POSTOPERATIVE PAIN SERVICES
Although dedicated individuals can improve postoperative pain
control for a few patients, more comprehensive perioperative pain management programs
(i.e., acute pain services) developed specifically to treat this problem can address
the needs for all patients within an institution. The organizational aspects of
such comprehensive services are considerable, necessary for effective and safe care,
and may
TABLE 72-9 -- Organizational aspects of an acute pain service
|
Educational Activity |
|
Anesthesiologists |
|
Health insurance carriers |
|
Hospital administrators |
|
Nurses |
|
Patients and families |
|
Pharmacists |
|
Surgeons |
|
Administrative Activity |
|
Economic issues |
|
Evaluation of equipment |
|
Human resources: pain service personnel, administrative-secretarial
support |
|
Institutional administrative activity |
|
Quality improvement and assurance |
|
Research (if applicable) |
|
Residency-fellowship teaching (if applicable) |
|
Nursing |
|
Continuing education and in service |
|
Defining of roles in patient care |
|
Nursing policies and procedures |
|
Pain service nurse (if applicable) |
|
Quality improvement and assurance |
|
Documentation |
|
Bedside pain management assessment flow sheet |
|
Daily consultation notes |
|
Educational packages |
|
Policies and procedures |
|
Preprinted orders |
include issues such as education, administration, nursing, and documentation ( Table
72-9
and see Table 72-1
).
With skills in regional anesthetic techniques and knowledge of the neurobiology
of nociception and the pharmacology of analgesics and local anesthetics, anesthesiologists
have been leaders in postoperative pain relief and development of acute pain services.
Provision of perioperative analgesia, along with other services such as critical
care medicine and preoperative evaluation, is highly compatible with the emerging
identity of anesthesiologists as perioperative physicians and enhances the role of
anesthesiologists as valued consultants outside the operating room.
Since the initial description of an anesthesiology-based acute
pain service in 1988,[5]
many publications have
described the establishment or maintenance of acute pain services.[497]
[498]
[499]
[500]
[501]
[502]
[503]
[504]
Although there are several models for the
development of acute pain services,[497]
[498]
the key organizational aspects are similar (see Table
72-9
). Development and maintenance of acute pain services require a commitment
and financial support at the national and local (institutional and departmental)
level. In the United States, there appears to be a dichotomy at the national and
third-party payer level between the call for improved postoperative pain control
with the introduction of practice guidelines or expanded roles for acute pain services
[4]
and decreased reimbursement for the provision
of such services.[505]
[506]
[507]
Because there are financial burdens associated
with the establishment of an acute pain service, high-volume or larger hospitals
are more likely have acute pain services and have access to more high-tech analgesic
techniques such as epidural analgesia.[37]
[449]
[500]
[508]
Despite the direct costs (e.g., personnel, equipment, medication)
associated with managing an acute pain service, data advocate the valuable contributions
of these services in improving the quality of postoperative pain management, increasing
patient satisfaction, decreasing overall costs, and decreasing morbidity rates, especially
with use of epidural analgesia.[23]
[203]
[498]
[502]
[509]
[510]
[511]
[512]
[513]
The introduction of an acute pain service
can decrease postoperative pain levels, with a decrease in the incidence of severe
pain by more than 50% in some cases.[498]
[509]
[512]
Some studies show that introduction of an
acute pain service may improve patient satisfaction.[502]
Acute pain services are also associated with a decrease in analgesic medication-related
side effects such as nausea, sedation, pruritus, and respiratory depression.[203]
[511]
[513]
Use
of postoperative epidural analgesia in the context of acute pain services may decrease
the cost of patient care through shorter intensive care unit stays and a decreased
rate of complications.[23]
Despite the costs associated
with implementation of an acute pain service and acute pain management practice guidelines,
[57]
acute pain services provide a valuable service
at the individual, institutional, and societal levels.
 |
