416 / Acute pain service at the “St.Catherine” Specialty Hospital CROATIA

Type of Patient Safety Practice Safe
Clinical Practice (CP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Medication / IV Fluids
Topic of the reported practice
Quality improvement project
Aim and the benefit of the Patient Safety Practice
Acute post-operative pain is defined as pain that is present in a surgical patient after a surgery procedure. It is the result of extension of tissue damage during surgery or procedure-related complications. Inadequately treated acute pain (pharmacological, surgical) result in development of chronic pain in 22.5% of these patients. Acute pain service (APS) as an organized intra-hospital specialty pain activity is the main base of postoperative pain management and good clinical practice in most countries.
APS “St. Catharine” Specialty Hospital is multi-disciplinary team (anesthesiologist, surgeon, physiotherapist, nurses) that implements all procedures required in the management of acute pain (APM) including pain assessment, pain treatment, pain management evaluation as patient and medical staff education about all acute pain procedures.
Unique standards of our acute pain management enhances patient safely in vulnerable postoperative period, reduces adverse effects of analgesic therapy, prevent the occurrence of unwanted complications and contribute to faster and safer outcome in patients after surgery.
Pain management in the perioperative setting refers to actions before, during, and 72 hours after a procedure that are intended to reduce or eliminate postoperative pain before discharge. Basic and uniformed algorithms of clinical procedures are implemented in all perioperative settings. The main goal of our APS is synchronization and optimization of post-surgery acute pain therapy for orthopedic and vertebral surgery adjusted to the needs of early physical rehabilitation in adults. Treatment of acute pain seems unique, but dynamic agreement from all involved specialists in the treatment of patients (anesthesiologists, surgeons and physiatrists). Pain therapy includes during perioperative settings opioid (morphine, fentanyl, alfentanil or sufentanil) or/and regional techniques of analgesia (epidural, peripheral nerve blocks, wound infiltration of local anesthetics). Multimodal therapy summarizes non-steroidal anti-inflammatory drugs (NSAID’s) or paracetamol to the opioids or regional block analgesia. The main APS purpose are: (1) secure the safety and effectiveness of acute pain management in the perioperative setting; (2) decrease the risk of adverse pain therapy effects and outcomes; (3) maximal preservation of all patient’s functional abilities and (4) increase the quality of life in patients with acute pain after surgical procedures. There are two vital points of our acute pain management (1) day-care surgery patients and (2) „Fast-track” orthopedic surgery with early physical rehabilitation and patient mobilization. Documented acute pain management procedure allows us a structural analysis of all conducted pain procedures in our patients what makes a base in improving our clinical work following the current knowledge in the treatment of acute pain. Also, they are the baseline in comparison of our acute pain management with other hospitals of similar principles: in acute pain management, standards, protocols and cost-benefit.
Description of the Patient Safety Practice
Patient safety practice in our acute pain management service includes:
1. Safety and uniform APS organization: „St Catharine“ Specialty Hospital is based on the proposal of the Expert Council and with the approval of the Governing Council of the hospital. Standards and protocols, before their implementation into clinical practice, must meet inside and minimal one outside hospital quality standard.
2. Our acute pain management’s protocols and standards are based on good clinical practice guidelines: ANZA (Australian and New Zealand Society of Anesthesia and Faculty of Pain), ASA (American Society of Anesthesiologist) and NYSORA (The New York School of Regional Anesthesia).
3. Secured 24-hours supervision of analgesia implementation and continuous monitoring of all therapeutic drugs effects with the goal of determining the optimal time for pain-accepted physical rehabilitation in patient where it is necessary.
4. Evaluation of the effectiveness of treatments of acute pain.
5. Patient satisfaction score.What does mean to patient? Anesthesiologist, surgeon and physiotherapist jointly adopt a basic plan of treatment of acute pain, dependent on the type of surgery and planned post-surgery physical rehabilitation. Anesthesiologist informs a patient about the safety pain therapy in relation to his existing disease, type of surgery and rehabilitation. On this way, patient becomes familiar before surgery with the analgesia procedures. APS-team educates a patient how to use pain-intensity-scale (VAS), when is pain acceptable and when is time for new analgesic dose. During 24-hours (and three-times at least) nurses and specialist check pain status with therapy effectiveness and potential analgesia side-effects. The start of physical therapy is allowed in satisfying general condition of the patient and pain intensity (VAS) between 1-4. Painless condition (VAS=0) post-pones active rehabilitation. Analgesic doses adapt individually to the needs of each patient. During acute pain management patient documents own experiences and satisfaction in pain-chart.
Main goals: Average postoperative pain intensity (VAS)2.5 in 80% of patients
Quality physical rehabilitation possible after 24h hours after procedure
Patient satisfactory with pain therapy ranged as 4 (1-5) in 90% of patient
1. Use of unique analgesia protocols for day-case/hospital stay, type of surgery and planed physical rehabilitation that complement the current assessment of pain (VAS)
2. Unique multidisciplinary check list of acute pain effectiveness with general side-effects of analgesics and their complication with priority of intervention
3. Control list of continuous intravenous and analgesic therapy (PCA)
The implementation of standardized acute postoperative pain management protocols in daily clinical practice under supervision of APS-team.
The main goal of APS is to raise the hospital organization (in presence of standard-equipment, educated staff and good clinical practice) to a higher platform of efficiency and quality of work in the field of care for acute pain. Organization of APS-team in the EU countries under these circumstances does not need extra cost. This was the reason why the price is not primary listed for the implementation of this process in its first presenting. In less-equipped hospital outside the EU implementation of APS will require additional bill planning (Total cost about 35000 Euro). These costs are:Medical equipment:          8000 Euro (perfusion, PCA-pump, regional catheters sets, drugs)
10000 Euro (ultrasound for peripheral nerve blocks, x1) or
2000 Euro (neurostimulator, x2)
10000 Euro (hardware, software)
Staff education:          2500 Euro /year (1 medical doctor, 2 nurses)-external
Communications supplies:     1500 Euro /year (1 medical doctor, 2 nurses)-internal
Educational print materials:     1000 Euro /year
Evaluation: Evaluation of acute pain management after completed procedure by hospital Pain Register
Evaluation of patient satisfactory by survey form of “Pain monitoring”
The evaluation procedure of acute pain therapy by:
1. Patient Q- patient evaluation of pain intensity after surgery with applied therapy. APS-team gives basic information about pain and its severity. It explains to patient in a simple way how pain would be measured by using pain scale (VAS). APS-team introduces itself, its work and goals with special focus to active patient’s participation in acute pain management during its stay in hospital. Quality and quantity of pain is evaluated before and after surgery (at home- in day care surgery) and during early physical rehabilitation under applied therapy. The medical data of the first part of Patient Q is evaluated through APS- Register in the hospital. The data from the second part of Patient Q (patient satisfaction, evaluation of the quality of engagement and the availability of APS-team) is anonymous and patient sends it to the Hospital by post.
2. APS-team
a) APS- Semaphore. A multidisciplinary daily evaluation of successful of ongoing acute pain therapy. Pain and analgesics effects are assessed by anesthesiologist (A), surgeon (S) and physiotherapist (F) at least 3(6) times during the day through general and local symptoms and pain intensity “semaphore”. RED, in any of them, need immediately intervention of specialist, YELLOW calls APS-nurse, GREAN means successful effect of pain therapy without significant adverse notices and open and safe way to proceed analgesia.
b) ASP-Quality. Evaluation of acute pain therapy in preservation of quality of life on the individual level. Due to synchronization of elected analgesics following uniform algorithm according to the type of operation and kind of physical rehabilitation. Triple-check (A, S, F) of the same analgesic’s dose in different patients: optimizing doses of painkillers-neither too little nor too much- to preserve all human functions and aspects of quality post-surgery recovery.
c) APS-Checklist of analgesia. Check of drugs dose, analgesic’s combinations, appropriate time of administration, technical equipment and materials, and appropriate time of analgesic’s administration. Evaluation of patient’s calls for need “more” during the therapy. Check of complications and adverse effects. Monitoring of the motor function and muscle strength in patients with regional analgesia prior to the commencement of physical rehabilitation.
d) APS- Register. Electronic database of a,b,c,d.
Total number of person days required to implement this Patient Safety Practice
Clinical staff:     30 days (1 anesthesiologist, 1 APS-nurse)
External consultants:     15 days (1 anesthesiologist, 1 APS-nurse)
Support staff:     90 days    (2 anesthesiologists, 1 surgeon, 1 physiatrist, APS-nurse, 2 department nurses)
Managerial staff:      5 days (Hospital mean manager)
Others:         30 days (IT Specialist), 30 days (administrator)
Not relevant:     30 days (independent drug and equipment provider)Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff:     3-6 months
External consultants:     1-3 month
Support staff:      6 months
Managerial staff:      15 days
Others:          3 months
Not relevant:      1 month
Attachment of relevant written information and/or photos, as appropriate
512_WP4_Bartolek HOUT 01092012.pdf
Effectiveness of the Patient Safety Practice
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
A baseline measurement before implementation of the reported practice was obtained
A measurement after full implementation of the reported practice was obtained
Evaluation of a “positive” effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Enclosure of a reference or attachment in case of published evaluation’s results
There is no specified text here
Health care context where the Patient Safety Practices was implemented
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation’s level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
Patient Involvement
Direct service user’s involvement as integral part of this Patient Safety Practice
Specification of the service users or their representatives’ involvement in the implementation of this Patient Safety Practice
Point of time in which service user or their reprasentatives’ involvement takes place
During implementation of the Patient Safety Practices
During evaluation of the Patient Safety Practices
Active seeking of service users’ opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Short description of the service users’ level of involvement
User-led, where the service users control the development and implementation of the PSP
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
List of sources where public information is accessible
Implementation of the Patient Safety Practice
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
Lack of sharing of progress information among involved staff
Specially trained staff not available
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Costs of the Patient Safety Practices
Completion of cost calculation related to this Patient Safety Practice
Total number of person days required to implement this Patient Safety Practice
Clinical staff:
External consultants:
Support staff:
Managerial staff:
Not relevant:
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff:
External consultants:
Support staff:
Managerial staff:
Not relevant:
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here