Amany E. Ayad MD, FIPP

Acute Pain Services; an Egyptian Experience

Dear Editor,

Inadequacies in postoperative pain relief have been evident for decades despite the availability of variable drugs and sophisticated techniques for management [1,2]. This is thought of due to lack of an appropriate service that deploys available expertise rather than the need for new medications or pain management modalities. Thus, establishing an acute pain service (APS) based on an evidence-based approach within the available resources sounds like a solution [3].

This organized APS team was proposed over 50 years ago [4]. More than a decade passed before the first specialized in hospital, APS emerged in 1985 in the United States and Germany [5,6]. Sustained administrative support and authoritative recommendation promoted a wide spread introduction of APS.

The publication of “Pain after Surgery” in 1991 [7], initiated the widespread implementation of APS. This was the beginning of the first known structured model for APS, a nurse-based model, the “European-Model” [8].

While the anesthesiologist has the overall responsibility for postoperative pain management, a specialist acute pain nurse (APN) plays a key role in the APS by making daily rounds on all surgical wards. The APN educates ward nurses, and gives necessary support to initiate and supervise analgesia [9,10].

Following, came the era of the anesthesiologist-based “USA-Model,” adopted by most major institutions in the United States [11]. The APS teams under this model often consist of staff anesthesiologists, specialist APNs, pharmacists, and sometime biomedical personnel. Patients under the care of APS are visited and assessed regularly by members of the team [11].

“USA-Model” essentially provides a “high-tech” pain management services such as epidural and patient-controlled analgesia (PCA) [11]. Pain management is often very satisfactory. However, the economic costs of such services are high, and therefore, the benefits are not available to all surgical patients because of reimbursement regulations [12].

Pain Physician Model, the “Egyptian-Model”

Despite being available in so many places, it was first thoroughly described in our publications [13]. It was implemented in Egypt in 2007 as a modification of the “USA-Model.” First, it was implemented in “Dar Al Fouad Hospital,” a medium-sized hospital (145 beds) running on the average 4,700 “surgeries” per year including major orthopedic, vascular, gynecologic, cardiac, chest surgery, neurosurgery, and organ transplant. Audits from Dar Al Fouad Hospital showed that in 2012, APS served 3,670 patients vs 2,190 patients in 2009 [13].

Following several reviews, we adopted a more applicable design that can cope within our resources and at the same time gain widespread acceptance by many hospitals within Egypt, including public hospitals with limited resources [13]. Cairo University Hospitals (3,880 bed), where we run on the average 68,000 major surgeries per year, has started to adopt this model.

APS team in a given day includes one pain consultant and one resident, with the help of one or two pain nurses. We have at maximum one PCA pump per 25 surgical bed census in our hospitals.

The APS under the “Egyptian-Model” monitors and manages acute pain in trauma, surgical, and medical patients suffering from pain throughout their hospital stay. All postoperative patients are automatically enrolled for the service during the first 48 hours. Other medical patients and patients from the emergency department require referrals to be enrolled for the APS. Patients under the “Egyptian-Model” are offered the service whether they are subjected to a high-tech modality or a pharmacological management under our agreed on protocols and guidelines [13].

Under the “Egyptian-Model,” a pain physician leads the APS assisted by a trained APN. The pain physician assesses pain, manages treatment regimens, conducts follow-up, and modifies plans for postoperative analgesia [13].

Pain physicians could support both chronic and APSs. This move would offer optimal pain management throughout the hospital and not limit them to the surgical wards, which typically happens in a USA-Model. Pain physicians are often more knowledgeable about pain management and capable to diagnose and effectively manage complicated types of pain, such as neuropathic pain. Staff anesthesiologists, residents, and ward nurses are also included as they are included in the USA-Model; apart from that, the follow-up rounds are carried out by the pain resident (supervised by the pain staff) and the APNs [13].

Frequent audits from our hospitals based on the pain scores of patients under the “Egyptian-Model” showed dramatic improvement in the percentage of patients having adequate pain control, i.e., achieving an average pain scores of 0–3/10 in the first 48 hours after surgery (utilizing the numerical pain rating score); 52% in our audits in year 2008, then gradually increased to reach up to 94% in 2011 Moreover, the percentage of patients having severe pain (average pain scores >7/10 in the first 48 hours after surgery), decreased from 4.6% in year 2008, down to 0.5% in 2011 [13].

We had several quality assurance department surveys for the APS. Most of them indicated that under the “Egyptian-Model,” we had a better understanding and performance in acute pain management within the hospital setting [13]. In our Egyptian experience, we focus on the manpower rather than the technology or new drugs, resulting in a better patient outcome.

Cost-Utility

As regards the cost utility of the APS under various models, there is no standard way of measuring it [14]. We tend to calculate the cost of the extra salaries of the personnel rather than calculating the cost of the drugs or disposables. We consider the later costs as part of the whole cost of the surgical procedure (like antibiotics and infusion pumps) that was used for a real clinical need. Some studies have taken into accountability the cost of postoperative morbidity and the length of postoperative hospital stay being affected by the APS [15,16].

The calculated cost per patient ranged from 7–10$/patient in the “Egyptian-Model” depending on the salary rate in various hospitals [13]. Previous studies of the cost of the “USA-Model” showed marked variability depending on the way of measuring it ranging from 2.28$/patient reaching as high as 242$/patient [17], while the Nurse based model can cost 2–3$/patient/day [10]. Knowing that the physician-based models are costly ones, physician salaries are lower in developing countries, making it a more cost-effective. Discussion on the cost of various models will otherwise continue to be a matter of opinion.

To Conclude

The literature is unclear about the optimal structure, staffing, and functions of APS. There is a need for developing a well-defined APS criteria and standards with which to assess performance. According to our preliminary audits, the “Egyptian-Model” may be an attractive option for developing countries, overcoming the barriers of lack of high-tech facilities for every patient by having a pain physician who manages the patient pain at a low cost.

Asking this physician, how much do you make? I make a difference!!

Source:

http://onlinelibrary.wiley.com/doi/10.1111/pme.12259/full

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