Perioperative pain may start from the time of hospital admission to the first 72 hours after the surgery, which varies in intensity due to the subjective variations. A good perioperative pain management provides good postoperative analgesia and is associated with less morbidity and mortality. On the other hand, unrelieved postoperative pain may not only delay the recovery and discharge process, but also can potentially lead to chronic pain conditions. The solution to this problem lies in setting up of the acute pain service (APS) based on evidence-based approach within the available resources with accountability.[1] A good regional anesthesia service can be crucial to any APS as it provides timely application of appropriate pain relieving methods, which improves the overall postoperative pain management and patient's hospital experience. Unfortunately, the regional anesthesia services are not well recognized, defined or structured and their function vary from place to place. El Harby and El Dawlatly have nicely described how to set up the regional anesthesia services in this issue.[2] The United States of America is amongst the first nations where the first organizational model of APS for managing the postoperative pain has been described.[3] Nowadays, we are witnessing an upsurge in the APS, especially in the developed countries, with a prevalence varying from 33 to 75%.[4] Anesthetists are usually the lead physicians who work closely with the paramedical staff and decide about the analgesic modality, managing side effects and patient safety. Ideally, APS pathway should include patient assessment, pain management delivery, documentation of records, patient's awareness program, audits and defined performance criteria for evaluation.
The important components of APS are as follows:
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(a)
Multidisciplinary committee comprising anesthetists, surgeons, nurses and pharmacists, supported by the secretarial staff. The committee should define the needs and suggest the equipments and infrastructure besides providing guidance to develop and manage the APS.
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(b)
Acute pain management protocols and modalities of APS.
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(c)
Regular pain assessment methods and guidelines to control pain within a defined time scale.
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(d)
Continuous professional development and teaching programs.
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(e)
Regular meetings, cooperation and networking amongst the members of the committee.
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(f)
Patient education and information regarding pain, treatment options and their side effects.
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(g)
Safe and secure central data keeping for a regular follow-up.
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(h)
Audits on methods, patient satisfaction and cost-effectiveness.
The APS model has to be simple and cost-effective to be a successful model. The pain management team must be a motivated and enthusiastic team of professionals with diverse skills. One of the successful models is the Swedish model, which is a nurse-based, anesthetist-supervised model.[5] Obviously, the anesthetists’ services are usually better in larger units at tertiary care hospitals compared with smaller peripheral units due to manpower and resource availability. The nursing and pharmacy are keys to the outcome of the APS. Clinical pain nurses play an important role in providing direct patient care. They coordinate, monitor and evaluate the services. Pain nurses also act as a link amongst the various members of the APS team. The ward nurses are responsible for assessing the pain intensity, provide medications and rescue medication, and monitor the efficacy and adverse effects. Therefore, nurses’ education should be an integral part of the pain management.[6] Patients should also be educated that any pain above 3 (on a 0–10 VAS) is not acceptable and they should inform the attending staff and seek intervention.[7] Pharmacy extends its help in consultation to the APS and organizes the pain medication upkeep.[8]
Surgeons do play their role in developing pain protocols, especially in wards as many patients may not be quite fit to receive standard pain management methods or may react to them later differently. Of late there has been a growing interest in developing regional anesthesia services. As a result, more and more patients are benefited and get appropriate, well thought regional anesthesia either as central neuraxial or peripheral nerve blocks. Surgeons may play an important role in outpatient surgery setting or otherwise, as they are an excellent link between the providers and beneficiary, especially where early mobilization and rehabilitation is desired.
The treatment modalities vary from non-interventional methods like oral non-steroidal anti-inflammatory drugs to intravenous or epidural patient controlled analgesia (PCA) with or without peripheral nerve blocks.[9] Every member of the APS must be involved with continuous professional development (CPD) plan in the form of clinical, academic and/or managerial educational activities. A minimum of 50% of CPD points should be earned by attending external educational activities. Patient education is also important to exploit the benefits of APS to its maximum. Patients should have some idea about the pain management methods, their potential benefits, risks and side effects. The APS team must appreciate that any unrelieved pain may negatively affect the surgical outcome. The members of the team must also believe that the patients have all the right to expect good pain management with multiple options available for their perioperative pain. Clinical audits are backbone of good governance. Good record keeping and data management are crucial. Records help in follow-up and evaluation of key outcome measures. Regular audits show whether the goals of the APS are achieved.
Gone are the days when perioperative pain and discomfort used to be the most fearsome experience for any patient. The introduction of APS (including regional anesthesia services) has increased the awareness amongst patients and medical professionals that proper pain management in perioperative period is important to enhance patient's well-being. A dedicated team, which aspires for excellence and good clinical governance, and appropriate organizational structure, will definitely help in achieving a pain-free hospital stay, especially for the surgical patients.
REFERENCES
- 1.Werner MU, Søholm L, Rotbøll-Nielsen P, Kehlet H. Does an acute pain service improve postoperative outcome? Anesth Analg. 2002;95:1361–72. doi: 10.1097/00000539-200211000-00049. [DOI] [PubMed] [Google Scholar]
- 2.Al Harbi M, El Dawlatly A. How to set up a standard regional anesthesia service.? Saudi J Anaesth. 2011;5:217–8. doi: 10.4103/1658-354X.82809. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Ready LB. How many acute pain services are there in the United States, and who is managing patient-controlled analgesia? Anesthesiology. 1995;82:322. doi: 10.1097/00000542-199501000-00055. [DOI] [PubMed] [Google Scholar]
- 4.Goucke CR, Owe H. Acute pain management in Australia and New Zealand. Anaesth Intensive Care. 1995;23:715–7. doi: 10.1177/0310057X9502300611. [DOI] [PubMed] [Google Scholar]
- 5.Rawal N, Berggren L. Organization of acute pain services- a low cost model. Pain. 1994;57:117–23. doi: 10.1016/0304-3959(94)90115-5. [DOI] [PubMed] [Google Scholar]
- 6.Taverner T. A regional pain management audit. Nurs Times. 2003;99:34–7. [PubMed] [Google Scholar]
- 7.Rawal N. Organization, Foundation and Implimentation of acute pain services. Anaesthesiol Clin N Am. 2005;23:211–25. doi: 10.1016/j.atc.2004.11.012. [DOI] [PubMed] [Google Scholar]
- 8.Goldstein DH, Ellis J, Brown R, Wilson R, Penning J, Chisom K, et al. Recommendations for improved acute pain services: Canadian collaborative acute pain initiative. Pain Res Manag. 2004;9:123–30. doi: 10.1155/2004/397452. [DOI] [PubMed] [Google Scholar]
- 9.Rathmell JP, Wu CL, Sinatra RS, Ballantyne JC, Ginsberg B, Gordon DB, et al. Acute post-surgical pain management: A critical appraisal of current practice. Reg Anesth Pain Med. 2006;31:1–42. doi: 10.1016/j.rapm.2006.05.002. [DOI] [PubMed] [Google Scholar]