Acute Pain Management Service Research Articles

Rib fractures in blunt chest trauma: factors that influence daily patient controlled opiate use during acute care

BackgroundOpiates are frequently used in the inpatient management of chest wall injury following blunt trauma. However, the daily sum of opiates used during acute care, and the impact that additional injuries or rib fracture displacement may have on daily opiate requirement is unknown. MethodsA retrospective sample of 85 adult patients admitted to a tertiary trauma centre between April 2018 and October 2019 after a major chest wall injury (Abbreviated Injury Scale >2) and referral to Acute Pain Management Service was used in this study. Daily opiate usage was calculated each day for the first seven days following initial admission and converted to morphine milliequivalents (MME). Additional adjunct analgesia therapy was also recorded each day. The presence of rib fracture displacement and concurrent clavicle/scapular fractures was also noted. A comparison of the average daily MME for the various subgroups of interest was performed. ResultsThe maximum average MME in patients with rib fractures typically occurs at day 2 post injury and admission, with the highest day 2 average MME being in the Patient Controlled Analgesia (PCA) and ketamine subgroup. Presence of rib displacement delayed the onset of maximal MME to day 3 and resulted in higher average MME over the total seven days. Patients with concurrent clavicle or scapular fractures also had higher average MME each day, regardless of the addition of a regional block. ConclusionsThis study has demonstrated the daily opioid requirement is maximal on day 2 post-admission following isolated major chest wall injury. The addition of a regional block resulted in a reduction of the average MME used each day over the first seven days post-admission, compared to ketamine when added to PCA. The presence of displaced rib fractures or clavicle/scapular fractures increased the MME used each day, changed the day of peak consumption and increased the average daily opioid requirement during acute hospitalisation.

866 Meeting the Challenge of Analgesia in a Pregnant Woman with Burn Injury Using Subanesthetic Ketamine: A Case Report

Abstract Introduction Burn injury is the fourth most common form of trauma worldwide, requiring unique management considerations and a collaborative approach to treatment. Thermal injuries sustained during pregnancy add considerably to case complexity. Overall, there is a low incidence of burns in gravid women living in developed countries, making management guidelines in this patient population scarce. Despite few data, it is recognized that early intervention and inter-disciplinary treatment are critical to optimize maternal and fetal outcomes. Thus, interventions including fluid resuscitation, excision and grafting, routine debridement and dressing changes, antibiotic administration, and early mobilization are the cornerstones of management. Effective pain management is crucial in allowing patients to tolerate these often-painful procedures, engage in rehabilitation, and to prevent pain-related morbidity. Methods The patient is a 34-year-old G5P3013 in her third trimester of pregnancy, who sustained partial and full thickness burns to 18% of total body surface area in a grease fire. She was brought to the ED approximately 2 hours post-injury by EMS. During her hospital stay, Acute Pain Management Service (APMS) was consulted for a comprehensive pain management plan. APMS recommendations included IV acetaminophen, hydromorphone PCA, gabapentin, and ketamine infusion with a reduced dose bolus for procedural analgesia. Risks and benefits of these medications were explained to patient and her family by the APMS, Maternal-Fetal Medicine, and the Burn team, stressing the importance of tolerating routine burn care to decrease morbidity. Although human data are limited, it was explained that low doses (as outlined in our regimen) present little fetal risk in animal models. Results The patient was discharged at hospital day 11 and seen for burn follow-up after 2 weeks post-discharge (35 weeks gestation) with returning color, no evidence of hypertrophy, and overall excellent wound healing. Patient reported no pain, and her pain regimen was discontinued. Patient demonstrated significant improvement in her injuries, and had a normal spontaneous vaginal delivery of a live born male 7 weeks post discharge, with APGAR scores of 8 and 9 at 1 and 5 minutes, respectively. Additionally, the patient brought her infant to the office visit and conveyed that the child was consistently reaching pediatric milestones. Conclusions Ketamine may be considered as an adjunct for procedural and background analgesia during the third trimester, as part of a multi-modal strategy in a short-term, monitored setting after a thorough and complete analysis of risks and benefits and careful patient selection. Applicability of Research to Practice Procedural pain management in a third-trimester burn patient.

861 Analgesia After Burns: A Case Series and Development of a Multimodal Analgesic Enhanced Recovery Pathway

Abstract Introduction Burn pain is grossly undertreated which may result in poorer outcomes including chronic pain, anxiety and persistent opioid use. Opioids are currently the mainstay of treatment with many burn patients receiving long term opioid management even in the context of the opioid crisis. We retrospectively reviewed the charts of burn patients admitted to our hospital to evaluate the impact of our multimodal pain management approach on overall opioid consumption. Methods Following IRB approval, a retrospective chart review of all patients with burn injuries over a one year period was performed. The Acute Pain Management Service was consulted for analgesic management for all patients. Patient data was collected from their electronic medical records on Epic HyperSpace and included total body surface area of burn, age and gender, length of hospital stay, amount of opioid usage throughout admission, average verbal numerical score for pain, and use of adjuvant analgesics was gathered. The amount of opioid usage was obtained from the chart and then converted to oral morphine equivalents (OME) using the CDC Prevention Conversion Chart. Results During the study period, eight patients met inclusion criteria. The average patient age was 42.5 years, with a mean of 26.8 % TBSA (Total body surface area) burn and mean length of stay of 23 days. Our pain pathway consisted of non-opioid analgesic adjuncts that were given around-the-clock with opioids used only on an as-needed basis. The nonopioid analgesics include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDS), gabapentin or pregabalin, and a ketamine infusion. Initial opioid consumption (on day of APMS consult) as well as median hospital day was compared to opioid consumption on day of discharge. Six out of eight patients showed a reduction in their oral morphine equivalent (OME) following APMS consult usage from day of admission with average 76 OME to 44.6 OME on day of discharge. Conclusions We were able to reduce patient’s opioid requirement in 6 out of 8 patients upon discharge. These findings suggest that a further more rigorous study is warranted to demonstrate the benefits of multimodal therapy in burn pain. Applicability of Research to Practice The multimodal approach to pain control for burn patients may possibly be able to reduce the overall opioid requirements and theoretically the opioid associated side effects.

Impact of Ketamine Use on Adjunctive Analgesic and Sedative Medications in Critically Ill Trauma Patients.

Ketamine may be used to manage pain and agitation that is refractory to what are usually considered traditional agents such as fentanyl, propofol, benzodiazepines, and dexmedetomidine; however, literature describing the use of ketamine continuous infusions for this purpose in critically ill trauma patients is limited. The primary objective of this study was to determine the impact of the initiation of a ketamine continuous infusion on sedative and analgesic use in critically ill trauma patients. Secondary objectives were to identify the patient population in which ketamine was initiated, assess the proportion of time patients were at their goal level of sedation, and determine the dosing patterns of adjunctive sedative agents. This single-center retrospective chart review over a 19-month period included critically ill mechanically ventilated adult trauma patients in whom a ketamine continuous infusion was initiated for management of sedation and agitation. Patients who received ketamine for other indications or by the acute pain management service were not included in this evaluation. Thirty-six patients were included in the study. Patients in whom ketamine was initiated tended to be white men with blunt trauma. Overall, the initiation of ketamine was associated with a decrease in the amount of opioids and propofol used and an increase in the amount of ziprasidone and dexmedetomidine needed to achieve the goal Richmond Agitation Sedation Score. When compared with the time period before ketamine initiation, the proportion of time that patients achieved goal sedation was not significantly different after the addition of ketamine. Although the use of ketamine in critically ill mechanically ventilated adult trauma patients was associated with decreased opioid use, it was also associated with increased use of dexmedetomidine and ziprasidone to achieve and maintain sedation. Further examination of clinical outcomes associated with these differences in drug use in a larger population of trauma patients is warranted before routine use of ketamine for analgesia and sedation can be recommended.

Anterior Quadratus Lumborum Block Versus Transversus Abdominis Plane Block with Liposomal Bupivacaine: A Case Report

A more posterior approach for abdominal wall blocks was described by Dr. Blanco as Quadratus Lumborum (QL) block. We performed the first reported transmuscular QL block using liposomal bupivacaine. We are describing the technique we used as well as other approaches used for QL block. This case report showed that QL block using a single dose of Liposomal Bupivacaine provided a sensory level and analgesia for 2 days. Our limited experience shows that this new type of block can prolong the analgesia along mid and lower thoracic dermatomes. to quadratus lumborum (QL) muscle has been sought for to potentially provide the patients with more visceral blockade and thus better analgesia [2,3]. Moreover, the effective period of this block can be prolonged by using liposomal bupivacaine [4]. This is the first report demonstrating injection of liposomal bupivacaine for a QL block. Description of the Case Institutional Review board of Cleveland Clinic waived written consent since there was no patient identifying information. The patient was a 32-year-old male with body mass index of 21.07 kg/m2 who was scheduled for a subtotal colectomy in the setting of ulcerative colitis. The surgery was scheduled to be performed through a midline incision extending from above the umbilicus to pubic symphysis. Preoperatively, our acute pain management service was consulted. The patient was initially offered an epidural catheter, which he refused due to previous ineffective analgesia. Thereafter, TAP and QL blocks were offered to the patient and the risks and benefits were explained. It was also explained to the patient that QL blocks and Liposomal bupivacaine use are not investigated thoroughly yet. The patient expressed understanding and agreed to proceed with the proposed set of blocks. The patient subsequently received a left QL (trans-muscular approach, type 3) and a right TAP single shot block for postoperative pain control to allow the right side to serve as a “control”. The blocks were performed in the induction room, with routine monitoring and midazolam (2 mg IV) sedation. The patient was initially placed in right lateral decubitus position. After sterile prepping and draping, a low frequency (2-5 MHz) curved array ultrasound transducer (Mindray, Nanshan, Shenzhen, China) covered in sterile plastic sheath was placed in the anterior axillary line between the subcostal margin and the

Challenges of pain control and the role of the ambulatory pain specialist in the outpatient surgery setting.

Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed.

Assessment of patient satisfaction with acute pain management service: Monitoring quality of care in clinical setting.

Background and Aims:Assessment of patient satisfaction is an important tool for monitoring the quality of care in hospitals. The aim of this survey was to develop a reliable tool to assess patient satisfaction with acute pain management service (APMS) and identify variables affecting this so that care can be improved.Methods:A questionnaire was developed and administered to patients after being discharged from APMS care by an unbiased person. Data collected from record included patient demographics, surgical procedure, analgesic modality, co-analgesics and dynamic and static pain scores. Questions included pain expected and pain experienced, APMS response time, quality of pain relief with treatment, professionalism of APMS team, overall experience of pain relief and choosing/suggesting same modality for themselves/family/friends again. Five-point Likert scale was used for most of the options. Statistical analysis was done using SPSS 19.Results:Frequency and percentages were computed for qualitative observation and presented on pie chart and histogram. Seventy-one per cent patients expected severe pain while 43% actually experienced it. About 79.4% would choose same analgesia modality in future for self/family/friends. Ninety-nine per cent found APMS staff courteous and professional. About 89% rated their experience of pain management as excellent to very good.Conclusion:The survey of patients’ satisfaction to monitor the quality of care provided by APMS provided positive inputs on its role. This also helps to identify areas requiring improvement in care and as a tool to gauge the quality of care.

An Evidence-based Guideline for Prehospital Analgesia in Trauma

Background. The management of acute traumatic pain is a crucial component of prehospital care and yet the assessment and administration of analgesia is highly variable, frequently suboptimal, and often determined by consensus-based regional protocols. Objective. To develop an evidence-based guideline (EBG) for the clinical management of acute traumatic pain in adults and children by advanced life support (ALS) providers in the prehospital setting. Methods. We recruited a multi-stakeholder panel with expertise in acute pain management, guideline development, health informatics, and emergency medical services (EMS) outcomes research. Representatives of the National Highway Traffic Safety Administration (sponsoring agency) and a major children's research center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide the process of question formulation, evidence retrieval, appraisal/synthesis, and formulation of recommendations. The process also adhered to the National Prehospital Evidence-Based Guideline (EBG) model process approved by the Federal Interagency Council for EMS and the National EMS Advisory Council. Results. Four strong and three weak recommendations emerged from the process; two of the strong recommendations were linked to high- and moderate-quality evidence, respectively. The panel recommended that all patients be considered candidates for analgesia, regardless of transport interval, and that opioid medications should be considered for patients in moderate to severe pain. The panel also recommended that all patients should be reassessed at frequent intervals using a standardized pain scale and that patients should be re-dosed if pain persists. The panel suggested the use of specific age-appropriate pain scales. Conclusion. GRADE methodology was used to develop an evidence-based guideline for prehospital analgesia in trauma. The panel issued four strong recommendations regarding patient assessment and narcotic medication dosing. Future research should define optimal approaches for implementation of the guideline as well as the impact of the protocol on safety and effectiveness metrics.

Brief review: Adoption of electronic medical records to enhance acute pain management

The purpose of this paper is to examine physician barriers to adopting electronic medical records (EMRs) as well as anesthesiologists' experiences with the EMRs used by the acute pain management service at two tertiary care centres in Canada. We first review the recent literature to determine if physician barriers to adoption are changing given the exponential growth of information technology and the evolving healthcare environment. We next report on institutional experience from two academic health sciences centres regarding the challenges they encountered over the past ten years in developing and implementing an electronic medical record system for acute pain management. The key identified barriers to adoption of EMRs are financial, technological, and time constraints. These barriers are identical to those reported in a systematic review performed prior to 2009 and remain significant factors challenging implementation. These challenges were encountered during our institution's process of adopting EMRs specific to acute pain management. In addition, our findings emphasize the importance of physician participation in the development and implementation stages of EMRs in order to incorporate their feedback and ensure the EMR system is in keeping with their workflow. Use of EMRs will inevitably become the standard of care; however, many barriers persist to impede their implementation and adoption. These challenges to implementation can be facilitated by a corporate strategy for change that acknowledges the barriers and provides the resources for implementation. Adoption will facilitate benefits in communication, patient management, research, and improved patient safety.

Post-operative analgesia for major abdominal surgery and its effectiveness in a tertiary care hospital

Background:Post-operative pain is often inadequately treated. Optimal utilization of the available resources is essential for improving pain management.Aims:The aim of our study was to determine pain management strategies employed after major abdominal surgeries at our institute and their efficacy and safety.Settings and Design:Prospective observational study conducted at a tertiary care hospital.Materials and Methods:Patients undergoing elective major abdominal surgeries were included. Post-operative analgesic strategy, co-analgesics used, pain and sedation scores, motor block, nausea and vomiting were recorded and patient satisfaction was determined.Results:Data was collected on 100 patients. Epidural analgesia was used in 61, patient controlled intravenous analgesia (PCIA) in 25 and opioid infusion in 14 patients. Multimodal analgesia was employed in 98 patients. The level of epidural was between L1-L3 in 31, T10-L1 in 20 and T8-T10 in 10 patients. Pethidine was used in 80% of patients receiving PCIA. Patients with epidurals at T8-T10 had lower pain scores. Fifteen patients had motor block, 73% of which were with epidural at L1-L3. Fourteen patients complained of nausea. Ninety nine out of 100 patients were satisfied with their analgesia.Conclusion:Epidural, PCIA and opioid infusions are used for pain relief after major abdominal surgeries at our hospital. Although there is limited drug availability, regular assessments and appropriate dose adjustments by acute pain management service (APMS) and use of multimodal analgesia led to a high level of patient satisfaction. We recommend that feedback to the primary anesthesiologists by APMS is of utmost importance to enable improvement in practice.

Pain and symptoms reported by patients on an acute pain management service in a Canadian tertiary care hospital: 2006-2011

Pain and symptoms reported by patients on an acute pain management service in a Canadian tertiary care hospital: 2006-2011

Introduction: value of regional anesthesia

Acute Pain Management Service, Yale University School of Medicine, New Haven, Connecticut, USA Correspondence to Thomas Halaszynski, DMD, MD, MBA, Associate Professor of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06525, USA Tel: +1 203 785 2804; e-mail: [email protected]

Acute Pain Management Efficiency Improves with Point-of-Care Handheld Electronic Billing System

Technology advances continue to impact patient care and physician workflow. To enable more efficient performance of billing activities, a point-of-care (POC) handheld computer technology replaced a paper-based system on an acute pain management service. Using a handheld personal digital assistant (PDA) and software from MDeverywhere (MDe, MDeverywhere, Long Island, NY), we performed a 1-yr prospective observational study of an anesthesiology acute pain management service billings and collections. Seventeen anesthesiologists providing billable acute pain services were trained and entered their charges on a PDA. Twelve months of data, just before electronic implementation (pre-elec), were compared to a 12-m period after implementation (post-elec). The total charges were 4883 for 890 patients pre-elec and 5368 for 1128 patients post-elec. With adoption of handheld billing, the charge lag days decreased from 29.3 to 7.0 (P < 0.001). The days in accounts receivable trended downward from 59.9 to 51.1 (P = 0.031). The average number of charge lag days decreased significantly with month (P = 0.0002). The net collection rate increased from 37.4% pre-elec to 40.3% post-elec (P < 0.001). The return on investment was 1.18 fold (118%). Implementation of POC electronic billing using PDAs to replace a paper-based billing system improved the collection rate and decreased the number of charge lag days with a positive return on investment. The handheld PDA billing system provided POC support for physicians during their daily clinical (e.g., patient locations, rounding lists) and billing activities, improving workflow.

The importance of the acute pain management service for regional techniques in cardiac anesthesia

This review focuses on the importance of a well integrated acute pain management service (APMS) as an infrastructural prerequisite to establish, maintain, and improve the implementation of regional techniques in cardiac anesthesia. The basic organization of the APMS is outlined; manpower, necessary technical equipment, and electronic data management are detailed. The most important part is the role of the APMS as an anchor to facilitate thorough information transfer between all the health care providers: anesthesiologists, cardiac surgeons, intensivists or nurses, and physiotherapists. The establishment of well-defined clinical pathways is necessary to avoid complications or enable the rapid recognition and treatment of complications. The APMS is a key in teaching new postoperative pain treatment modalities and allowing a smooth transition between regional techniques and oral multimodal pain strategies. Patient information sheets are presented for the principal regional techniques: spinal anesthesia, thoracic epidural anesthesia, or paravertebral blocks. In addition, multimodal pain models are presented. It is important that all health care providers are aware that complications of regional techniques in cardiac surgery can be severe; however, good organization and communication between all health care providers under the leadership of the APMS can help to prevent these complications and implement these promising techniques. Electronic data acquisition helps to maintain the quality of the care provided and can be the basis for clinical and scientific improvement.

Electronic Monitoring in an Acute Pain Management Service

Kingston, Ontario, Canada ABSTRACT Objectives. This article will address the process involved in the development and implementation of a clinician-driven portable electronic chart on an Acute Pain Management Service (APMS). We describe the latest version of the program and provide 1 year of clinical data. Setting. Tertiary care center in Kingston, Ontario, Canada. Patients. All patients admitted to the APMS between August 1, 2005, and July 31, 2006. Results. A total of 8,726 APMS visits were made to 2,528 patients. Mean length of stay on the Service was 2.3 days. Sixty-one percent of patients reported an active pain score > 3/10. Pain scores were highest with hip or knee surgery. Thirty-five percent of patients reported nausea. Conclusions. Executive sponsorship, alignment with institutional priorities, and user input are essen- tial to the development, implementation, adoption, and sustainability of an electronic patient record. Ready access to data at the bedside can improve quality of care, while ongoing, compre- hensive data can contribute to Phase IV drug trials. Incorporating both clinical and research outcomes in the database improves data quality and usability, but must be balanced with the impact of clinical time constraints on documentation. Wireless technology and Tablet computers provide portability and adequate screen size for documentation and reviewing of patient data on an acute pain service. It is necessary to provide solutions to process issues, such as printing electronic records during the transition from paper to electronic records.

Epiduralanästhesie: Schritt für Schritt zum Erfolg

Besides pain management in obstetric patients epidural anaesthesia plays a major role in the perioperative setting. Especially the technique of thoracic epidural anaesthesia (TEA) provides better postoperative analgesia when compared with systemic pain therapy. TEA is associated with improved outcome in high-risk patients and patients undergoing extensive surgery. An acute pain management service is required to guarantee high effectiveness and a low complication rate. TEA is an important part of a multimodal perioperative concept, especially in fast-track surgery, which means advantages for patients outcome and hospitals economics.

Pain, health-related quality of life and health care utilization after inpatient surgery: a pilot study.

Little is known about pain-related outcomes in surgical inpatients after discharge from the hospital. An ongoing risk and outcomes monitoring system would provide valuable feedback to improve the quality of patient care. The purpose of the present pilot study was to describe postoperative pain, medication use, health care utilization and health-related quality of life (HRQOL) immediately and four weeks after surgery; merge clinically captured data with Web-based follow-up data; and examine patients' willingness to complete Web-based health questionnaires. One hundred two consecutive surgical inpatients were approached for participation. Perioperative data were abstracted from the acute pain management service clinical database and linked to follow-up data captured four weeks postoperatively. Follow-up questionnaires were completed by 88 participants. Clinical assessment data were successfully linked to Web-based follow-up data. Average pain intensity (3.7) four weeks following discharge fell just short of the acute pain management service active pain score of 3.9. At four weeks, all 88 participants reported significantly impaired HRQOL, 36 were still taking pain medications and 15 had visited an emergency room. Two-thirds of the participants had access to the Internet at home and approximately one-half were willing to complete on-line health questionnaires. The study indicates that it is feasible to link clinical and research data, and shows a significant burden of pain and reduced HRQOL in the weeks following discharge. This approach to converting clinically captured data into meaningful information about surgical outcomes is valuable in the development of an ongoing risk and outcomes monitoring system.

Postoperative analgesic requirements – total laparoscopic hysterectomy versus vaginal hysterectomy

There is limited information available on the requirement for postoperative analgesic drugs in patients submitted to total laparoscopic hysterectomy (TLH) compared with patients undergoing vaginal hysterectomy (VH). To compare the postoperative analgesic requirements in patients who underwent a TLH with patients who had a VH. Chart review of 53 patients who had TLH and 47 who had VH and were seen postoperatively by an acute pain management service in order to assess postoperative analgesic requirements. Patient controlled analgesia (PCA) was part of the standard protocol for postoperative pain management. Analgesic requirement was recorded as the mean doses of morphine and number of days that patients used non-steroidal anti-inflammatory drugs (NSAIDs), oxycodone and tramadol. The requirement for total morphine was approximately half the dose in patients who had a TLH (10.8 +/- 12.6 mg) compared with patients who had a VH (19.4 +/- 21.9 mg) (P 0.017). The length of use of NSAIDs was significantly reduced in patients who had undergone a TLH (2.0 +/- 0.95 days) as compared with patients who had a VH (2.85 +/- 1.1 days) (P < 0.0001). Patients submitted to TLH require less postoperative analgesic drugs when compared with patients who had VH. Prospective randomised trials are warranted to compare analgesic requirements between patients submitted to TLH and VH.

Postoperative pain care among patients followed by an acute pain management service

Postoperative pain care among patients followed by an acute pain management service

Acute pain management services have progressed, albeit insufficiently in Canadian academic hospitals.

Acute pain management services (APMS) evolved in response to the desire for improved management of postoperative pain. The management of postoperative pain received formal support from international organizations over the past decade and by 1993 half of the Canadian university-affiliated teaching hospitals had implemented an APMS. The purpose of this survey was to describe APMSs in Canadian academic institutions, with specific emphasis on postoperative analgesics, new analgesic methods, training and research. Between June 2000 and January 2001, 62 Canadian hospitals affiliated with the 16 Canadian university anesthesiology departments were sent a postal questionnaire. Fifty of the 62 respondents returned a completed questionnaire representing a response rate of 81%. Eighty percent of the hospitals surveyed had at least 200 beds, 90% (45) had implemented an APMS. Anesthesiology was primarily responsible in all 45 hospitals with an APMS. The results presented are based on the 45 centres with an APMS. Since the early 1990s the percent of Canadian academic hospitals with an APMS has increased from 53% to 92%. These figures are comparable to the United States. Greater collaboration from nursing and pharmacy, mandatory training for medical and nursing students and residents, and a standardized approach to continuous quality improvement remain necessary.