APOP Acute Postoperative Pain APOP: A quality improvement initiative Feedback A quality improvement...
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Transcript of APOP Acute Postoperative Pain APOP: A quality improvement initiative Feedback A quality improvement...
APOP
Acute Postoperative Pain
APOP:A quality improvement initiative
Feedback
A quality improvement initiative in collaboration with:
APOP
Local Coordinator– Insert name here
Local APOP Team– Insert names here
Hospital APOP contacts Insert Hospital Logo Here
APOP
Overview
• Aims and methods
• Best practice in acute postoperative pain management
• Feedback on audit of current practice
• Education and ongoing monitoring
APOP
Aims of APOP
To improve the quality of acute postoperative pain management by targeting three key areas:
1. Pain assessment – pre and postoperative
2. Analgesic prescribing – promoting safe and effective use of analgesics
3. Communication at the point of discharge – to the patient and the general practitioner (GP)
APOP
Best practice for management of acute postoperative pain#
1. Optimal postoperative pain management begins in the preoperative period
2. Measure pain regularly using a validated assessment tool
3. Ensure all postoperative patients receive safe and effective analgesia
4. Monitor and manage adverse effects
5. 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
APOP
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
APOP
Inpatient Audit
APOP
Results: Patient Demographics
Audit 1(n =)
Audit 2(n =)
Median age (years)
Gender (female)
Data collection period: xxxx
Surgery Type:
APOP
Best practice: Optimal postoperative pain management begins in the preoperative period
Conduct preoperative patient evaluation:
• Ask about the patient’s pain history (e.g. ongoing/chronic pain issues, co-morbidities, concurrent meds, mood, cognition, coping strategies)
• Document in patient’s 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; 36:171-77.
APOP
Results: Preoperative measures
Audit 1 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
APOP
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 1992;305:1187-93.
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; 3:116-30.
The Joint Commission. Pain Management Standards, 2001.
APOP
Results: Postoperative pain scores
Audit 1 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)
APOP
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 2002;88:215-26.
Jin F, Chung F. Multimodal analgesia for postoperative pain control. J Clin Anesth 2001; 13:524-539.
Australian and New Zealand College of Anaesthetists Acute Pain Management: Scientific Evidence, 2nd ed, 2005, updated Dec 2007.
APOP
Results: Postoperative analgesic use
Audit 1 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
APOP
Results: Postoperative analgesic use
Audit 1 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
APOP
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.
APOP
Results: Sedation scores
Audit 1 Audit 2
n % n %
Patients with at least one sedation score recorded (prescribed at least one opioid)
APOP
Results: Nausea and vomiting
Audit 1 Audit 2
n % n %
Patients with documented episodes of nausea and/or vomiting
Patients prescribed at least one antiemetic
APOP
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; 74:92-7.
Australian Pharmaceutical Advisory Council (APAC). Guiding principles to achieve continuity in medication management. Canberra: Dept. Health and Ageing, 2005.
APOP
Results: Discharge medication & communication
Audit 1 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
APOP
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.
APOP
Results: Pain management plan at discharge
Audit 1 Audit 2
n % n %
Documented pain management plan
Of these with:
drug name
dose & frequency
duration of therapy
all of the above
APOP
Inpatient Interview
APOP
Results: Experiences as reported by patient
Audit 1 Audit 2
n % n %
Worst pain score in last 24 hours - score <4 - score 4 and <8 - score > 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
APOP
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
APOP
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
APOP
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)
APOP
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’
APOP
Acknowledgements
QLD, VIC, NSW, TAS & SA state DUE groups and state project committees
NPS staff – Pharmaceutical Decision Support team – Data analyst