gms | German Medical Science

Patients are medically-ethically and legally entitled to alleviation of pain. Thus, an adequate treatment of acute pain is part of the self-conception of medical care and a challenge for surgical and medical hospital wards. The quality of acute pain treatment in daily clinical practice however seems to be far away from optimal situation due to under- and misuse. The objective of specialised acute pain services (APS) is to improve the acute pain treatment. The standardised recording of quality indicators gives hospitals the possibility to examine and improve pain management on the basis of selected quality indicators.

The International Association for the Study of Pain (IASP) defines pain as a unpleasant sensation and feeling that is usually triggered by current or potential tissue damage. The individual sensation of pain varies a lot and is the result of the interaction between biological, psychological and social factors. Therefore pain treatment is based on the principle that the subjective pain assessment has priority over external assessment.

The numerical rating scale (NRS), the visual analogue scale (VAS) or the verbal rating scale (VRS) at rest or under strain of the patient are usually used to determine pain. Furthermore the beginning, duration and frequency of pain are identified as well as the localization, the quality of pain and pain provoking or reinforcing factors.

Psychosocial factors such as anxiety, depression, social support and family environment (especially among children and youth) should be identified. Information about current and former pain treatments (with and without medication) and their efficacy and compatibility as well as the expectations of the patient regarding the course of the pain are also part of an entire pain anamnesis.

Non-opiods, weak or strong opiods are given to the patient depending on the underlying causative disease or the recent operation and the individual pain sensation of the patient. The oral, rectal or parenteral application, systemic or locoregional, as personal or patient controlled epidural or periperal analgesia are common in acute pain treatment. Additionally continuous wound catheters are used.

The reports deals mainly with the question about effectiveness of acute pain treatment on surgical and medical wards and the evaluation on the basis of German and international study results. Furthermore it examines if the organisation of acute pain management (organisation structures, interface problems, interdisciplinary teams) and the quality assurance in hospitals are effective.

From economic perspective the question arises of the cost-benefit-effectiveness of acute pain treatment in hospital. Additionally it must be sorted out which ethical, social and/or juridical aspects regarding the acute pain treatment should be considered.

A systematic electronic database search for the period of 2005 until May 2012 has been conducted in 32 databases (e.g. MEDLINE, EMBASE, Cochrane), complemented by hand search. Important key search words are above others acute pain, postoperative pain treatment, pain clinic and their German equivalents. In October 2012 an additional database search with the key word fast track surgery was done.

The evidence classification of the Oxford Centre of Evidence-based Medicine was used for the evidence judgement. The methodological quality of the studies are evaluated by the check lists of the German Scientific Working Group Technology Assessment for Health Care.

16 medical studies were analyzed in the health technology assessment (HTA) report. The situation in Germany is described well with seven studies. The majority of the studies has a high evidence level (three studies 1A, 13 studies 2A to 2C). The number of patients with moderate or severe pain has decreased compared to the year 2000. 29.5% of the patients on surgical wards report moderate to strong pain at rest, the number on medical wards is 36.8%. The number of insufficient treated patients suffering from pain (55% to 58%) has not declined. Patients with pain on medical wards are less taken care of than postoperative patients.

The majority of the studies attests a significant pain relief by acute pain treatment. The large variation regarding the pain medication, application as well as the causative diseases makes it difficult to give clear statements in favour of individual therapies. On the whole the epidural analgesia (EDA) proves to be superior to patient-controlled analgesia (PCA) and wound catheter. However, it must be taken into account that there uncertainties regarding the clinical relevance of the determined pain reductions. Only two studies report about a pain reduction of >13% to 14% on NRS or >30% (20 mm) on VAS. The determined limit values of an acceptable pain tolerance at rest are NRS = 3, under strain NRS = 4 and NRS = 5 for maximum pain. As pain sensation shows interindividually a high variability, patient satisfaction is a further indicator for the efficiency of treatment. On the whole patient satisfaction with acute pain treatment is high.

The prevalence of APS is low, especially medical wards are heavily underrepresented. The crucial factor is the shortage of personnel on site and the work overload of the medical staff (doctors/nurses) at the hospital wards. An improvement in acute pain treatment can be achieved by adequate human resources of APS, pain measurement and treatment documentation on a regular and continuous basis, individually adjusted analgesia, comprehensive patient information, pain treatment trainings for doctors and medical staff and quality circles for pain treatment as well as a good organisation of interfaces.

Five studies deal with economic questions, three of these studies analyze the German situation. The results show that acute pain treatment is financially covered by the diagnosis-related groups. However an adequate cost assessment is only given if the costs are shared between the different care providers. The essential cost reducing effect occurs due to the reduction of hospital stays and a lower re-admission of patients. Therefore the implementation of an equivalent cost allocation procecure is necessary for a realistic cost assessment. 17.4% of the costs can be saved per case by APS.

No studies were found concerning ethical, social or juridical implications of acute pain treatment. However, the demand for a 24h-APS for surgical and medical wards can be deduced from the patient claim for pain relief.

It must be considered that a failure of pain treatment or a treatment which does not correspond to the current state of scientific progress may entail consequences according to criminal law (§ 223 of the Criminal Code personal injury, § 323c of the Criminal Code failure to give assistance).

The studies show no consistent results regarding sex differences in acute pain treatment.

The number of available studies about acute pain treatment regarding postoperative pain treatment is satisfying, but inadequate with regard to pain treatment on medical wards. Thus, the empirical research situation reflects the underrepresentation of APS at medical wards. It is becoming clear that acute pain treatment has still not found its way into the routine procedures of hospitals, although the results of the studies show for several years a stringent evidence of the benefit of APS for the improvement of acute pain treatment. Looking at the used scales to measure the intensity of pain it is striking that the margin of interpretation of the obtained pain relief is large. This is a hindrance for a standardisation of acute pain treatment. Interface problems are too seldom considered and analyzed in the studies.

The results show that acute pain treatment on surgical and medical wards is (cost) effective (by reducing the stays in hospital), but has to be improved furthermore.

A further systematic expansion of APS is recommended. The knowledge of the medical staff about acute pain treatment has to be secured and improved by trainings on a regular basis. The medical staff on site is a mediator between patient and doctor, therefore it is very important to include them into the treatment of pain. A comprising documentation on a regular basis of the pain measurement (at least VAS or NRS) and the medical treatment including side effects are necessary. This should happen for at least the first three days after operation. Written guidelines about standardized pain treatment, differentiated according to the individual diseases and the different operations, should be used to support the involved doctors. However, they do not replace the detailed analysis of the causes of pain and the relevant mechanisms of action. This is the base for an individualized pain treatment which secures highest efficacy. It is necessary to develop and implement standardized solutions for the interface problems between the wards as well as between the different care providers. This includes also a performance-related cost allocation. Acute pain treatment should go beyond the analgesic care of the patient. The capabilities of a non-medical treatment are not fully used in hospital routine, thus psychological aspects (e.g. anxiety) are covered insufficiently. The effectiveness of multimodal approaches in acute pain treatment has to be further evaluated, differentiated according to combinations of analgesics within randomised controlled studies. Gaps in research in the outpatient postoperative acute pain treatment have to be filled. Patients on medical wards have as well a legal right to achieve acute pain treatment and pain treatment in general, therefore the treatment of acute pain on medical wards is in urgent need of improvement.

The authors declare that they have no competing interests.

Checklist for HTA related documents (Attachment 1 [Attach. 1]).