Acute Postoperative Pain APOP: A quality improvement initiative

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Acute Postoperative Pain APOPA quality
improvement initiative

• Feedback
• A quality improvement initiative in collaboration
  with

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Insert Hospital Logo Here
Hospital APOP contacts

• Local Coordinator
• Insert name here
• Local APOP Team
• Insert names here

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Overview

• Aims and methods
• Best practice in acute postoperative pain
  management
• Feedback on audit of current practice
• Education and ongoing monitoring

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Aims of APOP

• To improve the quality of acute postoperative
  pain management by targeting three key areas
• Pain assessment pre and postoperative
• Analgesic prescribing promoting safe and
  effective use of analgesics
• Communication at the point of discharge to the
  patient and the general practitioner (GP)

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Best practice for management of acute
postoperative pain

• Optimal postoperative pain management begins in
  the preoperative period
• Measure pain regularly using a validated
  assessment tool
• Ensure all postoperative patients receive safe
  and effective analgesia
• Monitor and manage adverse effects
• Communicate ongoing pain management plan to both
  patients and primary healthcare professionals at
  discharge.
• Australian and New Zealand College of
  Anaesthetists Acute Pain Management Scientific
  Evidence, 2nd ed, 2005, updated Dec 2007
• Therapeutic Guidelines Analgesic, Version 5,
  2007

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Methods

• Quality improvement initiative
• Ethics approval obtained (where necessary)
• Collect data (insert month/year here)
• Data entered into APOP e-DUE Audit tool provided
  by National Prescribing Service
• x patients (inpatient data)
• Inpatient interview
• Evaluate data (insert month/year here)
• Reports generated
• Feedback data (insert month/year here)
• Intervention/education
• NPS an independent organisation promoting
  quality use of medicines, funded by the
  Commonwealth

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Inpatient Audit
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Results Patient Demographics
Audit 1 (n ) Audit 2 (n )
Median age (years)
Gender (female)
Data collection period xxxx Surgery Type
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Best practice Optimal postoperative pain
management begins in the preoperative period

• Conduct preoperative patient evaluation
• Ask about the patients pain history
• (e.g. ongoing/chronic pain issues,
  co-morbidities, concurrent meds, mood, cognition,
  coping strategies)
• Document in patients medical records
• Discuss pain management strategies and
  expectations of postoperative pain
• Correll DJ. Bader AM. Hull MW et al. Value of
  preoperative clinic visits in identifying issues
  with potential impact on operating room
  efficiency. Anesthesiology,2006 105(6)1254-9.
• Shuldham C. A review of the impact of
  pre-operative education on recovery from surgery.
  Int J Nurs Stud 1999 36171-77.

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Results Preoperative measures
    Audit 1 Audit 1 Audit 2 Audit 2
    n n
Patients documented to have attended a pre-admission clinic
Patients documented to have received patient education
Patients documented to have been on regular analgesics prior to admission
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Best practice Measure pain regularly using a
validated pain assessment tool

• Regular and routine assessment of pain will
  result in improved pain management
• The patient's own assessment is the most reliable
• Measure pain scores both at rest and movement
• Re-assess pain regularly
• Document pain assessment measurements as part of
  routine observations
• Gould TH, Crosby DL, Harmer M et al.
  Policy for controlling pain after surgery effect
  of sequential changes in management. BMJ
  19923051187-93.
• Gordon DB, Pellino TA Miaskoskwi C et al. A
  10-year review of quality improvement monitoring
  in pain management Recommendations for the
  standardized outcome measures. Pain Management
  Nursing 2002 3116-30.
• The Joint Commission. Pain Management Standards,
  2001.

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Results Postoperative pain scores
    Audit 1 Audit 1 Audit 2 Audit 2
    n n
Patients with at least one pain score documented
Patients who had a pain score documented at rest and movement (in the same set of observations)
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Best practice Ensure all postoperative patients
receive safe and effective analgesia

• Use a variety of approaches to improve analgesia
  and decrease dose of individual agents -
  multimodal analgesia
• When using analgesics on a regular basis have
  additional prn medication available for
  breakthrough pain
• Use individualised doses at appropriate dose
  intervals and titrate to patient response
• Romsing J, Moiniche S, dahl JB. Rectal and
  parenteral paracetamol, and paracetamol in
  combination with NSAIDs for postoperative
  analgesia. Br J Anaesth 200288215-26.
• Jin F, Chung F. Multimodal analgesia for
  postoperative pain control. J Clin Anesth 2001
  13524-539.
• Australian and New Zealand College of
  Anaesthetists Acute Pain Management Scientific
  Evidence, 2nd ed, 2005, updated Dec 2007.

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Results Postoperative analgesic use
    Audit 1 Audit 1 Audit 2 Audit 2
    n n
Patients prescribed at least one opioid
Patients prescribed regular paracetamol
Patients with PRN analgesia only (excludes PCA/epidural)
Patients prescribed multi-modal analgesia
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Results Postoperative analgesic use
Audit 1 Audit 1 Audit 2 Audit 2
n n
Opioid alone
paracetamol alone
NSAID/COX-2 inhibitor alone
opioid paracetamol
opioid NSAID/COX-2 inhibitor
paracetamol NSAID/COX-2 inhibitor
NSAID/COX-2 inhibitor opioid paracetamol
Other
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Best practice Monitor and manage adverse effects

• Monitor patient's prescribed opioids for
  respiratory depression and sedation
• - respiratory rate alone as an indicator of
  respiratory depression is of limited value
• - sedation scores are a more reliable indicator
• Monitor nausea and vomiting
• Monitor for other adverse events
• Australian and New Zealand College of
  Anaesthetists Acute Pain Management Scientific
  Evidence, 2nd ed, 2005, updated Dec 2007.
• Therapeutic Guidelines Analgesic, Version 5,
  2007.

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Results Sedation scores
    Audit 1 Audit 1 Audit 2 Audit 2
    n n
Patients with at least one sedation score recorded (prescribed at least one opioid)
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Results Nausea and vomiting
    Audit 1 Audit 1 Audit 2 Audit 2
    n n
Patients with documented episodes of nausea and/or vomiting
Patients prescribed at least one antiemetic
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Best practice Communicate ongoing pain
management plan to both patients and primary
healthcare professionals at discharge

• Communicate pain management plan to patients and
  primary healthcare professionals at discharge
• Review analgesia requirements and consider
  relevant risk factors 24 hours before discharge
• If prescribing a strong opioid consider limiting
  quantity prescribed
• Prescribe drugs for symptomatic relief of side
  effects where necessary
• Kable A, Gibberd R, Spigelman A. Complications
  after discharge for surgical patients. ANZ J Surg
  2004 7492-7.
• Australian Pharmaceutical Advisory Council
  (APAC). Guiding principles to achieve continuity
  in medication management. Canberra Dept. Health
  and Ageing, 2005.

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Results Discharge medication communication
    Audit 1 Audit 1 Audit 2 Audit 2
    n n
Patients prescribed at least one analgesic on discharge
Patients prescribed at least one new analgesic at discharge, not administered in the last 24 hours of hospital stay
Patients with documented pain management plan communicated to GP
Patients with documented pain management plan communicated to patient
Patients with documented pain management plan communicated to both the patient and GP
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Best practice Pain management plan at discharge

• List of all analgesics
• Instructions on intended duration of therapy
• Consumer-specific medicines information
• Instructions for monitoring and managing side
  effects
• Methods to improve function while recovering
• Hospital contact person
• Australian Pharmaceutical Advisory Council
  (APAC). Guiding principles to achieve continuity
  in medication management. Canberra Dept. Health
  and Ageing, 2005.

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Results Pain management plan at discharge
    Audit 1 Audit 1 Audit 2 Audit 2
    n n
Documented pain management plan
Of these with
drug name
dose frequency
duration of therapy
all of the above
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Inpatient Interview
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Results Experiences as reported by patient
    Audit 1 Audit 1 Audit 2 Audit 2
    n n
Worst pain score in last 24 hours - score lt4 - score ?4 and lt8 - score gt 8
Pain relief reported to be very helpful/somewhat helpful
Patients who experienced nausea and/or vomiting
Antiemetic reported to be very helpful/somewhat helpful
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Discussion Areas where we did well

• Customise this slide for your hospital by adding
  bullet points on areas where your hospital is
  doing well
• An example could be the of patients with at
  least one pain score documented

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Discussion Areas we can build upon

• Customise this slide for your hospital by adding
  bullet points on areas that your hospital project
  team has identified as an area of interest/focus
  of education
• An example could be current level of
  communication at discharge

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Action the next step

• Strategies to raise awareness of best practice in
  acute postoperative pain management
• Customise this slide for your hospital by adding
  bullet points on how you will implement some
  change.
• Examples of educational resources include
• Posters
• Bookmark reminder
• Pain assessment tools
• Discharge pain management plan reminder
• Group education sessions on current practice and
  comparison to best practice
• Educational visits (academic detailing)

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After the educational intervention

• Collect data on x surgical cases (similar to
  Audit1)
• Evaluate post-intervention (audit 2) data
• Feedback data and compare with baseline and best
  practice

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Acknowledgements

• QLD, VIC, NSW, TAS SA state DUE groups and
  state project committees
• NPS staff
• Pharmaceutical Decision Support team
• Data analyst