Taking the Pain out of Postoperative Prescribing

1
Taking the Pain out of Postoperative Prescribing
Walsh, S.B. , Strawbridge J. D. Pharmacy
Department, Mater Misericordiae Hospital, Eccles
Street, Dublin 7
Introduction

Postoperative pain is predictable and often
severe. It can delay postoperative mobilisation,
increase the risk of deep vein thrombosis and
prolong hospital stay. There are analgesics
available to relieve most forms of pain, however,
attitudes to prescribing and administration may
often limit their use.1 Aim To analyse the
provision of analgesic care to postoperative
patients in the Mater Misericordiae Hospital and
design guidelines to enhance this care.

• The retrospective audit of three surgical wards
  demonstrated that
• prescribing patterns exist that could be easily
  adopted as the basis of the guidelines
• where protocols exists there are significant
  economic savings to be made.
• The audit data was used to reconcile national and
  international acute pain guidelines to the
  situation pertaining in the Mater Misericordiae
  Hospital, with view to planning, piloting and
  implementing guidelines for postoperative pain
  relief on the Mater campus. The protocol which
  exists in the Cardiothoracic ward was not used,
  as it is different to the prescribing trends
  elsewhere in the hospital and therefore would be
  difficult to implement.
• It was decided to present the guidelines in a
  Schematic Format for ease of use, the step-wise
  approach to analgesia is visually demonstrated.

Method

• A questionnaire regarding analgesic guidelines
  was sent to 22 large teaching hospitals in the UK
  and Ireland.
• An evidence based review of analgesics was
  undertaken.
• A retrospective audit of analgesic use in three
  surgical wards (Orthopaedic surgery,
  Cardiothoracic surgery and Vascular surgery) in
  the Mater Misericordiae Hospital.

Results

• Fourteen replies were received from the 22
  hospitals surveyed. Of the replies, eight were
  from hospitals in the Republic of Ireland, four
  of whom had guidelines/protocols. Four of the
  replies were from hospitals in Northern Ireland,
  three of whom had guidelines and both of those
  hospitals in England that replied had guidelines.
  
• A general review the analgesics indicated those
  drugs which would be the safest and most
  efficacious for the treatment of each level of
  pain.
• Figures 1, 2 3 below demonstrate that
  prescribing patterns exist. The Cardiothoracic
  ward has protocol in place, and the expenditure
  on analgesics is only one third of the other two
  wards on a cost per patient per day basis.

Discussion According to the Report of the
Working Party of Pain after Surgery Provision
of effective, good pain relief leads to a
reduction in complications and morbidity and
increases what is an essential element of good
quality and patient satisfaction.2 The practise
of introducing specific postoperative analgesic
guidelines in the hospital setting is well
established3. Their intrinsic value relates to
issues of standardisation of service, which
in-turn promotes improved patient care and
minimises drug related errors. The derivation of
the guidelines in the project was undertaken with
a specific reference to simplicity, safety and
cost effectiveness. The drugs chosen are all
familiar to practitioners in the hospital and are
all already widely prescribed. It was an
integral feature to the process of deriving these
guidelines that substitution of familiar drugs
with newer and or less familiar agents, would
cause confusion and endanger the implementation
of the guidelines. The pilot of the guidelines
on the Orthopaedic ward was very successful.
They were well received, prescribing practices
improved, and economic benefits were demonstrated.
Conclusions The guidelines have been submitted
for approval by the Mater Misericordiae Hospital
Drugs and Therapeutics Committee for inclusion in
the next edition of the Mater Misericordiae
Hospital Drugs Formulary and Antimicrobial
Guidelines. This document is circulated
throughout the hospital and is issued to all Non
Consultant Hospital Doctors during their
induction to the hospital. The guidelines will be
promoted by the clinical pharmacy staff after the
launch of the new edition of the formulary though
education initiatives, stock list reviews and
prescription review.
Figure 3 TOTAL USAGE OF ANALGESIC DRUGS
Cardiothoracic Ward
1
4
4
5
0
1
2
3
1
1
31
References
47
1. Drugs and Therapeutics Bulletin, February
1993. Managing Postoperative Pain Vol. 31 No.
3 2. Report of the Working Party of Pain after
Surgery. Royal College of Surgeons of England
and College of Anaesthetics, 1990 3. Provision of
Pain Services. Published by the Association of
Anaesthetists of Great Britain and Ireland.