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Do-it-yourself pain control

Introducing self-medication for mothers after Caesarean section at Warwick Hospital
Why was the initiative launched?
What was done?
Is it working?
Tips for success
To find out more contact

Introducing self-medication for mothers after Caesarean section at Warwick Hospital


Why was the initiative launched?


The successful implementation of an acute pain service prompted questions about how pain control was managed for women after Caesarean section. Methods used there had evolved over time. Midwives and doctors thought it could be improved, but for different reasons, while no-one knew what mothers thought because they hadn't been asked.

What was done?


Two parallel paths of action were set in hand in 1996. One was a baseline audit to establish the nature of pain control being provided to mothers. The other was a review of the evidence about effective analgesic prescribing.

The audit involved case note review and interviews with 30 mothers in late 1996. Although mothers generally expressed satisfaction when asked, the audit suggested that pain control was not always satisfactory. Pain limited function, stopping some mothers from feeding and bathing their babies. Pain was not being routinely assessed.

The audit prompted the formulation of a local protocol for the management of post-Caesarean pain. From the review of evidence, an oral regime was adopted based on the Oxford league table and Chesterfield system. This three-step approach relied on the appropriate use of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and oral morphine. Key features of the protocol were the introduction of formal pain assessments, the use of pre-printed prescription labels to apply to drug charts and the introduction of self-medication by mothers.

The self-medication aspect of the protocol became practical after the Trust was persuaded to change its policy for Oramorph. Previously the Trust had treated all concentrations of Oramorph as controlled drugs even though there was no legal requirement to treat low concentrations (10 mg/5 ml) in this way. Information obtained from the Department of Health, the Royal Pharmaceutical Society and the United Kingdom Central Council for Nursing and Midwifery (UKCC) helped to convince the Trust that deregulating Oramorph would be acceptable.

A local education programme was introduced by professionals from the Acute Pain Service by individual face-to-face sessions (doctor to doctor, nurse to nurse) rather than through seminars. This ensured that the process had minimal impact on clinical commitments. The tutorials were designed to reflect the likely concerns and anxieties of professionals. For example, midwives were being asked to move away from the traditional approach to the control of drugs to one which placed responsibility on mothers. They would no longer be responsible for signing out drugs and needed to be assured of the legitimacy of the new approach.

The introduction of self-medication was supported by a patient information leaflet. Reflecting the three-step approach, the leaflet explained how mothers should handle mild, moderate and severe pain and how to seek advice if needed. These leaflets have a sell-by date ensuring they are kept up to date and are maximally helpful to mothers.


 



Is it working?


The new protocol was introduced in early 1997. The Acute Pain Service has monitored its implementation and ensured that any problems are tackled. The new approach has proved to be popular with mothers and is improving the management of pain. A re-audit in 31 mothers showed that:


The audit findings were encouraging in demonstrating progress, but it also helped to identify aspects of the care where further improvement could be achieved. For example, it identified that most pain was occurring as the regional anaesthetic wore off, before the self-administered analgesics were commenced. The first dose should be administered early enough to take effect before the spinal anaesthetic has worn off. The protocol has been revised to reflect this approach.

The length of stay of mothers was not recorded in the baseline audit but subsequent examination of hospital records revealed an encouraging reduction of one day between the baseline and re-audit. Based on the hospital's average number of Caesarean sections (438 a year), the average reduction of one postoperative day suggests a saving of about £95,000 per annum or 438 bed days. It could be argued that these savings are a direct consequence of the new protocol because there have been no other policy or operational changes in the care of mothers after Caesarean section.

Tips for success



To find out more contact


Dr Hugh Antrobus
Consultant Anaesthetist
Warwick Hospital
South Warwickshire General Hospitals NHS Trust
Lakin Road
Warwick CV34 5BW

Telephone 01926 495321 extension4488
Email jhl.antrobus@virgin.net

The following materials are available


ImpAct Bottom Line

Make adopting change easy for clinicians: find ways to facilitate change, which do not unduly add pressure to clinical commitments.
Don't believe that complex solutions are bound to be the best - simple approaches can be effective

 

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