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Improving oral postoperative analgesia

Why was the initiative launched?
What was done?
Creating a framework for action
Did it make a difference?
Tips for success
To find out more contact
The following material is available

Promoting an evidence- based approach at Stoke Mandeville Hospital, Aylesbury

Why was the initiative launched?

Successive initiatives in the 1990s at Stoke Mandeville Hospital had made progress in using new analgesic techniques like epidural, spinal, patient and nurse controlled analgesia. But management of subsequent 'step-down' prescribing of oral analgesics was not keeping pace. Patients' postoperative care was not the best because of the inadequacy of the oral component. Prescribing at this stage was unstructured, with a wide range of oral analgesics in routine use, without any evidence base. Expenditure on oral analgesia was rising rapidly.

There was a growing feeling that something needed to be done. An opportunity for action came following the publication in 1997 of a review of the effectiveness of prescribing for pain relief which offered the basis for implementing an evidence-based approach (HJ McQuay, RA Moore, D Justins. Acute pain. British Medical Journal 1997 314: 1531-35).

What was done?

A team of people (Trevor Jenkins, Principal Pharmacist and Elaine Taylor, Nurse Specialist, supported by Dr John Sale, Consultant Anaesthetist) took the initiative in the early months of 1998 to find ways to tackle the situation. Their initial analysis suggested three issues needed attention:

Creating a framework for action

The review provided a basis for recommendations for effective oral postoperative analgesics and a framework for care. Findings from local audit studies illustrated the diversity local prescribing practice: 13 different medicines were prescribed to 45 patients.

The framework was designed to be evidence-based (on analgesic efficacy), to focus choice on appropriate medicine, route, and mode of delivery and be simple and safe to use. It aimed at enhancing multi-professional working. The recommended medicines included diclofenac and paracetamol with or without codeine. Diclofenac 50 mg was recommended to minimise the number of changes required, and because of the range of preparations available.

To promote discussions the team arranged for their analysis and recommendations to be discussed with medical staff at a meeting in Autumn 1998 as part of the Trust's clinical audit programme. The session encouraged debate about diversity, about personal preferences, about the research evidence, and about responsibilities and training. After rigorous discussion, all anaesthetic and surgical consultants endorsed the framework: junior doctors welcomed the evidence-based approach. The meeting allowed progress to be made in planning how the changes would be implemented from 1 st January 1999.


A training initiative took the message to clinical staff: they did not believe that it would be practical to reach all those involved through educational lectures. The nurse specialist arranged visits to each ward to explain the new approach to nursing staff. Care was taken to ensure that these visits were convenient and that all nurses on the wards were involved. These ward-based workshops covered the new approach and how to advise medical staff on best choice and prescribing when asked, 'what does this hospital usually prescribe for pain relief?'. The Principal Pharmacist arranged similar sessions for clinical pharmacists in the hospital. Again care was taken with timing and location to ensure that all pharmacists were involved.

A fact sheet was prepared to link the evidence-base to the recommendations and provide a flow chart for managing prescribing. Posters of the framework, with a prescribing example, were put up on surgical wards to remind staff about the new approach. A clinical guideline was issued to all professions involved with postoperative care of patients.

The team has also involved patients in their work, by creating information leaflets for patients undergoing day surgery and adolescent in-patients.

Did it make a difference?

Two indicators show that the quality of prescribing has increased significantly at no extra cost, ie:

♦ increased use of recommended oral analgesics, especially paracetamol
♦ the apparent cost per surgical in-patient finished consultant episode (FCE) remained broadly the same or even fell

Anecdotally, nursing staff say that patients' postoperative pain is better controlled and patients' co-operation has improved. Pain control is being pre-empted and dealt with more effectively without any wait for alternative analgesia. The initiative has had the added benefit of promoting the roles of the Acute Pain Nurse Service and Pharmacists within the hospital. It has encouraged clinical staff to seek advice to improve patients' pain control.

The training initiatives have been particularly successful. Nurses now feel empowered and more confident they have an evidence base on which to advise junior doctors. The flow chart has bred new confidence in all staff when advising patients, relatives and colleagues on effective pain control. The six-monthly arrival of new junior medical staff provides a regular opportunity to reinforce the messages about the local approach. Within induction programmes the Acute Pain Service explain the use of the flowchart.

This work is a good example of collaboration between specialities working for the benefit of the patient:

Tips for success

To find out more contact

About the framework:
Trevor Jenkins
Pharmaceutical Adviser
Milton Keynes PCG
The Hospital Campus
Milton Keynes MK6 5NG
Tel 01908 243873
Fax 01908 243517
About the effects:
Elaine Taylor
Acute Pain CNS
Stoke Mandeville Hospital
Aylesbury HP21 8AL
Tel 01296 316552
Fax 01296 315264

The following material is available

Fact Sheet
The framework/flow chart
Adolescent in-patient information booklet
Day surgery discharge information sheet about analgesics
Cost comparison, before and after

ImpAct bottom line

Educate everybody involved. Take education to them and don't expect them to come to you


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