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, 2 nd 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): Shuldham C. A review of the impact of pre-operative education on recovery from surgery. Int J Nurs Stud 1999; 36:

APOP Results: Preoperative measures Audit 1Audit 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: 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: The Joint Commission. Pain Management Standards, 2001.

APOP Results: Postoperative pain scores Audit 1Audit 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: Jin F, Chung F. Multimodal analgesia for postoperative pain control. J Clin Anesth 2001; 13: Australian and New Zealand College of Anaesthetists Acute Pain Management: Scientific Evidence, 2 nd ed, 2005, updated Dec 2007.

APOP Results: Postoperative analgesic use Audit 1Audit 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 1Audit 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, 2 nd ed, 2005, updated Dec Therapeutic Guidelines: Analgesic, Version 5, 2007.

APOP Results: Sedation scores Audit 1Audit 2 n%n% Patients with at least one sedation score recorded (prescribed at least one opioid)

APOP Results: Nausea and vomiting Audit 1Audit 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 1Audit 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 1Audit 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 1Audit 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