October 3, 2007 - The American Society of PeriAnesthesia Nurses (ASPAN) today issued a 10-step action plan to address the factors that may lead to inappropriate medication use and potential adverse events for patients.
The report “The State of Postoperative Pain Management: A Need For Improvement” states that only by elevating postoperative pain management as a priority concern among healthcare institutions, providers and policymakers, will the significant costs of inadequate care be reduced in the U.S. According to studies cited in the report, up to 75 percent of patients experience pain after surgery. However, many receive inadequate treatment, which can result in extended hospitalization, delayed healing and mobility, higher morbidity and mortality, and the development of a chronic pain state.
Issued as a nationwide call to action, the report documents cases of overly aggressive pain management, which are associated with increases in over-sedation and fatal respiratory depression. In addition, the report cites the continuing problem of medication errors.
“Based on our assessment of the issues surrounding the management of acute postoperative pain, we know we need to address a number of complex problems, all of which impact patients receiving appropriate relief after surgery,” said Pamela E. Windle, MS, RN, 2007-2008 immediate past president of ASPAN, and nurse manager at St. Luke’s Episcopal Hospital in Houston. “In focusing our efforts on creating identifiable action steps in this report, we believe we provide a blueprint for a successful plan to address this major public health concern.”
In partnership with Ortho-McNeil Inc., ASPAN convened an expert panel of specialists in the field of acute pain management, who prepared the report following a thorough assessment of the current state of postoperative pain management and those trends that may lead to increased safety and better patient care in the future.
The ASPAN report identifies factors that contribute to inadequate pain relief after surgery: under-estimation of postoperative pain by physicians and nurses, deliberate under-treatment due to clinicians’ concerns about the potential for adverse events, and a limited understanding among healthcare professionals about therapeutic strategies for treating postoperative pain, which usually involve the administration of opioids using intravenous patient-controlled analgesia (IV PCA). Although IV PCA is supported by favorable efficacy and patient preference data, this system has been associated with needle-related injuries and IV-related phlebitis, accidental overmedication, narcotic-induced respiratory depression, and other adverse events.
To address these challenges in using IV PCA, the report describes a number of promising technologies using different analgesic agents and methods to deliver patient-controlled analgesia, including the introduction of a “smart pump” and the use of regional neural blockades combined with oral opioids in patients recovering from orthopedic surgery. Additionally, in development is the first needle-free, patient-controlled iontophoretic transdermal system and patient-controlled intranasal analgesia (PCINA), whereby opioids, in either a dry powder form or in a saline solution, are delivered using a syringe, nasal spray, dropper or nebulized inhaler.
While advances in technology are important, the ASPAN report concludes technology alone will not lead to safer and more effective postoperative analgesia. The panel identified 10 national priorities that will have the greatest impact in improving the state of postoperative pain management. This platform calls for action in the following areas:
1. Elevate postoperative pain management as a priority concern. The report calls on the healthcare community to recognize the extent of postoperative pain and the impact of inadequate treatment, which is the first step in increasing the resources for research funding, education and the development of new therapeutic options.
2. Expand efforts to educate surgical patients about their rights to effective pain management. Because inadequate education of patients regarding postoperative pain is one of the factors leading to under treatment, the report calls on hospitals to utilize existing tools, such as the Patient Care Partnership: Understanding Expectations, Rights and Responsibilities, a document that incorporates the Patients Bill of Rights into plain language for patients and caregivers, to become better advocates for their patients. The report also calls on advocates to raise patient expectations about what is possible regarding treating postoperative pain.
3. Pass the National Pain Care Policy Act of 2007 during the 110th session of Congress. Introduced in July 2007 (H.R.1283/S.626), this bill would provide federal research funds to advance clinical and basic research on pain and its management.
4. Double the federal budget for research on pain management. Although the National Institutes of Health created a Pain Consortium to identify research opportunities at its 18 Institutes and Centers and funds research on pain as it applies to specific disease states, only 1 percent of the total NIH budget ($170 million) is actually going into specific pain research. The report calls for doubling the NIH budget to $340 million for basic and clinical research on acute and persistent pain management.
5. Increase the visibility of pain research both within the NIH research community and with pain advocacy organizations and patient groups. With the goal of developing interventions to prevent and manage pain, the report calls for increased attention to the pain experience as a focus of NIH research and for wide dissemination of new research findings to the professional community.
6. Create the means to share information about best practices in postoperative pain management. In response to the 1999 Institute of Medicine report on medical errors, the healthcare community has put in place new practice guidelines and educational efforts, many of which address postoperative pain management. Now, the critical next step is for the federal government, through the National Institutes of Health or the Agency for Healthcare Research and Quality, to begin collecting data on best practices in the assessment, administration of analgesics, and documentation of pain management practices so that this information can be quantified and shared across specialties and healthcare facilities.
7. Eliminate the barriers to more effective postoperative pain management for the medically underserved. Because a number of studies have shown that minorities and the poor are at risk for inadequate pain control, pain advocates support new research initiatives that focus on cultural and ethnic differences in understanding and managing pain. Even in the absence of this data, the report states it is incumbent on hospitals and community treatment centers to be more proactive in addressing postoperative pain management.
8. Develop a curriculum on pain management for use in medical schools and allied healthcare institutions. Today, only 3 percent of medical schools have a separate required course on pain management, which is one of the reasons why there is a persistent gap in professional awareness about this subject. Accordingly, the report calls for developing a curriculum for medical students that focuses on the evaluation and treatment of pain as well as courses for faculty at medical schools and allied healthcare institutions.
9. Immediately implement and increase the funding for professional training on postoperative pain management.
Because inadequate postoperative pain management results when clinicians have an incomplete understanding about effective dose regimens and treatment options, an immediate need is for professional societies and recognized medical sub-specialty organizations to invest in expanded professional education through continuing education courses, as well as lecture series on pain management issues.
10. Move toward a less invasive, more cost-effective system for delivering acute postoperative pain management in the hospital setting. Besides expanding research funding and increasing professional education about postoperative pain management, the report concludes new and better approaches to postoperative pain management are needed to improve the standard of care and calls for accelerating the adoption of new technologies that use iontophoretic transdermal, intranasal and transpulmonary routes to deliver analgesia in a much less invasive way.
ASPAN is the professional organization representing more than 55,000 nurses practicing in all phases of preanesthesia and postanesthesia.
For more information: www.aspan.org