Skip to content. | Skip to navigation

Personal tools

Acute Pain Services – 20 years after Brian Ready

David Scott, Pam Macintyre, Lindy Roberts, Dan Carr, James Sartain


Downloads

 

 

Abstract

 

Where have we been? Where are we going?

Publication of the paper Development of an Anesthesiology-based Postoperative Pain Management Service by Ready et al in 1988,1 describing the first 18-month’s experience of an Acute Pain Service (APS) at the University of Washington (Seattle, USA), signified a major turning point in the management of acute pain. Until this time, in most hospitals, postoperative pain was commonly managed using prn opioid injections prescribed by (often junior) medical staff. Ready et al noted that while patient-controlled analgesia (PCA) and epidural analgesia (EA) had become more readily available (i.e. in the early 1980s), their widespread use was limited by, among other things, “a lack of structured programs for the provision of PCA and EA”

Ready’s concept of an APS was a service staffed by anaesthetists and a senior nurse. The predominant role of the APS was to supervise, on a daily basis, acute pain management in patients after surgery using one of the more “high-tech” methods of pain relief such as EA or PCA.

 

Among the stated goals in developing and implementing their APS were:

  • Improvement of postoperative analgesia

  • Application and advancement of new analgesic techniques, and

  • Clinical research in postoperative pain management

 

To this list should be added:

  • Auditing and review of APS activities and patient outcomes

 

How have APSs evolved over the following 20 years? Have these goals been achieved? What lessons have APSs helped us learn about the management of acute pain?

 

Evolution of APSs

Since 1988 many hospitals worldwide have established an APS and the number continues to grow. However, there is significant variation between hospitals in the structure and function of an APS. The model of APS used can vary from “low cost” nurse-based,2 anaesthetist-led but without daily participation by an anaesthetist,3 to anaesthetist-based with daily input by an anaesthetist and APS nurse and 24 hour cover by anaesthetists.4, 5

It has been argued2 that a “low cost” nurse-based anaesthetist-supervised model involves all nurses in the provision of better analgesia, regardless of technique (“high-tech” or “low-tech”) used, and that improved education and regular monitoring of pain and pain relief (“making pain visible”) leads to better analgesia for all patients. While some anaesthetist-based APSs have tended to concentrate on “high-tech” approaches to pain relief6 thus benefiting only a small proportion of patients in a hospital, this need not be the case.7, 8

Whatever the model chosen, an APS should assist in the safe and effective provision of all forms of acute pain relief in their hospital. In doing so, most will rely on an organised team and a standardised approach for all analgesic techniques used throughout the hospital, including aspects such as education (staff and patient), drugs used and their prescription (often using preprinted “standard orders”), monitoring requirements, recognition and treatment of adverse effects, and equipment.8 A key element of this process is the effective auditing of APS interventions and patient outcomes. Over the years this enables evidence-based improvements in clinical practice and sound epidemiological data on outcomes and adverse events.9 Up-scaling this to state-wide and even national data-set collection using internet-based tools is increasingly becoming a reality.

Postoperative vs comprehensive APSs

Initially APSs were primarily postoperative pain services. However, in many centres, the role of an APS has been extended so that a more comprehensive service is provided. Such an APS can assist with the management of:

  • Acute pain in non-surgical settings (eg. following acute trauma and some medical illnesses)

  • Acute-on-chronic pain (and possibly assist in the prevention of chronic pain)

  • Acute cancer pain (and sometimes acute palliative care)

  • Acute postoperative and other medical problems (perioperative medicine)

 

Have the goals been achieved?

Given the variety of APS models, it is difficult to come up with a meaningful analysis of their benefits or otherwise. A review of publications (primarily audits) looking at the effectiveness of APSs (all types) concluded that the implementation of an APS is associated with a significant improvement in postoperative pain and a possible reduction in postoperative nausea and vomiting.10 Individual publications have also reported that involvement of an APS can lead to reduced pain scores 11, 12, 13, 14 and fewer side effects.11, 14, 15, 16

When an APS also performed a critical care “outreach” role and systematically reviewed high-risk postoperative patients for the first 3 days after surgery, the incidence of serious adverse events and 30-day mortality was reduced.17

However, unfortunately, many services in Australia remain under-resourced.18 This has significant implications for the ongoing training of specialists in acute pain medicine.

 

Lessons learned from APSs

One of the roles of an APS is to collect audit data and then alter pain management practices on the basis of this information. Such data have led to a number of seemingly simple yet important changes that have had a significant impact on the general effectiveness and safety of acute pain relief overall. Examples of this include recognition that:

  • Increasing sedation is a more reliable clinical indicator of respiratory depression than a decrease in respiratory rate (first noted by Ready et al in their 1988 paper1)

  • Patient age is a better predictor of opioid requirement than patient weight19

 


References

 

  1. Ready LB, Oden R, Chadwick HS, et al. Development of an anesthesiology-based postoperative pain management service. Anesthesiology. 1988; 68: 100-6. PMID: 3337359.

  2. Rawal N. Organization of acute pain services--a low-cost model. Acta Anaesthesiol Scand Suppl. 1997; 111: 188-90.

  3. Powell AE, Davies HT, Bannister J, Macrae WA. Rhetoric and reality on acute pain services in the UK: a national postal questionnaire survey. Br J Anaesth. 2004; 92: 689-93. PMID: 15033893.

  4. Macintyre PE, Runciman WB, Webb RK. An acute pain service in an Australian teaching hospital: the first year. The Medical Journal of Australia. 1990; 153: 417-21.

  5. Schug SA, Haridas RP. Development and organizational structure of an acute pain service in a major teaching hospital. Aust N Z J Surg. 1993; 63: 8-13.

  6. Scott DA, Beilby DS, McClymont C. Postoperative analgesia using epidural infusions of fentanyl with bupivacaine. A prospective analysis of 1,014 patients. Anesthesiology. 1995; 83: 727-37. PMID: 7574052.

  7. ANZCA. Acute Pain Management: Scientific Evidence. 2nd edn. Melbourne: Australian and New Zealand College of Anaesthetists, 2005.

  8. Macintyre PE, Schug SA. Acute pain management: a practical guide. 3rd edn. London: Saunders, 2007.

  9. Cameron CM, Scott DA, McDonald WM, Davies MJ. A review of neuraxial epidural morbidity: experience of more than 8,000 cases at a single teaching hospital. Anesthesiology. 2007; 106: 997-1002. PMID: 17457132.

  10. Werner MU, Soholm L, Rotboll-Nielsen P, Kehlet H. Does an acute pain service improve postoperative outcome? Anesth Analg. 2002; 95: 1361-72, table of contents. PMID: 12401627.

  11. Miaskowski C, Crews J, Ready LB, et al. Anesthesia-based pain services improve the quality of postoperative pain management. Pain. 1999; 80: 23-9. PMID: 10204714.

  12. Sartain JB, Barry JJ. The impact of an acute pain service on postoperative pain management. Anaesth Intensive Care. 1999; 27: 375-80. PMID: 10470392.

  13. Stadler M, Schlander M, Braeckman M, et al. A cost-utility and cost-effectiveness analysis of an acute pain service. J Clin Anesth. 2004; 16: 159-67. PMID: 15217653.

  14. Harmer M, Davies KA. The effect of education, assessment and a standardised prescription on postoperative pain management. The value of clinical audit in the establishment of acute pain services. Anaesthesia. 1998; 53: 424-30.

  15. Schug SA, Torrie JJ. Safety assessment of postoperative pain management by an acute pain service. Pain. 1993; 55: 387-91.

  16. Stacey BR, Rudy TE, Nellhaus D. Management of patient-controlled analgesia: a comparison of primary surgeons and a dedicated pain service. Anesthesia and Analgesia. 1997; 85: 130-4.

  17. Story DA, Shelton AC, Poustie SJ, et al. Effect of an anaesthesia department led critical care outreach and acute pain service on postoperative serious adverse events. Anaesthesia. 2006; 61: 24-8. PMID: 16409338.

  18. Roberts L. Pain Medicine experience and FANZCA Training: an audit of hospital accreditation reports. Australian and New Zealand College of Anaesthetists Bulletin. 2008; March:

  19. Macintyre PE, Jarvis DA. Age is the best predictor of postoperative morphine requirements. Pain. 1996; 64: 357-64. PMID: 8740614.

Document Actions