Acute pain services: transition from the Middle Ages to the 21st century

Abstract

In this issue of the European Journal of Anaesthesiology, Rawal and co-workers are presenting data from a survey performed in 1993 about the acute pain services (APS) in Europe [1]. The investigators have revealed a negative picture in European contemporary acute pain management during 1993. Despite the evidence that APS result in an improved quality of patient care, [2] only one third of the selected hospitals provided an organized APS and even in those hospitals less than 65% kept strict protocols or guidelines for pain management. In addition, the limited quality assurance measurements made in acute pain management demonstrate another major drawback in acute pain therapy during the early 1990s. The first official guidelines for the management of severe pain, including acute post-operative pain, were published in Australia in 1988 [3] followed by the United Kingdom in 1990 [4] and the United States in 1992 [5]. These recommendations, in addition to other guidelines, included the need for acute pain teams together with audit and quality assurance. However, there is a clear discrepancy between the strong agreement among experts of the need for APS and its implementation into clinical practice as shown by this current survey. Insufficient funding was reported by the survey as one of the foremost reasons for the lack of APS at their separate institutions. The cost of such equipment including patient controlled analgesia (PCA) devices and the cost of trained APS members needs to be considered in terms of the clear-cut benefits of reduced mortality, morbidity or hospital stay. We have recently demonstrated, in our institution, that these result from the introduction of APS [6]. The high rate of dissatisfaction regarding individual APS indicated in Rawal's study clearly reflects the physician's position. If there is no improvement in acute pain therapy within the peri-operative setting, this negative perception could also be shared more and more by individual patients. In the competition for patients between hospitals, those providing an optimal APS [7] will be at an advantage. A number of guidelines have been published with regard to the techniques used for post-operative pain control [8]. Several different models for the optimal organization of APS have been described [9,10]. Future studies comparing the different approaches will be needed to achieve an evidence base for APS. The role of anaesthesiologists, with their particular professional skills, are essential to provide leadership for the integration of acute pain management in their institutions. The results of this study are both, discouraging on one side, but also stimulating on the other side, if the anaesthesiologists in Europe will take adequate action implied by this report. We are encouraging the authors to perform a follow-up study and hopefully a positive trend towards modern acute pain management will be demonstrated. H. Van Aken H. Buerkle Anästhesiologie und operative; Intensivemedizin, der Westfälischen; Wilhelms-Universität Münster, Germany