INADEQUATE POSTOPERATIVE PAIN CONTROL IN AMBULATORY SURGERY

Budapest 7 de Mayo de 2013

A. Jiménez, J.A. Gracia, E. Redondo, B. Calvo, B. Jiménez, M. Martínez.

  

BACKGROUND.

Ambulatory surgery constitutes near 50% of all surgery performed in Spain nowadays. Postoperative pain control is one of the most important objectives in this surgery in order to reach patient satisfaction and to avoid unplanned hospital admissions. Recent studies have shown that large numbers of patients suffer from moderate to severe pain during the first 24-48 hours (Rawal N. 2007).

 

 

 

 

 

 

 

This bad postoperative pain control forces to consult with general practitioner, causes adverse physiological effects (respiratory, cardiovascular, gastrointestinal, urinary and metabolic) and involves hospital admissions. These undesirable consequences induce the increase of costs associated with ambulatory surgery.

 

 

 

 

 

 

 

The Day Surgery Unit (DSU) of U.H. Lozano Blesa in Zaragoza, Spain, began its activity in 1995 as a multidisciplinary unit and in the last two years almost 3000 patients/year were operated on in the DSU. Protocols of postoperative pain control were improved in year 2000 after noticing a poor pain control in some patients.

OBJECTIVE.

 

 

 

 

 

 

This study was undertaken to examine the success or failure in the postoperative pain control in our multidisciplinary DSU and its relation to the different types of surgery.

METHODS.

The unit is integrated in a University General Hospital with independent facilities. A total of 24035 patients were scheduled to be operated on in the DSU from March 1995 to November 2012. The surgical specialties included were Ophthalmology (45.9 per cent of patients), General Surgery (19.8 per cent), Orthopedic Surgery (13.4 per cent), Urology (7.2%), Vascular Surgery (6.1 per cent), ENT (4.9 per cent) and Gynecology (2 per cent).

 

 

 

 

 

 

Patients and their caregivers were instructed in pain control using oral drugs as metamizol (dipyrone, non-opioid analgesic) or paracetamol (acetaminophen, NSAID analgesic) complemented sometimes with diclofenac (NSAID analgesic), every six or eight hours during the first 3-7 days after surgery, according to the expected pain, mild, moderate or severe.

 

 

 

 

 

 

 

Recovery events in the postanesthetic care unit and at home after discharge were registered in a database during the first 30 days of postoperative period. Statistical analyses were performed using Stat-View 5.1.0 software. Statistical comparisons were made with ANOVA test and t test according to qualitative or quantitative variables. Significance was defined as p<0 .05.="" o:p="">

 

RESULTS.

 

 

 

 

 

 

 

 

Among the 487 patients (2.1 per cent) with bad postoperative pain control (289 women, 198 men), median age was 55 years with a symmetrical distribution. However patients between 41 and 65 years old suffered significantly more pain than older (3.2 per cent and 1.2 per cent respectively) and than younger (2.3 per cent).

 

 

 

 

 

 

 

 

 

ASA status I patients had a significant higher incidence of pain than ASA status II or III patients (2.5 per cent, 2 per cent and 1.5 per cent respectively). These findings can be related to the different types of surgery as we will show later.

 

 

 

 

 

 

 

The most common types of anesthesia were local combined with sedation (31 per cent), retrobulbar block (29 per cent), spinal (22 per cent) and general anesthesia (12 per cent). Patients having spinal anesthesia and axillary plexus technique had significant higher incidence of bad postoperative pain control (4.5 per cent and 3.9 per cent) than local and retrobulbar block (1 per cent and 1.2 per cent).

 

 

 

 

 

 

 

 

The mean duration of surgery was 34 min (median 30 min) but the patients who had bad postoperative pain relief had longer duration (43 min) probably related to a more complex procedure and an increased tissue trauma.

 

 

 

 

 

 

 

The type of surgery is probably the factor that has most influenced the poor control of postoperative pain. As in the majority of studies orthopedic patients suffered most painful surgery (5.9 per cent) while ophthalmological and ENT patients (1.1 and 1 per cent) had the best postoperative pain relief. Vascular surgery and general surgery patients also suffered postoperative pain above the mean (3.3 per cent and 2.5 per cent). Analysing each type of surgery, the majority of published studies recognize that shoulder surgery has the greatest incidence of severe postoperative pain but we have a very short experience with this surgery in ambulatory basis.

 

 

 

 

 

 

 

Our study shows that hallux valgus correction with 8.5 per cent of patients suffering poor postoperative pain control is the most painful surgery followed by knee arthroscopy (6.7 per cent), hernia repair (3.4 per cent), varicose vein surgery (3.3 per cent) and anal surgery (2.5 per cent). On the other hand the cataract surgery was the less painful (1 per cent) followed by laryngeal microsurgery (1.3 per cent) and testicle surgery (1.4 per cent).

All these significant predictive factors are interrelated being the age and the type of surgery the most important probably. To probe this  we should have conducted a multivariable analysis. The body mass index is also an important factor in other studies but this index is not registered in our database.   

 

 

 

 

 

 

Among the 487 patients with poor postoperative pain control,  39  of them (8 per cent) needed immediate hospital admission and 4 were admitted after discharge. Our DSU has a mean of 2 per cent of unexpected hospital admission by different causes and of this small percentage, 0.13 is due to a poor postoperative pain control.

CONCLUSIONS.

1. Adequate pain control is important to avoid patient dissatisfaction, adverse physiological effects and unplanned hospital admissions.

2. Principally hallux valgus correction and knee arthroscopy, but also hernia repair surgery, varicose vein stripping and anal surgery are the procedures more frequently related to bad postoperative pain control.

3. In patients with risk factors as the type of surgery and anesthesia, the longer duration of some interventions, the age between 40 and 65 years of patients and even the ASA status I it’s necessary to develop more effective strategies for control of postoperative pain.

REFERENCES.

-F. Chung ete al. Postoperative pain in ambulatory surgery. Anesth Analg 1997; 85:808-16.

-F. Coluzzi et al. Determinants of patient satisfaction in postoperative pain management following hand ambulatory day-surgery. Minerva Med 2011; 102(3):177.86.

-O. L. Elvir-Lazo and P. F. White, PhD. Postoperative Pain Management After Ambulatory Surgery: Role of Multimodal Analgesia. Anesthesiology Clin 2010;28: 217–224.

-S. Mukherji and A. Rudra . Postoperative pain relief for ambulatory surgery. Indian J. Anesthes. 2006; 50(5):355-362.

-N. Rawal. Postoperative pain treatment for ambulatory surgery. Best Pract Res Clin Anaesthesiol 2007;21(1):129-48.

THE USE OF 8 INDICATORS TO MEASURE QUALITY IN AMBULATORY SURGERY

Budapest 6 Mayo 2013

A. Jiménez, J.A. Gracia, E. Redondo, B. Calvo, B. Jiménez, M. Martínez.

The aim of this study is to determine the evolution of quality in a multidisciplinary ambulatory surgery unit using 8 different clinical indicators during a period of 17 years.

METHODS: A total of 24035 patients were scheduled to be operated on from March 1995 to November 2012. The indicators monitored were: 1. Cancelled procedures. 2. Adverse events. 3. Wound infection. 4. Unplanned hospital admissions.  5. Hospital readmissions. 6. Ambulatorization index. 7. Substitution index. 8. Patient satisfaction index. Statistical analyses were performed using Stat-View 5.1.0 software.

CONCLUSIONS.

1. The monitored indicators show similar improvements to standards in Spain.

2. The cancellation of procedures would be reduced with a greater agility replacing patients, ring fencing the DSU from the interference of the rest of the surgical block and improving the pre-operative assessment of patients.

3. The overall morbidity would improve justo to reducing the porcentaje of urinary retention, 5.5 per cent, excessively high.

4. Unplanned hospital admission rates are acceptable and have remained steady along these years. Rates have not worsened by the inclusion of higher risk patients and procedures.

5. Indicators of efficiency of the DSU show a progressive improvement, but do not reach the average values published in Spain.

6. Patient satisfaction is high. This circumstance is common to the majority of the DSU.

 

QUESTIONNAIRE SURVEYS IN AMBULATORY SURGERY. CONCLUSIONS AFTER 13 YEARS USING QUESTIONNAIRES

Budapest 8 Mayo 2013
10th International Congress on Ambulatory Surgery.

A. Jiménez, J.A. Gracia, E. Redondo, B. Calvo, B. Jiménez, M. Martínez.

BACKGROUND.

Day surgery is expanding quickly in Spain and Spanish Hospitals are reaching an ambulatorization index (percentage of interventions performed in day surgery by all specialties) near 50%. As well as studying the outcomes of surgery it is also important to look at the “customer satisfaction” of a given service. Following the recommendation of Rudkin, patient satisfaction surveys must be performed in order to obtain comments from dissatisfied patients, explore the reasons for them and thus improve the quality of care.

The Day Surgery Unit (DSU) of U.H. Lozano Blesa in Zaragoza-Spain began its activity in 1995. In April 1999 a questionnaire, designed by experts, was implemented in the hospital in order to know the patient satisfaction in ambulatory surgery.

From that time until today there have been important changes in the unit. Protocols of postoperative pain control were improved in year 2000. In year 2009, some beds in the recovery area were replaced by recliner chairs increasing the number of patient cubicles from 12 to 17 with an important increase in outpatient surgery. Finally last year, forced by the financial and economic crisis in Europe, the activity in ambulatory surgery stopped its progression due to budget cuts imposed by the European Union to Spain provoking an important increase of number of patients in waiting lists.

OBJECTIVE.

Our aim is to analyze information provided by questionnaires in order to identify complaints, areas of improvement, the effects provoked by the increase of activity and, nowadays, the effects of budget cuts.

METHODS.

Our study has been done in a multidisciplinary DSU, integrated in a University General Hospital with independent facilities. Patients belonged to Ophthalmology, General Surgery and Orthopedic Surgery principally.

An anonymous questionnaire to be returned in a prepaid envelope, with 25 scaled close-ended items and 6 demographic variables, was delivered to 21631 patients, operated on in our day surgery unit from April 1999 to November

 2012, at the moment of discharge. Questions were grouped in 5 different areas: 1. Patient information and contact, 2. Patient comfort, 3. Health care provided, 4. Hospitality and organization, 5. General satisfaction. The answers were transformed into a score system with a maximum of 20 points per area and 100 points per questionnaire. The recommendation was to fill in the questionnaire one or two weeks after surgery and return it by mail.
 

 

Answers and scores were registered in a database created with Stat-View 5.1.0 software. This program allows descriptive statistics and comparisons. Statistical comparisons were made with ANOVA test. Significance was defined as p<0 .05.="">

RESULTS.

 

A total of 9283 patients (43 per cent) responded. The demographic characteristics of responders were: Gender: 50.6 per cent were men and 47 per cent women. Age: mean age was 59 years with a median of 62 years. Habitat: 65 per cent lived in urban environment and 32 per cent in rural areas. Civil status: 67 per cent were married, 14 per cent were single and 13 widowed. Level of education: 52 per cent had primary education, 23 per cent had secondary education and 11 per cent were graduates. Employment: 33 per cent were employed, 40 per cent retired, 4 per cent unemployed and 18 per cent were housewives.

A 84 per cent of responders were satisfied with day surgery unit and 95 per cent would choose the unit again if necessary. The average total score was 84,6 and only 19 questionnaires had the total score below 50. The fluctuation of this score was statistically significant during these years with the worst data at the beginning of DSU activity and in the years 2010 and 2011 in which there was an important increase of activity.

The analysis of areas showed:

- Area number 1 (Patient information and contact): 17.7 points (maximum 20). Responders were satisfied with the information about day surgery and the possibility of phone contact 24 hours. Only the question about preoperative information reflects improvement possibilities. The score on this preoperative information did not suffer significant variations during the studied years.

 

- Area number 2 (Patient comfort): 15.1 points (maximum 20). Anxiety during the night before surgery and deficiencies in the postoperative pain control were detected. Both findings should force a change in protocols to improve the control of preoperative anxiety and postoperative pain. Analysing the behaviour of the anxiety before surgery and postoperative pain scores during these years we found no significant differences.

 

- Area number 3 (Health care provided): 16.2 points (maximum 20). Patients were very satisfied with health cares provided at the DSU but the large waiting list impairs the score of this area. Analysing variations of waiting list score we have discovered an important statistical significance during these years, with the worst data in year 2012 coinciding with the budget cuts and the increased list.

- Area number 4 (Hospitality and organization): 18.5 points (maximum 20). Patients were very satisfied with the five questions of this area. However, it was important to know if the introduction of 9 recliner chairs in 2009 has impaired the specific score about comfort in the recovery area. The line plot shows a significant impairment of this score during 2010 and 2011 with a later recovery.

- Area number 5 (General Satisfaction): 17.1 points (maximum 20). Satisfaction was very high in this area but responders said that health workers asked for their opinion about cares rarely. Although cares at the DSU are protocolized, nurses and physicians should give further explanations to patients about the cares provided in the unit. The patients’ complaint about the possibility to discuss cares with health workers has remained stable during these years.

The demographic variables allowed comparisons among patients finding statistical significance. The highest scores were associated with male patients, with the age between 41 and 65 years, married and with the higher level of education. The lowest scores were associated with female patients, with age under 40 years, widowers and the primary level of education. There were no statistical differences related to rural/urban habitat or employment.

CONCLUSIONS.

1. Questionnaire surveys in ambulatory surgery allow, not only to know patients satisfaction, but to identify the reasons for patients dissatisfaction.
2. The transformation of qualitative data in a score system allows to monitor improvements and to compare groups of patients by applying more powerful statistical tests.
3. The most important area of improvement is related to waiting lists but there are also necessary actions in order to improve preoperative information, reduce anxiety the night before surgery, relief postoperative pain and to give more explanations about cares to patients.



REFERENCES.

-S. Ghosh and S. Sallam. Patient satisfaction and postoperative demands on hospital and community services after day surgery. Br J Surg 1994; 81:1635-1638

-A. Jiménez et al. Encuesta de satisfacción en cirugía mayor ambulatoria: Instrumentos para detectar puntos débiles y monitorizar mejoras. Cir May Amb 2002; 7(4):164-172

-P. Lemos et al. Patient satisfaction following day surgery. J Clin Anesth 2009; 21(3):200-5

-S. Mcintosh and J Adams. Anxiety and quality of recovery in day surgery: A questionnaire study using Hospital Anxiety and Depression Scale and Quality of Recovery Score. Int J Nurs Pract 2011; 17(1):85-92

- I. Shnaider and F. Chung. Outcomes in day surgery. Curr OIpin Anaesthesiol 2006; 19(6): 622-9.

-MW. Stomberg et al. Day surgery, variations in routines and practices a questionnaire survey. Int J Surg. 2013; Jan 9. Pii:S1743-9191 (13)


-D. Tong et al. Predictive factors in global and anesthesia satisfaction in ambulatory surgical patients. Anesthesiology 1997; 87:856-64