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									PAIN: THE 5TH VITAL SIGN
REVIEW OF ACUTE PAIN
   MANAGEMENT IN
      VICTORIA
          February 2003

                        Prepared by
        A/Prof Don Campbell and Dr Caroline Brand
     Clinical Epidemiology and Health Service Evaluation Unit
                        Melbourne Health

       A/Prof Tracey Bucknall and Beverley Copnell
      Victorian Centre for Nursing Practice Research
                 University of Melbourne




Commissioned by the Victorian Quality Council
       SURGICAL WARD: MEN

Something occurred after the operation
To scare the surgeons (though no fault of theirs)
Whose reassurance did not fool me long.
Beyond the shy, concerned faces of nurses
A single white-hot eye, focusing on me,
Forced sweat in rivers down from the scalp to belly.
I whistled, gasped or sang, with blanching knuckles
Clutched at my bed-grip almost till it cracked:
Too proud, still, to let loose bedlamite screeches
And bring the charge nurse scuttling down the aisle
With morphia needle levelled....
                                    Lady Morphia-

Her scorpion kiss and gyrating dreams-
She in mistrust of whom I dared out-dare,
Two minutes longer than seemed possible,
Pain, that unpurposed, matchless elemental
Stronger than fear or grief, stranger than love.
                                  Robert Graves
Review of Acute Pain Management in Victoria




                                            TABLE OF CONTENTS

EXECUTIVE SUMMARY ....................................................................................................................4
    KEY FINDINGS FROM LITERATURE .......................................................................................................4
    KEY FINDINGS FROM INFORMANT INTERVIEWS ...................................................................................5
    SUGGESTIONS..................................................................................................................................6
    A PATIENT CENTRED SERVICE .............................................................................................................7
    A COLLABORATIVE APPROACH ............................................................................................................7
    A KNOWLEDGE BASED SYSTEM OF CARE ............................................................................................7
INTRODUCTION ..................................................................................................................................9

LITERATURE REVIEW ....................................................................................................................11
    BACKGROUND ....................................................................................................................................11
    PAIN MANAGEMENT GUIDELINES.......................................................................................................11
    PROVISION OF PAIN MANAGEMENT SERVICES....................................................................................12
    BARRIERS TO INSTITUTING AND MAINTAINING FORMAL PAIN MANAGEMENT STRATEGIES ..............13
    EVALUATIONS OF PAIN MANAGEMENT STRATEGIES ..........................................................................13
    BARRIERS TO EFFECTIVENESS OF PAIN SERVICES ..............................................................................14
      Structural Issues ...........................................................................................................................15
      Organisational Issues ...................................................................................................................16
      Consumer Issues ...........................................................................................................................16
    NEEDS OF SPECIFIC GROUPS ...............................................................................................................17
CONCLUSION.....................................................................................................................................17

ACUTE PAIN SERVICES IN VICTORIA........................................................................................18
    METHOD .............................................................................................................................................18
    FINDINGS FROM INFORMANT INTERVIEWS .........................................................................................18
       Institutional Policy........................................................................................................................18
       APS Structural Frameworks .........................................................................................................19
       Training and Certification ............................................................................................................20
       APS Roles......................................................................................................................................21
       Pain Measurement ........................................................................................................................24
       Audit and Outcomes......................................................................................................................24
       Risk Management..........................................................................................................................25
       Special Issues................................................................................................................................26
       Barriers to the Delivery of Effective and Efficient Acute Pain Management................................28
       Provider specific barriers .............................................................................................................30
    ACUTE PAIN SERVICE WEBSITES ..........................................................................................................30

CONCLUSIONS...................................................................................................................................30

SUGGESTIONS ...................................................................................................................................31
    A PATIENT CENTRED SERVICE ...........................................................................................................32
    A COLLABORATIVE APPROACH ..........................................................................................................32
    A KNOWLEDGE BASED SYSTEM OF CARE ..........................................................................................32
REFERENCES .....................................................................................................................................34

APPENDIX I: WEBSITES ACCESSED............................................................................................39

APPENDIX II: GLOSSARY ...............................................................................................................41

APPENDIX III: KEY INFORMANTS...............................................................................................42




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EXECUTIVE SUMMARY
This review of acute pain services in Victoria was commissioned by the Victorian
Quality Council. The terms of reference for the review were:
1. to determine and scope the critical issues involved in the appropriate management
   of acute pain services within health services
2. to review existing pain management service delivery frameworks and practices
   within Victoria and comparable health systems
3. to identify specific areas where the delivery of acute pain management within
   Victoria may be improved and offer options for improvement.

The published international and local literature on acute pain management was
reviewed and relevant internet websites related to acute pain management services
were examined to determine the critical issues in service provision. A questionnaire
was developed and administered to a sample of service providers to establish the
range of Acute Pain Management services in Victoria in the acute care and
ambulatory services sector. Twenty-six interviews were conducted in total. The
majority of respondents were representatives of metropolitan and rural hospitals and
ambulance services within Victoria, while four were acknowledged experts in the
field of pain management from other states. Physicians from surgical, anaesthetic and
emergency departments, and nurses, were represented among the informants.

The professional leadership role of anaesthetists in developing Acute Pain Services to
date is acknowledged.

Quality in health care is identified as arising from a system that is patient-centred,
collaborative and knowledge-based. Hence, findings are summarised under these
headings.


KEY FINDINGS FROM LITERATURE
Systematic approaches to the management of acute pain have been advocated by a
number of published guidelines. International literature suggests that adoption of
recommendations has been limited and variable. Institutional commitment is cited as
the main barrier to implementation, with lack of resources – financial and other –
highlighted. Formal, institutionally-based, pain management strategies are widely
recommended. However, the evidence concerning their effectiveness is mixed.
Several studies indicate that some patients continue to experience severe pain despite
the availability of an Acute Pain Service (APS). The cost-effectiveness of APS has
not been established. There is mixed evidence concerning the safety of APS.

Patient Centred Service
Published guidelines recommend that patients be involved in their pain management
through routine assessment of pain and discussion of treatment options. Lack of
consumer knowledge and low expectations are cited as major factors in poor pain
relief. Provision of information to patients is seen as a key function of a pain service.
However, consumer input into the provision of pain services is not widely reported.
Patients’ views of appropriate outcomes do not appear to have been sought. The



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influence of context on pain assessment, and the meaning different individuals ascribe
to pain, have received little attention.

Collaborative Approach
A multidisciplinary approach to pain management is widely advocated. The literature
suggests this term has been variously interpreted in practice. The ideal structure of an
APS has not been determined. Generally, responsibility for pain management has
been assumed by anaesthetists. Nurse-led teams have been described, and are
proposed as being more cost-effective than anaesthetist-led models. Similar outcomes
have been reported from the two models, but no formal comparisons appear to have
been made.

Lack of collaboration between disciplines has been cited in the literature as a barrier
to effectiveness of pain management. It is reported to lead to lack of continuity of
patient care, with pain management being viewed as separate from overall patient
management.

Knowledge Based System of Care
Training and education of staff − within and beyond APS − are identified as the key to
effective pain management. International studies suggest that outdated practices
persist despite a considerable body of evidence. Organisational issues, which are often
complex, are strongly implicated in the persistence of mistaken beliefs and poor
management.


KEY FINDINGS FROM INFORMANT INTERVIEWS
Informants identified a number of barriers to effective pain management. Some
barriers are shared across all health providers and some are specific to certain settings.

Shared barriers include:
• Systems issues
       Education and awareness of all professional staff to issues relating to acute
       pain management.
       Inadequate resources
• Process issues
       Professional territorial imperatives
       Lack of allied health input resulting in transitional care problems
       Limited focus of APS
• Consumer issues
       Language and lack of interpreter assistance
       Lack of formal consumer information
       Limited consumer perspective in pain measurement.

Patient Centred Service
Service provision varies considerably. Provision of patient education and information
is often informal. Access to interpreters for non-English speaking patients was cited
as a problem. Most APS use some form of pain assessment. A variety of tools are
utilised and the frequency of pain measurement is variable.



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Most services did not undertake systematic program evaluation and risk management
was generally considered within the context of general hospital risk management
programs.

Collaborative Approach
Acute pain management in hospital wards is mainly provided by anaesthetists. Some
centres also have dedicated acute pain nurses and/or ward identified nurses with a
special interest in pain management. Informants in many cases considered that this
constituted a multidisciplinary team.

In rural areas, GPs are involved in provision of APS within the acute care sector,
either as the primary carer or as GP anaesthetists.

Informants identified a number of problems that appeared to be related to cultural and
territorial issues. These included anaesthetic/surgical interface, ED/surgical interface
and nursing /medical interface. Issues related to the interface between metropolitan
ambulance services and GPs are currently being addressed by both parties.

Knowledge Based System of Care
Education and training opportunities exist at formal undergraduate and postgraduate
certification and also for ongoing post-graduate education and accreditation. Higher
degree programs are offered at tertiary institutions for all health disciplines.

Most (but not all) centres require nurses to undergo formal training and certification
for administration of patient controlled and epidural analgesia, and for nurse-initiated
analgesia (NIA) in the Emergency Department (ED).

Education was identified as a major role of APS personnel. Lack of knowledge was
cited as a barrier to effective pain management. This is particularly important in light
of concerns raised about the potential for ‘deskilling’ of non-APS personnel. Conflicts
between health professionals were identified as impeding the transfer of knowledge
and the implementation of evidence-based pain management practices.


SUGGESTIONS
That the simple architecture for quality clearly enunciated by the Quality Chasm
report (Kelley 2001) underpin the redevelopment of Acute Pain Services in Victoria.

That a simple set of process and outcome measures for the APS be developed under
each of the headings identified as the guiding principles for safety and quality, along
with reporting requirements for these indicators, within a safety and quality
management system.

That the clinical governance arrangements for the APS be clearly identified in each
setting, along with an agreed set of criteria for these arrangements.




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A PATIENT CENTRED SERVICE
That an agreed parsimonious set of pain scales be developed and made available for
use, and the use of such assessment tools be regularly reported.

That information leaflets be produced for consumer use. Such information leaflets
should be developed with consumer input and address the issue of cultural and
linguistic diversity.

That the special needs of particular groups such as children and the elderly be
recognised and strategies to meet their needs be put in place.


A COLLABORATIVE APPROACH
That each service demonstrates how the service provided addresses the requirement to
be multidisciplinary.

That each service demonstrates how its clinical governance arrangements ensure that
a broad oversight mechanism is in place.

That the clinical governance arrangements should ensure the professional
development of service members.

That consumers should be represented in the oversight mechanism.

That minimum reporting standards should include a measure of the degree of
collaboration between service members and at transition points in the process of care.


A KNOWLEDGE BASED SYSTEM OF CARE
That an agreed library of supporting literature be available as a resource for service
providers. This could be made available on the Internet.

That clinical protocols for the management if common acute pain syndromes should
be readily available. Consideration should be given to facilitating the development of
computer order entry systems, which are linked to the protocols.

That credentialling for members of the APS be implemented, along with the
development of a standard pertaining to professional development of APS members,
with regular reporting against this.

That a set of sentinel event monitoring indicators be agreed upon, with responsibility
for reporting such events and actions arising therefrom to be developed as one of the
key activities supporting clinical governance for the APS.

That a set of agreed standards for drug delivery devices used by the APS be
developed and agreed, with regular audit of the drug delivery systems and reporting
on action to deal with any problems identified.



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That sentinel events reports and the audit data be made available in a transparent and
public manner to any parties with a legitimate right to know, for whom such
information may be important in choosing where to receive care.




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INTRODUCTION
The “Moonshot for Health” has been described as a safe and effective encounter with
the healthcare system (C Silagy, personal communication, May 2001). In setting out
to achieve the Moonshot, or goal, of an effective Acute Pain Service, what should be
our guiding principles? The Quality Chasm Report from the Institute of Medicine
(Kelley 2001) draws from complexity theory to suggest that simple rules must guide
us. The Quality Chasm Report identifies the three essential elements or simple rules
for a health care system which delivers high quality care as being: firstly, that it
should be patient-centred; secondly, that care should be collaborative; and thirdly, that
it should be knowledge-based where knowledge includes both evidence and expertise.
This Report concerning the provision of acute pain services unashamedly promotes
this view.

Many of our patients will experience pain during their encounter with the health care
system, whether as the primary reason for seeking care in the first place or as an
accompaniment or consequence of the care that they receive. Those who experience
pain may well take a nihilistic view of their experience, which they will endure rather
than seek relief. On their professional carers’ part, there may be a perception that pain
is a necessary or expected experience, or that to treat effectively may cause
habituation to analgesics and engender dependency. Is there a better way? What
would the system of care for these people look like if it worked perfectly from the
patient’s perspective? This is the challenge that confronts those who seek to redesign
and deploy effective Acute Pain Services for those who use Victoria’s healthcare
system.

Viewed in the context of the simple rules for quality, what should an Acute Pain
Service look like from the patient’s perspective? The literature review clearly
identifies what various protagonists identify as essential elements of an acute pain
service. The survey of pain service providers within Victoria and the limited number
of interstate providers contacted, suggests that any review and direction for the future
should take account of the simple rules approach. In many respects the reporting of
key performance indicators for an acute pain service could be redesigned and reported
against the rubric of these simple rules.

A patient centred service will acknowledge that the experience of pain and its
meaning to the patient are both important. The development of key performance
indicators relevant to the reporting of the experience of pain, its meaning, and its
timely management is relevant to meeting the needs of patients in the context of
overall management. The provision of appropriate information concerning the
experience of pain and its meaning incorporates a consumer perspective.

A collaborative approach to acute pain management will be met by ensuring that a
multidisciplinary team approach is taken. Whilst management of the service may be
nested within a vocationally oriented service department, there is clearly a need for a
range of service providers to be involved. Appropriate clinical governance
arrangements must be put in place to avoid professional groups from commandeering
the service to the exclusion of other disciplines with a legitimate role to play in
service provision. Thus it is the institution’s responsibility to ensure that an
appropriate oversight mechanism is in place for the APS which incorporates a

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consumer perspective, and ensures that relevant disciplines are involved. This
particularly relates to the acknowledged need for collaboration between surgeons,
anesthetists and nurses, but should not exclude input from Emergency Physicians,
allied health and other professional disciplines.

If collaboration is an important feature of a high quality APS, then there should be an
appropriate metric to measure and report this. Appropriate measures of the degree of
collaboration appropriate to the effective functioning of an APS should be identified
and reported on regularly as part of the overall approach to quality and risk
management.

Ensuring that all the available knowledge is brought to bear on the delivery of an
effective APS will require the body of evidence to be identified and available to the
APS. This includes both resource information and clinical protocols, to reduce
inappropriate variation in clinical management of acute pain syndromes. Expertise has
a critical role to play in the provision of an APS. At one level this can be met by
ensuring the appropriate credentialling of members of the APS, however the
continuing professional development of team members is essential. Regular reporting
against agreed performance indicators for professional development of team members
will ensure that the APS is not critically dependent upon key players, leading to
problematic service delivery in their absence. Further, the contribution of the APS to
the undergraduate education of relevant professionals and ongoing contribution to
post graduate education is an essential feature of a viable APS.

Clinical governance for an APS will require that the APS regularly reports
performance against agreed KPI’s under the above headings, and demonstrates that
appropriate risk management strategies are in place. Further, the institution must have
a mechanism to ensure reporting of sentinel events and inadequate performance
against performance indicators, and have a mechanism to ensure that action is taken in
response to such events. A voluntary incident reporting system for the APS would be
a healthy first step in achieving such clinical governance arrangements.

We should always remember FW Peabody’s exhortation that “the secret to care of the
patient is to care for the patient”. This report will be a success if it helps institutions to
focus on the needs of our patients, rather than allowing a nihilistic view of the
experience of acute pain and its management to persist (Peabody 1927).




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LITERATURE REVIEW

BACKGROUND
Acute pain is defined by the International Association for the Study of Pain as “an
unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage” and as being “always subjective. Each
individual learns the application of the word through experiences related to injury in
early life” (quoted by Anand & Craig, 1996). It is distinguished from chronic pain,
which is defined as pain that persists beyond the duration of an injury, or as arising
from an unidentifiable cause. This review is concerned only with the management of
acute pain.

Relief of pain is increasingly being viewed as a basic human right and, hence, an
ethical rather than purely clinical concern for health professionals (Cousins, 2000).
There is also growing recognition that unrelieved pain can adversely affect outcomes
from surgery and may lead to persistent (chronic), long term pain, with associated
financial and societal costs (NHMRC, 1999a). It is suggested that pain should be
viewed as the “fifth vital sign”, recorded, assessed and managed as regularly and
routinely as other physiological parameters (Stanik-Hutt, 1998; Winslow, 1998).

The problem of inadequate pain relief has been well documented in all developed
countries for many years (Manias & Bush, 1999). Numerous studies (such as Warfield
& Kahn, 1995; Yates et al., 1998) have demonstrated that despite developments in
analgesic techniques, many patients continue to experience severe pain. Health
professionals often lack understanding of the effects of pain. Indeed, underestimation
of patients’ pain, and underprescription and underadministration of medications, have
all been acknowledged as contributing factors.

Lack of knowledge is highlighted as a key issue in ineffective pain management.
Nurses and doctors frequently demonstrate inadequate understanding of
pharmaceuticals, and misconceptions concerning opioids, relating to the risk of
addiction, physical dependence, tolerance, and problems with side adverse effects.
Consequently, doctors may be reluctant to prescribe, and nurses to administer,
appropriate medications and doses (Coyne et al., 1999; Manias & Bush, 1999).


PAIN MANAGEMENT GUIDELINES
In response to these problems, a number of organisations in several countries have
developed guidelines to promote a systematic approach to pain assessment and relief.
These bodies include the UK Royal College of Surgeons and College of Anaesthetists
(1990); the Agency for Health Care Policy and Research in the USA (1992); the
American Society of Anesthesiologists (1995); the Australian and New Zealand
College of Anaesthetists (2000); and the American Academy of Pediatrics (2001).
The chief focus of the guidelines is postoperative pain, with an underlying assumption
that the same principles apply to other types of acute pain. Carr and Goudas (1999)
summarise the common elements of these guidelines as:
• Preoperative assessment of pain management options with the patient
• Preoperative instruction of cognitive-behavioural techniques

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•   Routine pre-emptive assessment and treatment of pain
•   Use of both pharmacological and non-pharmacological interventions
•   Selection of treatment according to clinical setting and modification to the
    patient's response
•   Provision of pain relief after discharge

The majority of guidelines also advocate a formal, institutional approach to pain
management. Institutionalised approaches aim to incorporate basic principles of pain
management into daily practice, rendering it an integral part of the culture of an
organisation (Merlin et al., 2002). Such interventions fall into two broad categories:
dedicated-service strategies such as Acute Pain Services, and multi-level strategies
developed through Quality Improvement or research utilisation programs.

The Australian National Health and Medical Research Council (NHMRC) have
produced a comprehensive set of guidelines based on best available evidence
(NHMRC, 1999a). The guidelines stress the need for a multidisciplinary approach to
pain management, and state that training and education of staff is the key to effective
management. The main focus of the guidelines is specific modalities of pain relief,
and no specific structure of service provision is advocated. A number of groups are
highlighted as having special needs and requiring particular attention, most notably
children, elderly patients, obstetric patients and those with cognitive or sensory
impairment.


PROVISION OF PAIN MANAGEMENT SERVICES
Surveys have been conducted in a number of countries to map the provision of pain
services and determine the extent to which published guidelines had been adopted.
They include five studies in North America (Zimmerman & Stewart, 1993; Warfield
& Kahn, 1995; Carr et al., 1998; Rayos & McDonough, 1999; Jiang et al., 2001); two
in the UK (Davies, 1996; Windsor et al., 1996); two in Europe (Rawal & Allvin,
1998; Stamer et al., 2002); three in Australia and New Zealand (Goucke & Owen,
1995; Merry et al., 1997; Turner & Halliwell, 1999) and one in Hong Kong (Hung et
al., 2002).

Results of these studies have been variable. The majority of studies indicated that
while the number of Acute Pain Services (APS) had increased, there was considerable
variation in service provision, and in understanding of what constituted an APS.
Monitoring and documentation also varied. Windsor et al. (1996) found 18% of
hospitals in the UK with a formal APS did not routinely assess pain and sedation.
Rawal and Allvin (1998) found that 39% of European hospitals used an instrument to
assess pain, and that routine assessment was performed in only one hospital. Turner
and Halliwell (1999) found that auditing practices in Australian APS varied widely,
with recording of side-effects of analgesic techniques varying from 30-63% of
services. Overall, the studies concluded that implementation of guidelines has been
limited and variable.

In addition, Warfield and Kahn (1995) found that the guidelines appeared to have had
little impact on the public. They conducted a survey of adults who had undergone



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surgery. They found that the majority had experienced moderate to severe pain, and
that 77% believed that postoperative pain was inevitable.


BARRIERS TO INSTITUTING AND MAINTAINING FORMAL PAIN
MANAGEMENT STRATEGIES
Institutional commitment, financial and otherwise, is identified in the literature as the
chief limiting factor in provision of pain services and the adoption of published
guidelines. Lack of commitment has been described as arising from lack of
motivation and the existence of other priorities (Davies, 1996; Stamer et al., 2002)
and disbelief in the clinical, economic or legal benefits of pain management strategies
(Jiang et al., 2001). Financial issues have also been highlighted: Davies (1996) cited
lack of funding as the main reason for no APS being instituted in UK hospitals, with
the majority of established services being funded from within existing budgets. Rawal
(2001) argues that anaesthetist-based APS – the commonest model in the USA – are
unsustainable due to their high cost, with many already being downsized. He argues
that a nurse-led team is a more cost-effective model. Lack of other institutional
resources – such as personnel skilled in pain management (Jiang et al., 2001) or staff
to provide 24-hour cover (Norman & Jackson, 1998) – has also been cited as a barrier.

In an effort to increase institutional commitment, in 2001 the US Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) incorporated pain
management standards into its manuals for accreditation of various health care
facilities. The guidelines mandate the regular assessment of pain and the
establishment of policies and procedures for effective pain relief (Phillips, 2000). It is
as yet too early to determine the effect of this initiative.


EVALUATIONS OF PAIN MANAGEMENT STRATEGIES
Since the implementation of formal pain management strategies, a number of studies
have investigated their effectiveness. Merlin et al. (2002) conducted a systematic
review of 32 such studies, of which 22 concerned multi-level strategies (MLS) and 10
dedicated services (ie, APS). The majority of studies were uncontrolled before-and-
after studies. The main findings of the review were:
• APS reduced the intensity of patients’ pain, although this reduction was not
    always clinically significant. MLS showed no consistent, clinically important
    effects on pain.
• Patient functional ability improved with both approaches (limited evidence). Data
    to assess the impact on quality of life is insufficient.
• Patient satisfaction with pain management increased with both approaches. The
    evidence for APS is of a higher level than that for MLS.
• Analgesia-related adverse events were reduced with both approaches; the
    evidence for APS is of a higher level.
• The practice of analgesia administration altered with both approaches: the use of
    patient-controlled or intravenous analgesia increased while intramuscular
    administration decreased.
• Prescribing practices were altered with both approaches. With APS, opioid
    prescription decreased while NSAID and paracetamol use increased; non-
    pharmacological methods increased with MLS.

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Werner et al. (2002) conducted a review of Acute Pain Services that included 44
audits and 4 clinical trials containing outcome data for over 84,000 postoperative
patients. The review found that most studies reported a decrease in patients’ pain
since the establishment of an APS, some studies reported a decreased incidence of
nausea and vomiting, and there was some evidence that postoperative sedation could
be decreased. There was mixed evidence on cost-effectiveness and the incidence of
adverse events. The authors emphasised the importance of integrating pain
management into the entire framework of perioperative care.

Only one evaluation study of an APS was found that was not included in either of the
above reviews. MacKintosh and Bowles (2000) studied nurses’ knowledge and beliefs
concerning pain before and after the introduction of a nurse-led APS in a UK hospital.
They found a trend, mainly non-significant, towards improvement in both areas.
However, it was difficult to attribute this finding to the effect of the APS, as no
attempt was made to survey the same individuals in both phases of the study.

Several studies, while not investigating directly the effectiveness of APSs, have
nevertheless contributed to knowledge in this area. Dolin et al. (2002) reviewed
studies that had pain or pain relief as an outcome. They determined that between 1973
and 1999 the incidence of severe pain had reduced by 1.9% per year. Nevertheless,
the overall incidence of severe pain was 11%, while almost 1 in 5 patients reported
poor or fair pain relief. Warfield and Kahn (1995), in a US study, found that most
patients who had undergone surgery experienced moderate to extreme pain and that
the pain continued after they received medication. This study was conducted three
years after publication of pain management guidelines in the USA, at which time 42%
of hospitals had established an APS. In a survey of UK hospitals, Austin (2002) found
that although 92% of hospitals surveyed had an APS, there were deficiencies in the
provision of epidural analgesia. Only 30% of hospitals offered epidurals to patients in
all surgical disciplines, and there were wide variations in policies and standards.
Karling et al. (2002) investigated paediatric pain management in Sweden by
surveying nursing and medical staff in all departments, except emergency, involved in
the treatment of children. Although 65% of departments surveyed had access to an
APS, and 72% had a nurse responsible for pain management, pain management was
found to be sub-optimal. Moderate to severe pain was estimated to occur in 23% of
postoperative patients and 31% of patients with pain of other origin. Pain assessments
were not performed regularly in most departments and pain measurement with a
validated tool was even less frequent.

Hence, the literature suggests that establishment of an APS is not sufficient to
guarantee effective pain management. The question remains: what makes an APS
effective?


BARRIERS TO EFFECTIVENESS OF PAIN SERVICES
Deficiencies in pain services, or possibilities for improving their effectiveness, do not
appear to have been investigated systematically. However, a number of issues emerge
from the literature as worthy of consideration. These issues can be categorised as
relating to the structure and function of the pain service, organisational factors, and
consumer concerns.

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Structural Issues
As already noted, the literature reports wide variation in the constitution and role of
APS. Rawal (2002) argues that the ideal structure of an APS has yet to be defined.
There is lack of agreement on even basic standards, both within and between
countries. Hence, it is difficult to compare outcomes. Some writers have argued for
standardised performance indicators and development of a minimum data set to be
adopted by all services (Turner & Halliwell, 1999; Sanders & Michel, 2002; Stamer et
al., 2002). Stamer et al. (2002) proposed five quality criteria for an APS, derived from
the various published guidelines:
• assignment of personnel to pain management
• organisation of patients’ care at night and at weekends
• written protocols for pain management
• regular assessment of pain scores at least once a day
• documentation of pain scores
Rawal (2002), however, argues that this should be a minimum standard and that a
good APS should do much more.

Risk management is another area of quality control in which there is little consensus.
The majority of published studies, as reviewed by Werner et al. (2002) and Merlin et
al. (2002) addressed the issue by monitoring adverse events. As discussed above, such
studies have had varying outcomes. Chen et al. (1998) proposed that incident
reporting would be a more effective tool and can help prevent adverse events from
occurring. They point out that critical incidents need to be defined in order for this
strategy to be utilised.

One aspect of the structure of a pain service is its composition in terms of personnel.
The majority of published guidelines recommend a multidisciplinary approach, but
the term is open to several interpretations. In practice, pain management appears to be
dominated by anaesthetists. This situation seems to have evolved because pain
management is seen as a logical extension of anaesthesia (Rawal, 2001; Concepcion
& Eappen, 2002), rather than having any scientific basis. Rawal (2001) suggests a
multidisciplinary team should consist of anaesthetists, nurses, pharmacists and
physiotherapists but it is not clear from the published literature how widely this
recommendation is adopted. Interestingly, this proposal excludes surgeons. The
NHMRC (1999) guidelines recommend inclusion of psychologists to advise on non-
pharmacological therapies. The effects of various disciplines on pain management do
not seem to have been investigated.

As discussed above, anaesthetist-led pain teams may not be cost-effective. Nurse-led
teams are common in Europe (Rawal & Allvin, 1998; Rawal, 2001) and have been
described in the UK (Gabrielczyk & McGonagle, 1997; Mackintosh & Bowles, 1997).
This structure does not appear to have been compared with a physician-led team in
formal studies; however similar outcomes have been reported by both (Merlin et al.,
2002).

Rawal (2001) suggests that the major problem with anaesthetist-led teams is lack of
continuity of patient care, and stresses the need for pain management to be integrated
into overall patient management. He also indicates that conflict, rather than



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cooperation, between surgeons and anaesthetists may be a common problem (Rawal,
2001; 2002). Strategies to overcome these problems are not addressed.


Organisational Issues
A number of organisational factors have been identified as impacting on pain
management practices. Those ostensibly the easiest to address include policies and
protocols relating to prescribing, checking and administering medications (Mann &
Redwood, 2000; Karling et al., 2002). Rawal (2002) stresses that nurses, the
professionals who have the most contact with patients, need to be able to administer
intravenous and intrathecal medication if it is to be delivered promptly. Other writers
suggest that nurse-initiated medication, using protocols, improves efficiency and can
be successfully implemented (Coman & Kelly 1999; Kelly 2000).

Other organisational factors may be more subtle. Nash et al. (1999) and Manias et al.
(2002) suggest that persistence of “norms” – attitudes, beliefs and expectations of
staff outside the pain service – may be difficult to overcome. The complexity of
organisational or contextual factors has been identified by several authors (Hester et
al., 1997; Wild & Mitchell, 2000; Bucknall et al., 2001, Manias et al, 2002). Wild and
Mitchell (2000) found organisational factors differed between wards in the same
institution, stressing the need for investigation of such factors at local level.


Consumer Issues
Consumer issues are mainly addressed in the literature in terms of knowledge and
expectations, in the wake of studies demonstrating that patients believe pain is
inevitable and that it can only be reduced, not eliminated (Warfield & Kahn, 1995;
Carr & Thomas, 1997). Provision of information to patients is included in all
published guidelines, while the NHMRC has produced a consumer version of its best
practice document (NHMRC, 1999b). While self-reporting is held to be the
cornerstone of pain assessment, there is little acknowledgement that reporting of pain
may be a complex issue. Anand and Craig (1996), for instance, suggest that the
context of the assessment – including who is eliciting the report, the tools used, the
reasons for assessing pain and the patients’ perceptions of the consequences of
reporting pain – is extremely important in determining whether and to what extent
pain will be reported.

Consumer input into the provision of pain services is not widely reported in the
literature. No studies appear to have been conducted to determine what outcomes
patients deem important.

An outcome that is frequently measured is patient satisfaction. However, as several
studies have found (Dawson et al. 2002; Dolin et. al, 2002; Merlin et al. 2002)
patients consistently report satisfaction with pain management in spite of experiencing
severe pain. A limited number of studies have investigated this phenomenon. Dawson
et al. (2002) suggested that patient expectations of pain and their relationship with the
care provider were important influences on patient satisfaction. Hwang et al. (2002)
found that pain perception and satisfaction were complex issues that changed over
time. One qualitative study (Sherwood et al., 2000) found that satisfaction was related

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to patients’ views of health professionals as caring and knowledgeable, and could be
low even if pain was relieved. No studies were found that investigated the meaning of
pain for individuals, and that accounted for contextual influences such as gender or
culture.


NEEDS OF SPECIFIC GROUPS
As indicated above, it is recognised that certain groups such as children and the
elderly have special needs in relation to pain management (NHMRC, 1999). It is
beyond the scope of this review to investigate the needs of these groups in detail.
However it should be noted that the literature suggests that pain may be less well
managed in these groups than the general population (Gaston-Johansson et al., 1999;
Golianu et al., 2000). This problem may be increased if patients are not cared for in
specialised units. For example, Karling et al. (2002) found that inadequate pain
management in children was more likely to occur in departments where adults and
children were treated together. Provision of family-centred care is held to be the
cornerstone of paediatrics; one study suggests this principle is not incorporated into
pain management practices (Simons et al, 2001). The needs of these groups are not
addressed specifically in the literature concerning formal pain strategies.



CONCLUSION
In summary, despite a proliferation of guidelines on pain management, and the growth
of dedicated pain management services, the literature indicates that patients continue
to experience moderate to severe pain. Evidence concerning the effectiveness of
formal strategies is generally of a medium to low level, and studies have yielded
mixed results. Consumer views are underrepresented in published literature.
Importantly, more work is needed to determine how improvements in pain
management can be achieved and sustained.




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ACUTE PAIN SERVICES IN VICTORIA

METHOD
The information for this review was elicited mainly from telephone interviews with
key informants. Informants were initially identified by staff within the Department of
Human Services and by searching of relevant web sites. During initial interviews a
number of informants suggested additional key personnel who should be contacted;
that is, a snowballing technique was utilised.

Thirty interviews were conducted in total. The majority of respondents were
representatives of metropolitan and rural hospitals and ambulance services within
Victoria, while four were acknowledged experts in the field of pain management from
other states. Physicians from surgical, anaesthetic and emergency departments, and
nurses, were represented among the informants. Acute dental care has not been
considered for the purposes of this report. A list of informants is provided in
Appendix II.

The interviews were structured and administered by phone or personal appointment.
They included the following domains: Institutional policy, current provision and role
of acute pain services, standardisation of pain assessment, auditing and feedback, risk
management processes, issues related to the interface of health professional groups or
healthcare sectors, barriers to effective acute pain management and opportunities for
capacity building. The interview transcripts were returned to the informants for
verification.

In addition, an Internet search was undertaken to identify information concerning
Acute Pain Services. The websites were accessed and their content assessed.


FINDINGS FROM INFORMANT INTERVIEWS
Institutional Policy
Statements relating to pain management are not formally incorporated into
expressions of hospital institutional clinical governance. One informant suggested this
accurately reflected institutional lack of support, "there's no money in pain".
Individual units, usually anaesthetic units or emergency departments, may include
principles of pain management, such as standards and best practice, in departmental
mission statements. The majority of respondents equated the presence of guidelines or
protocols for specific interventional methods of analgesia with institutional policy.
These were typically in the areas of pain assessment, epidurals, patient controlled
analgesia and multi modal management.

The ambulance service metropolitan (MAS) and rural (RAS) offers website
information that cites pain management as one of the major roles of the service.




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APS Structural Frameworks

Driving Forces
A significant number of metropolitan and rural centres have developed acute pain
service frameworks. In most part this has been in response to multiple factors. These
include: perception of a gap in current provision of APS, a documented audit gap in
the provision of APS, the presence of a (often new) clinical champion for provision of
APS, and evolutionary change due to extension of usual post-operative pain
management into the wards. None of the respondents specifically related the APS
development to the presence of national or international guidelines for development
of APS except for one metropolitan centre currently in the early development phase.

APS Constituency
In-patient APS
Acute pain management, in most instances, is provided by one or more anaesthetists
whilst a number of metropolitan and rural centres also have dedicated acute pain
nurses and/or ward identified nurses with a special interest in pain management. Most
respondents identified this clinician mix as ‘multi-disciplinary’ but recognised the
lack of allied health input. Although many identified a close working relationship
with allied health professionals, there is not dedicated funding for such staff outside
the persistent pain area. Very few identified easy access to psychological services for
acute pain management. Allied health staff, pharmacists and trainees of different
health professional groups may accompany the APS on ward rounds in some centres
although this was uncommon. It was more likely that they were consulted on a case
by case basis and they were usually associated with Chronic Pain Services.

In almost all institutions in which a formal APS exists, the in-patient service was
developed within the anaesthetic unit operational budget. The exceptions relate to
centres in which APS is provided primarily by a pain nurse, employed by the hospital
and supervised by nursing divisional heads. In such cases a close working relationship
has developed between the nurse and the anaesthetic department.

Emergency Departments (ED)
ED delivery of acute pain management generally occurs in isolation from inpatient
based APS provision. ED physicians and nurses provide pain management using a
framework of guidelines/protocols. A number of centres have introduced Nurse
Initiated Analgesia (NIA) although the methods vary between institutions. Legal
issues were raised as a concern: “Are the nurses prescribing or are they fulfilling
standing orders?”. One institution managed this issue by having a medical officer
countersign the order at the time of prescription. Another countersigned at a later time
in the treatment episode. Several informants suggested current legislation needed to
be reviewed to address this long-standing problem. In addition, the recent changes to
the Nurses (Amendment) Act 2000 to include the title Nurse Practitioner has the
capacity to allow the appropriately credentialed Nurse Practitioners, who may be Pain
Nurses, to legally prescribe analgesia and hence overcome these concerns.

Ambulance Services
Ambulance paramedics, intensive care paramedics (ICPM) and rural ambulance
volunteers are involved in providing acute pain management to the general public.

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Those who have trained in the Advanced Life Support (ALS) program can now
administer intravenous morphine.

General practitioners (GP)
GPs are involved in provision of APS within the acute care sector in rural areas. They
are often the primary carer in the inpatient setting and GP anaesthetists may be
involved in dedicated APS. In the community, in addition to ambulatory pain
provision on a daily basis and administration within the setting of residential care,
acute pain care is also provided in the emergency setting whilst awaiting ambulance
transfer.

Training and Certification
Medical staff
Undergraduate training provides problem-based teaching of acute and persistent
(chronic) pain management. This is often ad hoc and several informants felt this
arrangement to be inadequate. A current Australia and Pacific review of medical
school curricula is being undertaken with teaching of pain management having been
identified as a specific area of interest.

The ANZCA provides dedicated training in the provision of acute and persistent
(chronic) pain management for Anaesthetists. Advanced post-graduate training in pain
management is available through the Faculty of Pain Management, a medical faculty
that is multi-disciplinary. Currently one accredited position exists in Victoria at
Barwon Health. Other units have expressed an interest in participating in this training
program.

Postgraduate teaching to junior and senior resident staff varies between centres. Junior
staff are often offered a formal teaching program in which pain management may
form part of anaesthetic, surgical and ED teaching. However, more senior resident
medical staff receive ad hoc teaching according to unit and consultant exposure.
Interventions such as regional nerve blocks are commonly taught through the
traditional supervision method, “see one, do one, teach one”. Many pain nurse
consultants provide ad hoc education to residents and registrars and would prefer to
see more formalised multidisciplinary approaches to training.

Nursing staff
Most, but not all centres require formal training and certification for administration of
analgesic interventions such as patient controlled analgesia (PCA) and epidural
analgesia (EA). NIA in emergency departments also require training and certification.
Training for these interventions is usually provided by members of the anaesthetic
department, and by nurse educators who may have attended “train the trainer” type
sessions developed and offered by Acute Pain Nurses to build the capacity of the
institution.

ED and ward-based staff receive education from APS personnel. An issue raised in
relation to teaching was the, sometimes, rapid turnover of staff (especially in the
metropolitan area) and the difficulties this presented for retaining corporate memory
within a unit. The pain nurse consultant often provided an ongoing source of


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education in this situation. The education most frequently consisted of sessions on
managing PCA and EA, new drugs and multi modal methods of management.

Ambulance paramedics
Ambulance paramedics complete either; a three-year diploma or a 12-month program
(for those who have a health professional background). ICPM training requires at
least two years of work as an ambulance paramedic. Entry into the 12 month program
involves a selection process. Both ambulance paramedics and ICPM trainees undergo
role-specific pain management training. Those who undertake the ALS undergo a
yearly revision for ongoing accreditation. The RAS in the Ballarat area has had
training in the administration of femoral regional nerve blocks by Dr Mark Fitzgerald,
an ED director and trained paramedic who has provided consultative expertise to the
service for many years. This training is expected to extend statewide in 2003.

Ongoing education
In addition to those areas in which yearly revision is provided (primarily for
credentialling purposes), many health professionals are familiar with and have easy
access through personal, ward or ambulance-based copies of guidelines and/or
protocols for provision of acute pain management. An issue that arose in discussions
was the preferred use of the term ‘guidelines’ by medical professionals and some
nursing professionals. It was felt that the term ‘protocols’ raised the possibility that
management would be too restrictive and not individually tailored. One informant
suggested the use of this term could also result in potentially negative legal
implications.

Several informants mentioned the use of concurrent strategies for continuing
education such as link clinicians who had an interest in pain management, train the
trainer sessions, and practice prompts.

APS Roles

Pain Intervention
The extent to which services are provided varies considerably between institutions
and often in relation to the size of the anaesthetic department and the case mix of the
hospital. Most dedicated services offer medical and nursing cover during Monday to
Friday 9-5. They also offer some form of cover after hours and at weekends through
an anaesthetic registrar or an on call consultant anaesthetist. A minority of APS offer
service provision across campuses within a health service. Most are confined to a
single institution. One interstate hospital (Royal Adelaide) provides a phone service to
metropolitan and rural providers throughout the state.

In-patient APS
Metropolitan in-patient APS provides primarily post-operative pain relief. A small
proportion of APS provision is for non-operative pain relief in general medical or
general surgical wards. In some centres care is also provided for multiple trauma
patients and for burns. Obstetric and paediatric care is provided by the relevant
medical specialists in metropolitan hospitals and, frequently, by general practitioners
in the rural areas.



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Acute and persistent (chronic) pain management occurs largely in isolation from each
other. Most informants indicated a need for better integration of acute and persistent
pain services. Attempts by some APS units to integrate with existing persistent
(chronic) pain services have been successful whilst others have experienced
difficulties related to territorial issues. This is a problem if postgraduate training
positions are to be accredited by the faculty of pain management as one of the
requirements for accreditation of training includes training within a unit that provides
both acute and persistent (chronic) pain management training.

Pain medication is prescribed in the peri-operative area, is written up by medical staff
and is administered by nurses. Most dedicated services perform one (and, in some
cases, two-four) ward rounds per day, to follow up post-operative PCA and EA. Other
patient groups seen tended to be more complex or those with unrelieved pain. One
informant felt that this focus was ignoring the majority of hospitalised patients with
acute pain needs.

Whilst informants tended to discuss mainly interventional analgesic services, most
also provide expertise in multi-modal therapies. Alternative methods of pain control
were discussed by a paediatric surgeon and an academic nurse researcher. Both
indicated they considered there was a lack of consideration for such methods. This
may be partly related to the institutional imperative to minimise length of stay. It is
also probably related to the pain perspective of the predominant providers of APS,
anaesthetists. This view is supported by the emphasis on interventional methods of
analgesic administration. In addition cultural differences between communities may
influence the involvement on alternatives to pharmacological analgesia. One
anecdotal example cited, was that of the beneficial effect of stroking and breast
feeding in infants who had undergone surgery that was noted by a surgeon whilst
working in less developed countries. The surgeon also described his own use of
cognitive behavioural techniques for parents pre-operatively.

ED
The focus of discussions surrounding ED provision of acute pain management was
directed towards use of NIA and improved delivery of APS using Breakthrough
collaborative methodology. The latter is a method of implementing change in clinical
management by using simple measurement techniques and regular reporting of
performance against targets. In this instance the issue was that of “time to analgesia”.
In the ED APS are provided for trauma, acute surgical conditions, burns, acute
medical conditions (in particular chest pain) and acute on persistent (chronic) pain
requests.

NIA is available for management of fractures in one institution, for administration of
opiate analgesia in another and for administration of oral analgesics, anti-
inflammatory agents and morphine in another. Most EDs have a separate protocol for
management of migraine headache. Several informants identified a gap in APS
provision for acute on persistent (chronic) pain patients: “They are considered low
priority and generally attend solely for analgesia and not for diagnosis, and therefore
often wait considerable periods of time”. Regarding pain as a low priority fails to
acknowledge the physiological and psychological sequelae that may result from poor
pain management. Another informant felt there were inadequate community referral
options and in the rural setting, often no options at all.

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Ambulance Services
There are limited choices for provision of acute pain management in the MAS and
RAS. For acute pain of non cardiac origin, paramedics have access to inhaled
methoxyfluorane and morphine. There are no alternatives for those with opiate
intolerance or allergy although the latter was described as extremely rare.

There is a planned initiative to evaluate, within a randomised controlled trial design,
the benefits of intranasal fentanyl in comparison to intravenous morphine. This study
represents collaboration between RAS and the Department of Rural Health at Monash
University. It is currently unfunded.

Another initiative plans to assess the use of midazolam combined with morphine in
order to reduce the dose of opiates required.

Education
Education was identified as a major activity of all APS in all areas of service
provision. Education was predominantly viewed with regard to maintaining standards
of training, particularly of nursing staff responsible for analgesia administration.
There was emphasis on competencies in interventional analgesia, new drug therapies
and multi-modal management. Frequently nurses delivered pain education to
multidisciplinary groups on an informal basis although some participated in graduate
tertiary courses.

‘Champions’ of acute pain management identified gaps in undergraduate medical and
nursing training and for postgraduate ward-based staff. However, concerns were
raised, by surgical staff in particular, that dedicated APS provision, controlled in
isolation from surgical management would potentially result in de-skilling of junior
(surgical) staff. This was seen to be a particular problem as only a small proportion of
post-operative patients receive intervention from the APS. Nursing staff also indicated
some concern about de-skilling of ward staff where the APS “took over as the
experts”. The preferred model of APS provision was for pain nurse consultants to
provide a liaison role between parent unit and APS and to focus on empowerment of
the ward staff through education and support.

Patient education was not discussed as a priority issue. Pre-operative patient
information is often informal (discussion without written documentation) and was
considered “patchy” by some. There appears to be some uncertainty as to the level of
information required and the best methods for dissemination. The information given
currently relates primarily to the use of interventional post surgical PCA and EA.
There is no standardised documentation of patient expectations and preferences.
Several informants felt this to be a deficit in institutional policies given the research
demonstrating the positive effect on patient outcomes of pre-operative information
and education. Issues of cultural and linguistic diversity are not addressed as part of
APS provision currently.




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Pain Measurement
Most APS reported using some form of pain assessment. In most instances this
consisted of either a numerical rating scale or visual analogue scale of patient self-
report. Several informants described the addition of pain intensity scales to the vital
signs observation charts, which acted as a practice prompt for clinicians and raised the
profile of pain to what is commonly expressed as “the 5th vital sign”. Multi-
dimensional scales are uncommonly used and for patients unable to communicate
through age or language difficulties, behavioural indices, smiley faces, sliding scales
or “guess” were used. Two centres routinely use the multi-dimensional FLACC scale
for paediatric patients. One centre used modality-specific questions, which included
objective and subjective, static and dynamic measurements.

Interpreters were used in some centres but problems with access were cited and most
informants felt they were more likely to be utilised for patients with persistent pain
problems.

Frequency of pain measurement is also variable.

Pain researcher Dr Kay Price identified a problem with pain measurement in that it is
highly dependant upon the perspective of the person who is administering the
measurement. Dr Price suggested a better patient-centred approach to measurement
would focus on function. A daily assessment of functional expectations would then
include pain assessment as one of a number of factors potentially contributing to
barriers to achieving the desired level of function. Dr Price stated

         “…. many would say this is a backward movement in relation to
         pain management as it is about understanding that some people
         are stoical and will not ask for pain relief. However, if nurses were
         given the time to be able to communicate with people (to talk to
         them and support them) then we could understand their needs and
         they could have the education and support necessary to guide them
         in ensuring effective pain relief is administered”

Audit and Outcomes
Desirable outcomes were generally reported in terms of "good pain control with
minimum side effects" rather than within an holistic patient functional framework.
Few informants described a systematic approach to program evaluation that
incorporated structural elements, process elements and patient-centred outcomes.

The barriers to adequate data collection and analysis identified through the
discussions were;
• Lack of knowledge of data management and evaluation techniques
• Lack of personnel resources to collect and enter data
• Lack of departmental support for data collection and evaluation
• Lack of institutional support for data collection and evaluation
• Lack of equipment for data storage




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Whilst many hospitals used incident reporting forms, several informants stated the
lack of reporting on particular adverse events, such as Naloxone administration for
respiratory depression or equipment malfunction, masked the true picture of patient
outcomes, except in severe cases.

A number of units however indicated a desire for, and in some cases were beginning
to pilot, rapid entry options such as palm pilot data entry. Several informants
indicated the potential benefits of standardised assessment forms and an agreed
minimum data set for data collection. In the rural area these would need to be
carefully considered in relation to the special needs of these communities. A major
problem was identified with regard to the inappropriate and ineffective translation of
national and international guideline recommendations within the rural setting.

Outcome indicators tended to be considered only within the context of the peri-
operative setting and ED setting where target times to recovery room discharge and
time to analgesia were used respectively. One informant had instigated a policy of
pain management that aimed to achieve a pain intensity score of less than 3 or the
patient states that they are comfortable enough to cough, deep breathe and move.

Risk Management
Risk Management was generally considered within the context of general hospital risk
management programs, within anaesthetic departmental governance, within the
provision of specific interventions such as PCA or EA or not in any formal manner at
all.

Education
Education was considered an integral activity for risk management and harm
minimisation. On-call services, after-hours availability and twice or more daily ward
rounds were all considered part of risk management. Interestingly, in this survey,
none of the APS employed pain nurses out of regular hours. This was considered by
several nursing staff to be problematic as the anaesthetic registrars lacked dedicated
time on weekends to review patients, but rather added it to their other duties.

Equipment
This area was considered of prime importance in risk management. Several
informants described the use of pumps that were lockable, rate limited, easily
recognisable, not interchangeable, non-tamperable, and had specific delivery systems
for PCA and EA. Most, but not all metropolitan and some rural centres hospitals had
these pumps. Lack of resources was cited as the major reason some centres did not
have dedicated equipment. There was awareness of previous coronial inquiries related
to the use of non-dedicated pumps. The question was raised as to whether there
should be restriction of one dedicated pump for each intervention: “It may be better
for safety in the short term but worse for education in the long term”. The issue of
experience-based learning (learning by doing or learning from mistakes) and
appropriate monitoring of performance requires further exploration in the context of
risk management and a safe effective encounter for the patient. The Royal Adelaide
Hospital uses premixed 'cocktails' of defined dosage regimes supplied by the
pharmacy department.

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Accreditation
This has been discussed earlier. Most, but not all, nurses undergo formal credentialing
and reviewed competency annually for administering PCA and EA. The courses are
not standardised and may be delivered by non specialist nurse educators who have
been trained by the pain nurses to run competency based courses.

Pharmaceutic agents
All centres have similar ward-based procedures with regard to the administration of
analgesic medications. Patients do not have control over oral pain management
therapies. In the rural setting, where communities are isolated from pharmacies,
especially after hours and on weekends, initiatives, such as NIA and access through
community health services are being explored. Trained volunteer paramedics can
provide inhaled methoxyfluorane. One informant described prescription limits being
set such that emergency prescriptions from the lock zone can be given in response to
identified changes in BP, pulse rate and respiratory rate. Another informant described
the use of naloxone prescription rates as a proxy marker of over sedation.

Patient satisfaction
A limited number of informants identified specific pain questions within hospital and
ambulance general satisfaction surveys. Other groups perform APS satisfaction
assessments. The usefulness of patient satisfaction and the appropriate identification
of patient satisfaction were raised as issues for further discussion. Assessment of
patient functional outcomes and patient driven VAS target scores were raised as
options.

Adverse Events
Most centres have formal structures in place for the reporting of adverse events,
however the reporting of events that are not critical incidents is not standardised and
such decisions may be made by the APS consultant or director. This could result in
potential conflicts of interest. The responsibility and potential conflict of interest
inherent in such a system have been addressed within the MAS and RAS where there
is a formalised audit system performed by independent personnel that accounts for
every patient service.

Special Issues

Transitional care
A number of informants identified significant problems with regard to transitional
care from hospital to home. Early post-operative discharge could potentially result in
early transition from parenteral to oral analgesic medication such that post discharge
pain levels may not be adequately controlled, thus limiting mobility and potentially
increasing respiratory risk and delayed recovery. Some patients would benefit from a
short course of oral opiates after discharge but the current prescribing guidelines don’t
allow less than one month’s supply. This will result in unnecessary wastage and a
large burden of unused health cost. Potential solutions to these problems were


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suggested; the use of HITH for some surgical patients, use of a ‘pain pack’ with
multi-modal therapies and improved consensus with regard to clinical pathways or
protocols for postoperative pain management.

Transitional care issues are generally not a problem in the rural setting as GPs are
usually the prime carer and are involved in the hospital admission process.

Transition from GP to ambulance paramedic care for hospital transfer has been an
issue in the metropolitan setting. It is perceived that there has been inadequate pain
management whilst awaiting paramedic attendance in some instances. This is
currently being addressed by discussions between the MAS and GP groups. The MAS
also has an initiative that involves the use of a dedicated locum service for
management of conditions thought not to require ED assessment. This will include
patients with acute pain. Within the RAS such issues have not been identified to be a
major problem.

Transition from ambulance paramedic to ED was not identified to be associated with
specific issues.

Health Professional Interface
Several areas were identified that appeared to be related to cultural and territorial
issues. These included anaesthetic/surgical interface, ED/surgical interface and
nursing /medical interface.

Surgical Issues
The previously identified problem between ED and surgical staff with regard to pain
relief prior to surgical assessment appears to have largely settled. Several informants,
surgical and non-surgical, referred to the previously held opinions that pain relief
impaired surgical assessment of the acute abdomen as “largely mythical”. ED
indicated that their targets for administration of pain relief was 30 minutes and
surgical staff had no formal processes in place by which assessment could be
guaranteed within such a period. Often patients waited “hours” for surgical
assessment.

All surgeons identified potential problems with APS that were not integrated within
surgical management. Anecdotal examples of adverse effects of inappropriate
medication were cited, as well as difficulties when the APS team was called overnight
without notification of the surgical unit who might not assess the patient until 9am the
following day. Surgeons emphasised the need for appropriate consideration of
surgical complications that the continuity of surgical management offered. One Pain
Nurse Consultant agreed with these comments and stated she always notified the
surgical unit if she was called. Once again, the difficulty of access to the surgical
registrar and delay in assessment by the surgical team in contrast to the APS
encouraged consultation of the latter.

A further issue for surgical staff is the different perspective on pain exhibited by the
APS. This appears to be more of an issue for some specialist areas than for general
surgery. In particular some informants felt that the APS use more analgesia than
necessary and for longer periods than necessary and that this delays mobility and

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ambulation and increases length of stay. A rural centre has been currently auditing the
outcomes of epidural analgesia and some limited data suggests that outcomes are
better for those with adequate analgesia (defined) within the first 24-48 hours. Further
information and research in this area is indicated.

In general surgeons felt that in the ideal model of APS, the service would provide
drug and therapeutic administration expertise but that pain management responsibility
would lie with the surgical management team. If the APS was notified regarding a
patient, the surgical team should also be notified and that there should be a culture of
“shared concern rather than a culture of competition, posturing and politicking”.

The issue of ‘de-skilling’ has been discussed above.

Pain Nurse Consultants
A significant concern for informants was the attitudes they encountered from some
surgeons when checking postoperative pain management on patients. Some
informants commented on the hostility encountered and possessiveness of surgeon.
Several informants felt that some surgeons disliked the automatic referral system that
alerted the pain nurses to postoperative patients. In addition it was felt that some
surgeons used traditional and in some cases outdated pain management practices that
directly informed behaviours of younger medical staff.

Outdated pain management practices by surgeons was a further concern noted,
particularly when their knowledge was transferred to less experienced medical staff.

Executive Support
Very few informants noted the need for executive support in changing clinician
behaviours. This was surprising given the overwhelming call by all informants for
further resources and in view of the published literature evidence that such support is
necessary for effecting behavioural change. (Donald, A et al, 2002)

Paediatrics
As noted in the literature review, children’s pain management needs differ to those of
adults. Issues include appropriate pain assessment methods, the influence of anxiety
and fear on pain perception, and the need for comfort in addition to analgesia.
Informants from the Royal Children’s Hospital Pain Management Service expressed
the view that, outside of the specialised environment of the Royal Children’s Hospital,
paediatric pain was poorly managed and frequently did not accord with the NHMRC
guidelines (for instance, intramuscular injections were in some institutions the only
method of analgesic delivery).

Barriers to the Delivery of Effective and Efficient Acute Pain
Management
There are barriers that are shared across all health providers and barriers specific to
certain settings. Shared barriers have been categorized into three areas.



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Shared Barriers

Systems
All informants agreed that resource inadequacy was a major issue impacting on the
quality and scope of the service. This was evident in the altered coverage for the
service out of hours and at weekends, which typically had an anaesthetic registrar
picking up the role in addition to normal duties. Most providers indicated a lack of
resources to perform program evaluation and in particular to perform audit and
feedback on APS effectiveness. Some providers felt that there was a lack of dedicated
equipment that would increase the safety of usage and prevent adverse events.

All informants identified education and awareness of all professional staff to issues
relating to acute pain management as less than optimal. Some suggested that poor
practices were passed on from experienced to less experienced clinicians rather than
the use of research evidence. This was particularly evident in the under-treatment of
pain in specific groups such as the elderly, children and the cognitively impaired. Pain
management was not highly prioritised by clinicians generally so there was low
motivation to attend continuing education sessions. Specific areas within accreditation
were highlighted in metropolitan and rural settings. Lack of nursing staff in one
metropolitan hospital resulted in use of cubicles for acute on persistent (chronic) pain
patients who required parenteral analgesia and follow-up supervision. Some providers
indicated deficiencies in resources with regard to environmental limitations in ED
such as limited cubicles, chairs and space.

It was also noted by some informants that there was a restricted choice of analgesia
sometimes due to economic constraints affecting pharmacy coverage and supply of
medication.

Process
Several significant issues arose from the survey surrounding the organisation of care
in APS. In particular professional territorial imperatives were primarily identified as a
barrier in the metropolitan hospital setting. Interpersonal tensions between disciplines
has been discussed earlier.

The transition of care was discussed by several informants in relation to the lack of
Allied Health input into complex cases, particularly those patients presenting with
acute on persistent (chronic) pain management requirements. It was difficult to
manage these patients when the services for persistent (chronic) pain patients were
deficient in the system and their acute episodic requirements were attended to.
Clinical pathways tended to deal with specific operative procedures and management
afterwards.

The limitations of Acute Pain Services were recognised by several informants in
relation to the focus being on PCA and EA pain management when the majority of
hospitalised acute care patients require pain management of a less technological
nature.




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Consumer
Interestingly barriers relating to consumers were less frequently raised by the survey.
The most frequently reported barrier was language and lack of assistance with
interpretation. This leads to considerable difficulties conducting pre-operative
education, which even without the barrier of language, was suggested by informants
as being infrequently or never conducted. A further barrier was the lack of available
written information for patients. Despite the fact that most providers use either VAS
or NRS as the preferred tools of assessment, written information about how these
tools inform staff about the intensity of patient pain and the effect on patient outcomes
was absent.

Provider specific barriers

Rural Issues
A number of rural issues were identified. These included:

•   Lack of hospital and community-based persistent pain services for integration
    with acute pain services. Lack of outpatient services for follow up of persistent
    pain problem
•   Inadequate access to a range of pharmaceutical therapies for acute pain
    management in remote areas.
•   Lack of culturally sensitive guidelines for acute pain management in the rural
    setting.
•   Lack of training facilities and expertise for nurse administered PCA and EA


ACUTE PAIN SERVICE WEBSITES
Seventeen websites were accessed. The websites varied considerably in the amount,
quality and consistency of detail provided. Relevant material was frequently difficult
to find. Generally, the websites contained scant information for patients.



CONCLUSIONS
The review of the existing acute pain services in Victoria that is reported in this
document clearly demonstrates the problems that bedevil the development of a
consistent and accountable service. Kelly and Tucci (Kelley 2001) describe US health
care as being fragmented, with no common information systems, no national payment
standard, and only a handful of national quality standards.

        “Providers are driven by highly individualised value needs, not by any
        common desire to improve health care. Before we invite experimentation in
        this challenging environment, we should candidly explore the motivation and
        incentive of those who provide care in this current environment. Without the
        knowledge and use of internal rewards to create and sustain key behaviours in
        providers, we have little chance of widespread, enduring improvement in the
        processes and systems of health care”.



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This brief review demonstrates that the growth of APS has been driven by the highly
individualised value needs of the professionals who constitutive service providers.
Similarly the governance arrangements for such services should surprise no one with
the briefest knowledge of the working of an acute health service, by virtue of their
seeming lack of accountability and lack of provision of reliable service audit data
beyond such data as is provided to sentinel event reporting programs within
Departments of Anaesthesia.

The literature review indicates that many organisations have identified the need to
improve the quality of care for acute pain management. The evidence in support of
best practice is well documented, as is the variety of service management approaches
taken. The literature is less clear about how service improvement is to be achieved
and maintained. Kelley and Tucci’s (Kelley 2001) advice to undertake research to
determine the motivations and incentives of providers is particularly apposite when
there is an urgent need to promote enduring improvements in the process of care for
patients who require a safe, effective Acute Pain Service.

The emerging interest in the concept of clinical governance provides an opportunity
for shared ownership of the safety and quality agenda. Whilst some have advocated an
initial emphasis on safety above quality, the Acute Pain Service provides an
opportunity to develop a framework for clinical governance, which moves beyond the
professional accountability model to one which involves integration of the clinical
quality framework with other organisational structures. (Smyth 2002).

Scott has argued that the successful implementation of clinical governance will
require: better information systems and methods of communication, organisational
change, and a cultural shift on the part of practicing clinicians towards a more open
and impartial evaluation of clinical care and its outcomes (Scott 2002).

If evaluation against agreed standards is at the heart of clinical governance, along with
a desire to remedy any perceived gaps in clinical practice (Scott 2002), then firstly the
standards must be identified and agreed upon.



SUGGESTIONS
It is suggested that a simple set of process and outcome measures, be developed along
with reporting requirements for these indicators within a safety and quality
management system. Clinical governance means that responsibility for these simple
requirements moves beyond the service departmental structure based on an individual
professional discipline.

We suggest the use of the simple architecture for quality clearly enunciated by the
Quality Chasm report, as the basis of the redevelopment of Acute Pain Services in
Victoria. The overarching principle, to guide the redevelopment of the APS, should be
to produce and maintain a system of care that is safe and effective from the patient’s
perspective.

The clear needs are for an agreed set of indicators to be developed and for the clinical
governance arrangements for the services to be clearly identified in each setting. It

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would be particularly useful if an agreed set of criteria could be developed for the
clinical governance arrangements.

The performance indicators for the APS be developed under each of the headings
identified as the guiding principles for safety and quality.


A PATIENT CENTRED SERVICE
We suggest the development and promulgation of an agreed parsimonious set of pain
scales and regular reporting of the use of such assessment tools. We suggest the
production of information leaflets for consumer use. Such information leaflets should
be developed with consumer input, and should address the issue of cultural and
linguistic diversity. The special needs of particular groups such as children and the
elderly must be recognised, and appropriate strategies to meet their special needs put
in place.


A COLLABORATIVE APPROACH
We suggest that each service demonstrate how the service provided addresses the
requirement to be multidisciplinary. Each service should demonstrate how its clinical
governance arrangements ensure that a broad oversight mechanism is in place that
ensures the professional development of service members.

We suggest that consumers should be represented in the oversight mechanism.

We suggest that minimum reporting standards should include a measure of the degree
of collaboration between service members and at transition points in the process of
care.


A KNOWLEDGE BASED SYSTEM OF CARE
We suggest the development of an agreed library of supporting literature be available
as a resource for service providers. This could be made available on the internet.

We suggest that clinical protocols for the management if common acute pain
syndromes should be readily available and that consideration should be given to
facilitating the development of computer order entry systems, which are linked to the
protocols.
We suggest the institution of credentialling for members of the APS, and the
development of a standard pertaining to professional development of APS members,
with regular reporting against this standard.

We suggest the development of a set of sentinel event monitoring indicators with
responsibility for reporting such events and actions arising therefrom to be developed
as one of the key activities supporting clinical governance for the APS.

We suggest regular audit of the drug delivery systems and action to deal with any
problems identified. In particular there should be a set of agreed standards for drug
delivery devices used by the APS.

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The sentinel events reports and the audit data should be made available in a
transparent and public manner to any parties with a legitimate right to know, for
whom such information may be important in the decisions they make in relation to
choosing where they receive care.




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Smyth T. Safety and quality. Australian Health Review. 2002;25:78-87.

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.




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APPENDIX I: WEBSITES ACCESSED
Alfred Hospital
http://www.alfred.org.au/departments/anaesthesia_and_pain_management.html

Southern Health MMC
http://www.southernhealth.org.au/

Southern Health Dandenong Hospital

ARMC
http://www.armc.org.au/

Eastern Health Maroondah Hosp
http://www.easternhealth.org.au/maroondah/maroon.html

Eastern Health Angliss Hospital
http://www.easternhealth.org.au/angliss/ang.html

Barwon Health Geelong Hospital
http://www.barwonhealth.org.au/

Melbourne Health
http://mh.org.au

St Vincent's Health, St Vincent's Hospital
http://www.svhm.org.au/

Western Health Western Hospital
http://www.wh.org.au/contact/

Women's & Children's Health
http://www.rch.unimelb.edu.au/index-ext.html

Bendigo Health Care Group
http://www.bendigohealth.org.au/

Mildura Base Hospital
www.mildurabase.ramsayhealth.com.au/mildurabase/

The Victorian Ambulance Service
http://www.ambulance-vic.com.au/

Other
Pain.com: A world of information on pain http://www.pain.com/

American Academy Of Pediatrics http://www.aap.org/

Agency for Health Care Policy and Research http://www.ahcpr.gov/

American Society of Anesthesiologists http://www.asahq.org/

American Society of Regional Anesthesia and Pain http://www.asra.com

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ANZ College of Anaesthetists http://www.anzca.edu.au/

Partners Against Pain http://www.partnersagainstpain.com/

Joint Commission on Accreditation of Health Care Standards (JCAHO).
http://www.jcaho.org/

Joanna Briggs Institute http://www.joannabriggs.edu.au/




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APPENDIX II: GLOSSARY
Multi level pain management strategies (MLS): interventions that attempt to
change the practice of pain assessment and management at all levels of the institution.
Strategies are developed to modify existing pain assessment and management
policies, procedures and practices. May be developed by a multi-disciplinary pain
management committee or taskforce, and sometimes piloted on a single ward or unit,
before being implemented hospital or institution-wide. Strategies may be developed
through Continuous Quality Improvement activities or as research utilisation
(evidence-based practice) programs. Interventions may target staff, patients, or both.

Clinical governance: ‘corporate accountability for clinical performance'. It provides
a coherent framework through which the goals of safeguarding high standards of
clinical care, and facilitating continuous improvement in the quality of care can be
realised.

The FLACC Pain Scale: intended for use with infant and pediatric patients age 0-3
years, cognitively impaired patients, and those patients unable to use other scales. Has
five categories: (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability. Each
category is scored from 0-2, which results in a total score between zero and ten.

Visual Analogue Scale (VAS): Employs a 10-cm line rated from ‘no pain’ to ‘worst
possible pain’, on which the patient marks their pain. The pain score is the distance
from the ‘no pain’ point to the patient’s estimate.

Numerical Rating Scale (NRS): Asks the patient to rate their pain between 0 (no
pain) and 10 (worst possible pain).




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APPENDIX III: KEY INFORMANTS

Metropolitan Hospitals

Anaesthetics
Alexander Gillies                Eastern Healthcare
Colin Goodchild                  Southern Health
David Lindholm                   Bayside Health
David Skewes                     Peter MacCallum Hospital
Daryl Williams                   Melbourne Health
David Scott                      St Vincent's Hospital

Surgery
Rodney Judson                    Melbourne Health, general surgery,
Stephen Graves                   Melbourne Health, orthopaedic surgery
Paddy Dewan                      Women and Children's Health, paediatric surgery,

Emergency Department
Mark Fitzgerald                  Bayside Health
Anne-Maree Kelly                 Western Health
Michael Yeoh                     Austin Repatriation Medical Centre

Nursing
Stephanie Dowden                 Royal Children's Hospital, Pain Nurse Consultants,
Sueann Penrose                   Royal Children's Hospital, Pain Nurse Consultants,
Jenny Gozdzik                    Royal Women’s Hospital, Pain Nurse Consultant,
Pauline Parker                   Melbourne Health, Pain Nurse Consultant

Geriatrics
Mike Dorevitch                   Austin Repatriation Medical Centre

Rural Hospitals

Annette Cudmore                  Goulburn Valley Health, Pain Nurse Consultant
Brett Walker                     Goulburn Valley Health, Emergency Department Nurse
                                 Unit Manager
Alan Wolff                       Wimmera Healthcare, Medical Director

Sue Roney                        Mildura base Hospital, Theatre Nurse
Pam Reeves                       Barwon Health, Pain Nurse, Chair of Pain Nurses
                                 Special Interest Group
Tony Weaver                      Barwon Health, Anaesthetist

Ambulance Services

Grant Hocking                    Metropolitan Ambulance Service, Acting manager,
                                 clinical standards and audit.
Tony Walker                      Rural Ambulance Service, Manager of clinical and
                                 educational services

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National Key Informants

Kay Price                        University of South Australia, Senior Lecturer
Pam MacIntyre                    Department of Anaesthetics, Royal Adelaide Hospital,
                                 SA.
Ross MacPherson                  Royal North Shore Hospital, NSW, Anaesthetist
Patsy Yates                      University of Technology, QLD, Associate Professor
Geoff McColl                     University of Melbourne, Dean Clinical School, Royal
                                 Melbourne Hospital




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