INTRODUCTION:
Pain is
an inevitable outcome of surgery. Patient’s who undergo surgery will invariably
have pain because of the intra operative tissue handling, which leads to tissue
damage results in pain. Pain relief has been accepted by the World Health
Organization as a basic human right and is now considered as the 5th Vital sign
(1)Globally, postoperative pain is a major
concern and is well known that untreated or suboptimal treated postoperative
pain , could lead to a variety of negative consequences such as, myocardial
ischemia, pulmonary complications, delayed mobilization with increased
incidence of thromboembolic episodes , impair rehabilitation, prolong hospital
stay decrease quality of life and increase the risk for the development of
persistent postsurgical pain and thereby chronic pain (2)
However, Pain relief and the procedures done thereof, are also
associated with certain side effects such as sedation, respiratory depression, postdural
puncture headache (PDPH), nausea, vomiting etc.
Traditionally, pain scores and
side effects were the major outcome measures for service improvement,
however in recent times patient satisfaction is considered an important tool to
measure outcomes.
Patient satisfaction is the measure of the extent to
which the patient is content with the health care they receive from the
provider. (3) Pain management may be affected by multiple
factors such as the gender ,age, preoperative expectations, information given
prior to surgery, ASA status, pain medications, type of surgery & anesthesia,
communication of staff with patient, prior experience of pain and current pain
relief which may affect patient satisfaction.
In 1991, the American Pain Society (APS) published its first American
Pain Society-Patient Outcome Questionnaire (APS-POQ) as part of quality
assurance (QA) standards for the treatment of acute and cancer pain to assist
health care organizations to explore patient experiences and outcomes (4). The revised version American
Pain Society-Patient Outcome Questionnaire revised (APS-POQ-R) measures
6 aspects of quality, including (1) pain severity and relief; (2) impact of
pain on activity, sleep, and negative emotions; (3) side effects of treatment;
(4) helpfulness of information about pain treatment. (5) ability to participate
in pain treatment decisions; and (6) use of non-pharmacological strategies. (5). The APS-POQ-R has since been found to be easy to
administer and useful for quality evaluation in postoperative pain management. (6)
The revised
version of the questionnaire APS-POQ-R has been translated & validated in
Indian languages, chiefly Hindi & Marathi (7)
At our
hospital approximately 9652 surgeries
are performed annually. Majority of the patients, especially those undergoing
thoracic, GI, Gynecology Urology and limb surgery have their postoperative pain
managed by the Acute Pain Service (APS). In the last 6 months a total of 1797 patients were managed
by the APS team. The APS team of doctors and a
pain nurse visits the patients for the first 3 -4 postoperative days and
sometimes longer as per need with the chief aim of ensuring good pain relief
with no adverse effects. Pain scores, catheter
site check (epidural or otherwise) and any related side effects are documented
and managed by the team. The pain scoring is based on a ten point numerical
rating scale. The pain considered mild if scores are 3 or less, moderate when
scores are 4 but less than 7 and severe when scores are greater than 7 on a
Numerical rating scale which is a ten point scale from 0-10. Pain is assessed
regularly after shifting to the PACU,
and at regular intervals in the postoperative period .
Despite improved knowledge, and advances with
better options and modalities for postoperative pain management, suboptimal
satisfaction with postoperative pain management is quite common. (8)
We
therefore aimed to assess the level of satisfaction among our patients with the
care provided by the Acute Pain Service.
AIM
Primary:
To
assess patient satisfaction with the postoperative pain management by the APS
using the APS-POQ-R that is percentage of patients satisfied with acute pain
services.
Secondary:
to identify
1. Predictors
of satisfaction as obtained from the satisfaction questionnaire
2. Pain
relief in first 48 hours based on Pain score (average & worst in first 48
hours)
3. Side
effects of pain management techniques/drugs
METHODOLOGY
Prospective
observational study will be conducted over a period of 6 months after Institutional
Ethics Committee approval and CTRI registration. Eligible patients will be
enrolled after obtaining their consent.
The
data will be retrieved from EMR and APS data and revised APQ form which will be
administered by Pain sister under APS team on postoperative day 3 or post
catheter removal. The information regarding age, sex, body mass index, ASA
grading, name of surgery and other modalities used with general anesthesia to
reduce postoperative pain will be collected. The postoperative pain on the day
of surgery and POD 1 and POD2 will be recorded. The revised APQ form will be
filled by patients with help of pain nurse in the language best suited to them that
is Hindi, English, Marathi.
CONSENT
Written
informed consent will be obtained from each study participant after a clear
explanation of what they would have to do and take part in the study. Anyone
not willing to participate in the study will be informed that they have the
full right not to participate or stop at any time and those who are not
voluntary will be excluded. Confidentiality will be guaranteed by keeping the
secrecy of personal identification, keeping the completed questionnaires and
checklist results in a well-secured area.
SAMPLE SIZE
Based on the departmental
data, we estimate to screen more than 2000 patients in 6 months and therefore
approximately 2000 patients can be recruited in 6 months (whichever is
earlier).
STATISTICS
Categorical
data will be reported as counts (percentage) and continuous variables will be
reported as Mean (sd) or Median (IQR) depending on the distribution of data.
The
Primary Objective Patient satisfaction is an item measured in the APS-POQ-R
will be presented as mean(sd) or median(IQR) based on the distribution of data.
Linear and logistic regressions will be used to identify the potential risk
factors and subscale scores from the APS-POQ-R (except “patient satisfactionâ€),
and surgical and demographic factors that will be predictors of
satisfaction. Risk factors significantly
associated with patient satisfaction in univariate analysis were included in
multiple linear regression, including gender, diagnosis (cancer), and chronic
pain history, as well as all other items from the APS-POQ-R (except “patient
satisfactionâ€). Average & worst in first 48 hours Pain score will be
presented as mean(sd) or median(IQR) based on the distribution of data. Side
effects of pain management techniques/drugs will be presented as counts and
percentages. Normality assumptions will be assessed using the
Kolmogorov-Smirnov test. P value set at 5% level of significance. All data analysis
will be carried out using SPSS version 25.
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