.
10, February 1998
81
Table
Postoperative Considerations
5.
Geographic Consideration
East
South
Percent of the time that the anesthesiologist No. responses Anesthesiologist 95% CI Surgeon 95% CI
47 55% (45,65%)
39% (29,49%)
No. For For For For For For
of responses IV PCA epidural IV opioids IM opioids parenteral NSAIDs oral NSAIDs
Midwest
Hospital Far West
or surgeon makes the postoperative
34 52% (41,63%) 36% (24,48%)
Percentage of the time that anesthesiologist
Location
57 37% (29,45%) 49% (41,57%)
51 50% (40,60%) 52% (42,620/o)
writes various postoperative
Bed Size
200 to 400
s-400
Grand Total
51
189
analgesia decision: 74 50% (43,57%) 45% (37,53%)
64 43% (35,51%) 47% (37,57%)
(42,60%) 42% (32,52%)
51%
48% (43,53%) 45% (40,50%)
analgesic orders:
47 36%
39 40%
61 24%
65 14%
75 24%
77 28%
60 31%
100%
97%
97%
100%
96%
100%
100%
99%
46%
39% 6% 31% 6%
29% 2% 29% 2%
16% 2% 12% 2%
35% 4% 22% 4%
29%
30% 2% 35% 5%
31% 3% 29% 3%
6% 44% 6%
CI = confidence interval; IV PCA = intravenous patient-controlled drugs.
Posto@rative Decision-Making The specific type of postoperative analgesic program to be used is selected by the anesthesiologist 48% of the time, with no noticeable differences with respect to hospital size group. However, a lower percentage (37%) is seen in Midwestern hospitals than in those in other regions of the country, which ranged from 50% to 55% (Table 5). The surgeon makes this decision in 45% of the cases surveyed, with no evident differences occurring between various bed size or geographic groups. The physician who writes orders for analgesia varies according to the pain management modality being used. If IV PC4 is to be used, the anesthesiologist writes the orders in 27% of cases, while if epidural analgesia is to be used, he or she writes the orders in virtually all cases. The anesthesiologist writes 31% of the orders for IV opioids, but only 3% of the IM opioid orders. If parenteral or oral NSAIDs are used, the percentages of orders written by the anesthesiologist are 29% and 3%, respectively. In all of the above instances, those orders not written by the anesthesiologist are written by the surgeon. The use of preprinted orders for postoperative pain management programs is nearly universal in all hospitals (97%).
1% 31%
1%
analgesia; IM = intramuscular; NSAIDs = nonsteroidal
189 27%
antiinflammatory
The use of a numeric rating scale to assess the degree of postoperative pain is widely recommended, and 72% of respondents indicate that their institutions have implemented such a practice. However, patient complaints are used to assess pain “very frequently” in 70% of the cases, while the numeric pain scale is used “very frequently” in only 40% of the cases (Fig-ure 1). The percentages of respondents using other possible indicators of pain or analgesia, such as physical signs, the number of PCA boluses used, and number of IM opioid doses given, are depicted in Fig-ure 1.
Nonphawnacologic Techniques The use of nonpharmacologic techniques for managing postoperative pain was repeatedly stressed in the published guidelines. However, in this survey, measures such as relaxation, guided imagery, hypnosis, and transcutaneous electrical nerve stimulation (TENS) are used by less than 5% of respondents. Patient education was cited by 52% as a nonpharmacologic method for managing postoperative pain.
Postoperative Pain Relief Documentation PostoperativePain Therapy Regimens used for patients with moderate or severe postoperative pain vary according to specific therapy, but not with hospital size and/or geographic region (Table 6). IV PCA is used by 29% and epidural by 15% of respondents. Opioids, given IV or IM, account for an additional 15% and 19% of postoperative pain therapy, respectively, while parenteral and oral NSAIDs are used by 13% and 9%, respectively. There are no differences in these practice patterns with respect to either hospital bed size or location. 82
J.
Gin. Anesth., vol. 10, February 1998
Pain therapy and pain relief are documented in the nurse’s notes in 85% of respondents, and 50% stated that documentation is noted in the physician’s notes. A pain management flowsheet is used by 39% of respondents, while therapy records, graphic sheets, and pain team notes are used less than 30% of the time. Pain intensity is assessed by staff nurses on the day of operation on an average (i SD) of 9.0 2 5.2 times with epidural analgesia, 7.6 ? 4.7 times with IV PCA, and 6.8 * 4.4 times with IV or IM opioids. On the first postoperative day, the comparable figures are 7.6 t 4.7 for epidural
Surv~
Table
6.
Postoperative
Pain
Consideration often
East is each
No. responses IVPCA Percent of the 95% CI Epidural Percent of the 95% CI IV opioids Percent of the 95% CI IM Opioids Percent of the 95% CI Parenteral NSAIDs Percent of the 95% CI Oral NSAIDs Percent of the 95% CI IV PCA drugs.
SO&b
of the following
therapies
used
Hospital
Location Midwest
Far West
in postoperative
et
200 to 400
>400
Grand Total
pain management?
61
65
75
77
60
212
time
24% (21,27%)
27% (22,42%)
32% (29,35%)
31% (27,35%)
29% (25,33%)
28% (25,31%)
30% (27,33%)
29% (27,31%)
time
17% (14,20%)
15% (11,19%)
15% (12,18%)
13% (10,16%)
12% (10,14%)
17% (14,20%)
17% (14,20%)
15% (13,17%)
time
16% (13,19%)
18% (13,23%)
11% (9,13%)
17% (13,21%)
18% (15,21%)
16% (13,19%)
12% (9,15%)
15% (13,17%)
time
23% (l&28%)
22% (17,27%)
17% (14,20%)
16% (12,20%)
20% (16,24%)
17% (14,20%)
20% (16,24%)
19% (17,21%)
time
11% (9,13%)
11% (9,13%)
14% (12,16%)
14% (12,16%)
12% (10,14%)
13% (11,150/o)
13% (11,15%)
13% (12,14%)
(7,?%)
(5,K$)
11% (9,13%)
(7;::)
10% (8,12%)
(7,Z)
(7,;:)
9% (S,lO%)
time
IV or
patient-controlled
IM
al.
Bed Size
39
analgesia;
CI = confidence
analgesia, 6.0 ? 3.7 for IV PCA, and 5.2 + 2.7 for IV or IM opioids. The responsible physician assesses pain intensity on the day of operation on average 2.2 t 1.6 times for epidural analgesia, 1.7 2 1.2 times for IV PCA, and 1.6 t for
Carr
47
= intravenous
1.2 times the first
management:
Regimens Geographic
How
ofperioperatiue pain
opioids.
The
respective
figures
for
postoperative day are 1.6 2 1.1 for epidural analgesia, 1.4 t 1.0 for IV PCA, and 1.3 + 1.1 for IV or IM opioids.
interval;
IM
= intramuscular;
= nonsteroidal
antiinflammatory
Trends in PostoperativePain Management Two-thirds of respondents report declining reimbursement for IV PCA over the past year or two (Table 7)) and 29% believed that this trend will lead to a decrease in IV PCA use in the future; 54% expect use to remain unchanged, in the belief that the attending surgeon will take over its management Declining reimbursement for epidural analgesia was reported by 73% of respondents, and 56% believed a continuation of this trend would decrease its future
i ElFrequently (30 - 90 %)
NSAIDs
use.
Regional anesthetic techniques were considered costeffective by 89% of respondents. In addition, 45% believed that use of regional anesthetic techniques would remain unchanged, while 38% believed that use of this technique would increase.
60%
Other Issues Patient
satisfaction with their postoperative pain managemost often measured by spontaneous comments (69%), but specific questions relative to satisfaction are asked by 35% of respondents. Written questionnaires to assess satisfaction are used by 44% of respondents, and post-discharge telephone surveys are employed by 29% of respondents. A final question in the survey requested an assessment of the overall efficacy of postoperative pain management programs by respondents in their own institutions: 52% of respondents rated their institution’s program as “very ment
Patient Complaints Figure 1. Frequency No. - number; PCA muscular.
Pain Scale
Physical Signs
of use of various - patient-controlled
No. PCA Boluses
No. IM Opioids
methods to assess pain. analgesia; IM - intra-
is
J. Clin.
Anesth.,
vol. 10, February
1998
83
Special
Article
Table
7.
Trends
in Postoperative
Pain
Management
Reimbursement
Geographic Consideration
East
Has the respondent No. responses No. of yes answers 95% CI
experienced
Has the respondent No. responses No. of yes answers 95% CI Does
experienced
(%)
a decline
consider
patient-controlled
good” or “excellent” “good”.
in reimbursement
anesthesia
45 41 (91%) (83,99%)
(%)
IV PCA = intravenous
regional
analgesia;
their
for
62 56 (90%) (83,99%) CI = confidence
84
J, Clin. Anesth.,
of pain especially
vol. 10, February
control when
1998
anesthesia
epidural
the
Grand Total
48 34 (71%) (64,78%)
181 119 (66%) (61,71%)
212 155 (73%) (67,79%)
196 174 (89%) (8593%)
past 2 year,+
69 40 (58%)
64 46 (72%)
(4670%)
(61,83%)
anesthesia
>400
200 to 400
over
49 26 (53%) (39,67%)
Size
over
the past 2 years?
58 42 (72%) (60,84%)
78 50 (64%) (53,75%)
73 57 (78%)
(68,87%)
61 47 (77%) (66,88%)
48 ;i%) (75,940/o)
77 68 (88%) (81,95%)
69 62 (90%) (839%)
50 44 (88%) (19,97%)
institution
interval.
as
Numerous studies of perioperative pain management have addressed such matters as specific outcomes, various physiologic measures, length of hospital stay, incidence of complications, patient satisfaction,6-11 the benefits of “preemptive” analgesia’*-l4 and of regional anesthesia,r’-r7 and/or the costs associated with such care.r’-*’ To a large extent, these previous studies have been limited to one or a few institutions and/or to a relatively narrow group of interests. While our study was in progress, a more comprehensive overview of certain aspects of the current state of practice related to postoperative pain management was published by War-field and Kahn.‘l Their paper presented results of a 300-hospital telephone survey that dealt primarily with such matters as the establishment of a formal pain program; the goals, components, and types of services offered; the staffing of such programs; and the familiarity of the institutions with the AHCPR guidelines. In general, our results are in agreement with their findings in the few areas in which direct comparisons can be made. Our survey was specifically designed to obtain detailed, comprehensive information on institutional issues and practice patterns in a large number of institutions of varying bed size and geographic region. Two guidelines that influenced our survey were those prepared by the AHCPR’ in 1992 and the ASA in 1995.’ These and other guidelines3,22-24 share many common, widely endorsed recommendations, including the establishment of institutional policies and the implementation of these policies within the framework of quality improvement; individualplanning involved,
c200
Bed
to be cost-effective?
Discussion
ized preoperative cation of all staff
IV PCA
66 47 (71%) (60,82%)
33 29 (88%) (77,99%)
and 39% rated
for
54 31 (57%) (44,0%)
39 30 (77%) (64,90%)
36 (4793%)
Far West
in reimbursement 34 25 (74%) (69,89%)
(61,85%)
the respondent
No. responses No. of yes answers 95% CI
a decline
Hospital
Midwest
SOUth
44 38 (86%) (76,96%)
(%)
Location
options; “high
edutech”
nodes
of pain
relief
delivery
are
employed;
assessment
and
documentation of pain intensity and the effectiveness of its control; and the use of nonpharmacologic modalities. Excerpts from the AHCPR and ASA guidelines describing each of these key points are shown in Table 8, along with a summary of the findings from the present survey. Although a high percentage of institutions follow many of the guidelines’ recommendations, some shortfalls still exist, particularly concerning the use of nonpharmacologic pain control measures and the use of postoperative IM opioids on an “as needed” basis. The cost-effectiveness of modern pain therapies is of great importance today. 25-27 Our participants seem concerned that the failure of appropriate reimbursement for their services may well result in the decreased use of modern pain control measures by the very teams that are
Table 8. Comparison and ASA Guidelines
General
Guideline
of General with Findings
Recommendations of Current Study
Affirmative Responses in Cm-rent Survey
Recommendations
Pain management team/service Formal pain management committee Formal QI program Education of personnel Proactive planning Documentation of pain and pain relief Systematic solicitation of patient satisfaction Systematic patient education/training Use of numeric pain scale Postoperative use of IM opioids AHCPR = Agency for Health Care American Society of Anesthesiologists; = intramuscular.
of AHCPR
63% 29% 44% 77% 48% >85% >69% >86% 72% 19%
Policy and Research; ASA = QI = quality improvement; IM
Survey
most qualified to provide them. Another important finding in our survey is the nearly uniformly greater adherence to guideline recommendations in the larger compared with the smaller hospitals, a finding that in our opinion indicates that advanced technological procedures have better outcomes in institutions that perform these procedures more frequently and that are, therefore, more likely to occur in larger hospitals. The analysis of responses according to geographic location revealed no obvious regional differences in the approaches to perioperative pain management. We have no ready explanation for the lower overall response rate from institutions in the South compared with those of the other regions. Another limitation of our study is the focus on anesthesiologists as respondents who were identified by their institutions as the physician most responsible for perioperative pain management. Independent confirmation of our findings from an outside source or by a non-anesthesiologist (such as a pain management nurse within each institution) would be desirable. While our survey was not intended to test any particular hypothesis, it does provide broad descriptive findings that may guide in developing future studies, targeting future resources, and providing “benchmark data” against which the evolution of clinical practice can be compared. Major changes in future practice are to be anticipated. For example, the replacement of board-certified anesthesiologists by less highly trained health care professionals in providing pain control services may occur. In addition, as the trend toward decreasing invasiveness of many major surgical techniques continues, the severity of postoperative pain and, therefore, the therapy for its relief is diminished. The increasing emphasis on ambulatory surgery suggests that a detailed survey of perioperative pain management in that setting would be welcome.
References 1. Carr
DB, Jacox AJ, Chapman CR, et al: Acute Pain Management: OT Medical Procedures and Trauma. Clinical Practice Guideline. Rockville MD: Public Health Service, U.S. Department of Health and Human Services. Agency for Health Care Policy and Research, Pub. No. 92-0032, Feb. 1992. 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. AnesthesioZogy 1995;82:1071-81. American Pain Society: Principals of Analgesic Use in the Treatment oj Acute Pain and Chronic Cancer Pain, 3d ed. Skokie, IL: American Pain Society, 1992. American Hospital Association: Hospital Statistics. Chicago: American Hospital Association, 199495. American Hospital Association: Guide to the Health Care Field. Chicago: American Hospital Association, 1994. Sinatra RS, Hord AH, Ginsberg B, Preble M: Acute Pain: Mechunisms and Management. St. Louis: Mosby Yearbook, 1992. Operative
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1998
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