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Quality improvement by audit: Pain relief after day surgery


Bandolier actively seeks examples of how delivery of healthcare can be done effectively - often called "doing the right thing right". Unfortunately such examples are rare. Given the academic slant of many of our medical journals, these must seem pretty mundane, and it must be hard to catch an editor's eye. So many thanks to a pharmacist friend of Bandolier for bringing to our attention a super example.

Pain relief after day surgery

In an eight week period in 1993, 150 adults having surgery in a day surgery unit in Cardiff (general surgery, gynaecology, ophthalmic or ENT) were audited using a postal questionnaire for pain at home after their operation. At 24 and 72 hours they rated their pain as mild, moderate or severe, and recorded analgesic drugs used over three days. The hospital had an analgesic prescribing policy which covered about half these patients.

The results of the audit showed that of the 111 usable questionnaires returned, 29 patients (26%) reported severe pain at at least one time, and 12 patients (11%) contacted their GP or were readmitted to hospital because of poor pain control. For some operations (hernia repair, for instance), almost all the patients had severe pain and over a third sought GP advice or were re-admitted.

Action taken

Briefly, the prescribing policy was revised to include 'missing' procedures. Procedures were ordered into those where mild pain was expected (cataracts, for example), moderate pain was expected (varicose veins, for example), or severe pain was expected (hernia repair, for example). Prescribing policy was adjusted to take account of the expected pain level:

  • Mild pain: Paracetamol 1000 mg four times a day
  • Moderate pain: Co-codamol 1 or 2 tablets four times a day
  • Severe pain: Co-codamol 1 or 2 tablets four times a day plus naproxen 500 mg twice a day
  • (with, of course, appropriate adjustments for certain patients with ulcers or asthma).
In addition a system of 'rubber-stamping' prescription forms was devised so that appropriate prescriptions were given for appropriate operation types.

Results of this action

An audit of 200 patients over a 10 week period in 1994 showed that the prescribing policy was followed in 89% of cases. There were 130 returned questionnaires. They showed that the number of patients reporting severe pain at 24 or 72 hours at home had been reduced almost to zero (about 10% reporting severe pain in but four of 12 operation types). No patient had cause to contact their GP for provision of postoperative pain relief.

Comment

Simple really, when put like this. Some thought, some organisation, and a will to do things better, and everyone benefits.

Reference:

  1. TK Haynes, DE Evans, D Roberts. Pain relief after day surgery: quality improvement by audit. The Journal of One-Day Surgery, Summer 1995, 12-15.



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