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Education, assessment and postoperative pain management

Clinical bottom line

A standardised process of education, assessment and standardised prescriptions can improve postoperative pain management.


M Harmer, KA Davies. The effect of education, assessment and a standardised proscription on postoperative pain management. Anaesthesia 1998 53: 424-430.


Following a survey of all NHS hospitals, units were identified where there was no formal mechanism for postoperative pain management. A representative hospital was chosen from each NHS region, from small district hospitals to teaching hospitals.

The project had four stages:

  1. An initial survey of 100 postoperative surgical inpatients or a one-month survey. Patients were interviewed at 24 hours and four days to record complications and pain using a standardised questionnaire.
  2. A programme of education for all staff led by a lead clinician and nurse. Education consisted of the use of a four point verbal rating scale and an algorithm to allow a flexible and safe provision of intermittent intramuscular opioid use after surgery. Patients with moderate or severe pain were managed according to sedation, respiratory rate, blood pressure and time since last dose.
  3. Standard guidelines were introduced, initially in two surgical wards.
  4. After four to six months, a repeat survey was undertaken.

Surgery types included gynaecological, orthopaedic, general, urological and vascular. Operations were classed as major, intermediate and minor.


There was information from 1,416 patients in the first survey and 1,322 in the second. Groups were similar in terms of sex distribution, age, and proportions of major, intermediate and minor surgery.

More patients (73% received information about pain and its relief in the second survey than in the first (46%). More patients found their pain better than expected in the second survey than in the first (Figure 1).

Figure 1: Patient expectation of pain

Pain at rest, on movement, and on deep inspiration was better in the second survey, with fewer patients having moderate or severe pain (Table 1). The proportion with severe pain on movement fell from 37% to 12%.

Table 1: Percentage of patients with moderate or severe pain

Percent of patients


First survey

Second survey

Pain at rest



Pain on movement



Pain on deep inspiration



Moderate to severe nausea fell from 37% in the first survey to 23% in the second, and moderate to severe vomiting fell from 22% to 12%. There was also a reduction in the number of patients reporting postoperative complications by the fourth day, particularly chest infection, constipation and paralytic ileus.


An important paper this, because it demonstrates that doing simple things well can make postoperative pain much better. The elements are simple. They involve some staff education (doctors and nurses), actually asking patients about their pain and recording it, and doing something about the pain using a system that avoids mistakes while ensuring that what can be done easily is done easily, a with rules about when to seek help. It isn't just one thing, it is doing several together that makes this sensible.

The paper is a must-read, if only to extract the charts and algorithm.