: As the initial vision of the working group for the creation of the APS was that of a cohesive, supportive, highly specialized, multidisciplinary environment for the care of our patients after surgery it was clear that the foundational elements of the pyramid were the hospital personnel. The multidisciplinary team in this APS includes members of the departments of anesthesiology, nursing, pharmacy, physiotherapy
, psychology and cardiac surgery. Though the daily work is carried out largely by the members of the departments of nursing, anesthesiology and pharmacy all members contribute to the elaboration and revision of protocols when required.
: An educational program, supported by the department of nursing, existed prior to the implementation of the pain service but has become more structured and official since its inception. Elements of the new program include a course on the evaluation and treatment of postoperative
pain for all currently employed nursing personnel; given 6 to 7 times a year. The topics covered in this course include: 1) screening for pain and the ABC’s of evaluation of pain, 2) medications: their indications, uses and side effects, 3) appropriate patient surveillance, 4) trouble-shooting for the patient with uncontrolled pain. An additional ½ day course is given to all newly employed ICU nurses. It includes problem-based learning questions to discuss the evaluation and treatment of acute post-operative pain. Finally, all newly hired ICU nurses receive a 1.5-hour course on the surveillance, evaluation and treatment of pain. The overall time commitment to this program is 50+ hours per year.
Tool for practice
: The tools for practice are of two types: visual aids and standardized protocols. The tools for practice include hand held documents and posters that cover the same material as that conveyed during the formal courses. This includes information on narcotics, their type, commonly used dosage, equivalencies, and adverse effects. A bookmark including the Numerical Pain Rating Scale, the Ramsay sedation
scale and a memory aid for the “PQRST” mnemonic as well as a 4-page brief on the appropriate evaluation and management of pain was circulated to all medical personnel. Standardised postoperative pain management protocols have been implemented and revised several times. As new modalities of pain control have been integrated into hospital functioning additional protocols for the management of patient controlled analgesia (PCA) and regional analgesia, such as paravertebral blocks, have also been implemented.
: A strong, institutionally supported, research program has included: 1) evaluation of patient attitudes and fears towards the use of narcotics
]. 2) The evaluation of the efficacy of ketamine infusions during surgery and for the first 48 hours post-surgery for pain relief of post-operative pain [13
]. 3) The evaluation of benefits of a patient educational handbook (study in progress).
Audit of practice
: The establishment of a computerized database has allowed the acute
pain service to evaluate the benefits accrued. Over the past 3 years we have evaluated over 5684 patients and have over 17347 pain scores and 19672 follow-up visits in the database. 2029 side effects have been reported, 681 complications and 5795 interventions have been performed.
With implementation of the APS decreasing levels of pain were noted reflecting the change between pre-APS [3
] and 3 years after inception. The mean level of “average pain at rest”, for patients who have pain, is now 3.9 on Day 1 (from 4.0) and 2.9 on Day 4 (from 3.7). Mean levels of “average pain on movement” for patients with pain are now 4 on Day 1 2 (from 5.3) and 3.1 on Day 4 (from 4.6). The proportion of pain free patients on Day 1 has increased from 27% to 50% and from 34% to 77% on Day 4.
A smaller long-term follow up of patients has shown that levels of chronic
pain have also declined. Of a total of 489 patients, at an average of 10 months after surgery, 19.8% of men (68/343) and 25% of women (37/146) had pain in the last 24 hours. Pain scores with movement, using the NRS of 0 to 10, were mostly in the lower ranges with 6.7% of patients between 1 and 3, 4.7% of patients between 4 and 6 and only 2.2% of patients stated 7 or more.