Does an acute pain service improve postoperative outcome?

Abstract

ain relief after surgical procedures continues tobe a major medical challenge. Alleviation of painhas been given a high priority by the medicalprofession and the health authorities. Improvement inperioperative analgesia not only is desirable for hu-manitarian reasons, but is also essential for its poten-tial to reduce postoperative morbidity (1–4) and mor-tality (2).Inadequacies in postoperative pain relief have beenevident for decades (5,6). The importance of establish-ing an organization for the management of postoper-ative pain relief, with special attention to a team ap-proach, was proposed more than 40 yr ago (7).Although several editorials (8–10) from 1976 to 1980again advocated the introduction of an analgesia teamto supervise and administer pain relief and to takeresponsibility for teaching and training in postopera-tive pain management, almost a decade passed beforea specialized in-hospital postoperative pain serviceemerged. Thus, in 1985 the first acute pain services(APSs) were introduced in the United States (11,12)and in Germany (13). Immediate and sustained formalsupport and authoritative recommendations from var-ious medical and health care organizations promoteda widespread introduction of APSs (14–22). One doc-ument explicitly stated “that this service should beintroduced in all major hospitals performing surgeryin the UK” (15); this is in agreement with recommen-dations from the Agency for Health Care Policy andResearch (United States) and the National Health andMedical Research Council (Australia), which state thatall major acute care centers should have an APS(14,18).Furthermore, provision of an APS is presently aprerequisite for accreditation for training by the RoyalCollege of Anaesthetists (23) and the Australian andNew Zealand College of Anaesthetists. A Canadiansurvey from 1991, including 47 university-affiliatedteaching hospitals, showed that 25 hospitals (53%)operated an APS and that an additional 17 (35%) wereattempting to organize one (24) (Table 1). A survey inAustralia and New Zealand in 1992–1993 from 111larger institutions showed that 37 (33%) had an APSand 58 (53%) would have liked to or had plans toimplement the service (25). Repeated surveys in 1994and 1996 from New Zealand indicated in 22 largerinstitutions an increase from 12 to 17 APSs (29). In aEuropean survey from 1993, including 105 represen-tative hospitals from 17 countries, 34% of the hospitalshad a formal APS (26). Forty-two percent to 73% of UShospitals, depending on size and academic affiliation,had an APS in 1995 (31,32). In the United Kingdom,the number of hospitals providing APSs increasedfrom 3% in 1990 to 43% in 1994 (27,28,36), to 47% in1996 (37), and to 49% in 1999 (35). In a recent surveyfrom Germany, 36% of hospitals operated an APS, butthe quality of criteria for the service was very variable(34).The introduction of APSs has led to an increase inthe use of specialized pain relief methods, such aspatient-controlled analgesia (PCA) and epidural infu-sions of local anesthetic/opioid mixtures, in surgicalwards. Implementation of these methods may repre-sent real advances in improving patient well-beingand in reducing postoperative morbidity (38).However, a pertinent question is whether the exten-sive resources allocated to these commitments havebeen successful and cost-effective. The objective of thisstudy, therefore, was to critically review the literatureon APSs regarding outcome: pain relief, side effects ofthe postoperative pain treatment, patient satisfaction,therapy-related adverse events, morbidity, hospitalstay, and cost issues.