Introduction
It is a well-known fact that the patients who undergo surgery need a special treatment. Basically, this is due to the postoperative pain, which can be extremely dangerous for the organism. This kind of pain can cause a set of disorders, such as hyperglycemia, decreased gastric emptying, atelectasis, anxiety, ischemia, urinary retention, and reduced mobility (Rigg, 2002). Taking into consideration such risks, it is obvious that the prevention of pain and effective pain relief is extremely important for patients who underwent surgery.
One of the most popular methods of pharmacological pain relief which is currently used in all the hospitals of the world is analgesia (Loeser, Bonica, Butler, and Chapman, 2001). This therapy includes giving the patients drugs like opioids, which release people from painful feelings. There are two basic ways of relieving pain with analgesia, namely PCA (patient controlled analgesia) and NCA (nurse controlled analgesia). The first type is considered to be traditional and is used for the patients of all ages. This method means that a doctor is responsible for periodical injections of drugs.
The doses are defined by a therapist; the duty of the doctor in nurse controlled analgesia is to push the button on a machine which lets the medicine be sent to the patient’s bloodstream (Stoelting, 1990). The second type of analgesia is realized by the patients themselves. Depending on the strength of the pain attack and personal senses the patient is to decide when to take the medicine and how much they need it. The patient controlled analgesia is sometimes allowed for adults and is based on the notion that the needs for opioids are individual.
The both methods have their own benefits and disadvantages; for instance, the nurse controlled analgesia can guarantee a safe dosage (Czarnecki, Ferrise, and Jastrowski, 2008), but, unlike the patient controlled analgesia, it does not allow the patients to decide when to make the procedure. Therefore, the effectiveness and safety of both methods are still being discussed by the leading professionals of the world. The analgesic preparations are considered to be most effective when taken on a regular basis (Pang, Mok, and Lin, 1999); however, the patient controlled analgesia suggests taking the medicine depending on the patients’ needs.
Thus, this paper is aimed at comparing the two methods and defining which one is more effective for post operational pain relief. It contains analysis of different studies on the subject and also presents the recommendations for practice changes which can be implemented in the surgical practice.
Research question
We use the PICO format for formulating the research questions concisely.
- Patients: those who have undergone surgery process and are in the process of recovery (post-surgery patients).
- Intervention: patient-controlled analgesia during the post operational period.
- Comparison: the nurse controlled analgesia will be compared to the patient controlled analgesia.
- Outcome: the expected outcomes of the both types of analgesia are the patient-reported levels of pain and amount of analgesia used.
Based on the PICO format, the question to be answered in this paper is: What is the best practice for managing pain for postoperative patients, patient-controlled analgesia or the nurse-controlled analgesia (usual care) to patient-reported level of pain and /or amount of analgesia used?
Search terms
For this paper, we searched for different articles and works devoted to the topic, in order to learn the experience of other authors and consider the results of their studies. We used the World Wide Web and various databases like CINAHL for this purpose. The free text key words insertions were used in order to find the relevant works. In addition, the high-specificity search was organized for meeting the demands of our narrow research question.
The main search terms for the literature were “post operational pain management”, “patient controlled analgesia”, and “nurse controlled analgesia”. We also tried adding details to these phrases, for example “pain score” or “analgesia use”. As a result of such search, we found a multitude of works. Having got acquainted with every literature source, we selected only the articles which contained the significant information for the current paper. In addition, among the range of works with a rather general content we have chosen only those which had a narrow topic, suitable for our study.
Relevant Articles
Among all the found works, only six studies were selected. The first criterion for the works was the date of their publication, which had to be later than in year 2000. The second criterion was the article’s relevance to the topic of our paper.
The firs study is a quantitative systemic review of the patient controlled analgesia use. It analyzes the data from 32 trials, comparing the PCA and opioids with conventional opioid treatment in the post operational setting (Walder, Schafer, Heinz, and Trame, 2001). The next work is an article, which also compares the patient controlled analgesia to the nurse controlled analgesia, considering the possibility of early pulmonary complications in each case (Gust, Pecher, and Gust, 2002). One more article studies the influence of the mentioned methods of analgesia on the patients who underwent the cardiac surgery. It focuses on the pain management during the first 48 hours after operation (Martin, Bainbridge, and Cheng, 2005).
Another article studies the patient controlled analgesia alone, and gives advice for the doctors who work with patients in the post operational setting (Maddox, Williams, and Fields, 2004). We also have selected an article which systematically lists the advantages of the PCA for pain relief after surgery (Spinasanta, 2007). Finally, for this paper we have also chosen an article which is based on a study about the PCA and NCA and is aimed at finding out if the first method can be considered as superior to the second one (Bainbridgea, Martin, and Chenga, 2004).
Critical Appraisal of Systemic Review and Summary of Article
The systemic review (Walder, Schafer, Heinz, and Trame, 2001) addressed an important clinical issue. It deals with the postoperative pain management, which is one of the most common practices in the hospitals nowadays. While the NCA was accepted as a basic method for post operational pain relief, the authors tried to study the PCA as another possible option. Their aim was to access the safety and efficiency of the patient controlled analgesia, and the authors were successful at this task. The question was answered explicitly, supported by experimental evaluation and real-life data.
In order to carry their experiment and develop the article, the authors had to search for a number of studies which were made previously and could be helpful for their work. The search was rather detailed, as the criteria for the selected works were maximally narrowed down. The relevant studies were demanded to report on both the program of the PCA device and the control opioid regimen (Walder, Schafer, Heinz, and Trame, 2001).
The works that contained comparisons with other administration ways or different opioids were not considered, which limited the number of searched works. The search appeared to be rather challenging, and the authors had to try several methods, such as free text key words insertion, high-specificity search, and low-sensitivity search. All in all, the search for relevant studies was exhaustive, yet successful.
The primary studies presented in the systemic review can be considered as those of high methodological quality. One of the reasons for that is that all the selected works had to be published. The authors considered mainly full reports or randomized comparisons of the opioid given in two ways: by PCA and subcutaneously. The high methodology of the primary studies can also be proved by the fact that the authors checked the bibliographies of every study. The studies published by people who might be interested in some promotion or advertisement (manufacturers of PCA devices, different authors) were also not considered, which once more points to the objective character of the chosen works.
The assessment of the studies i the review can be considered as reproductive. The authors had a well-development system of studies assessment, which consisted of several steps, which can be followed again if needed. In addition, the strict criteria for the assessment define certain features which need to be present in the works. The methodological validity of the retrieved reports was accessed by several independent authors. Furthermore, using the 5-point, 3-item Oxford scale made the procedure of assessment easy to repeat.
Due to the fact that the criteria for studies selection were extremely strict, the results of analyzed reports are rather similar. The review analyzed only one sort of the patients, namely adults who underwent surgery. In addition, all the medications given to the patients were of the opioid family. For instance, most of the studies report about the cumulative opioid consumption during the first 24 hours, and only several reports note that the duration of the consumption can last up to 48 hours in some cases. Another example is the stable level of pain intensity in patients. Furthermore, the duration of hospital stay also appeared to be unchangeable from study to study.
However, there were also some data which varied in different studies. This can be explained by the fact that the different reports contained different content. For instance, only several studies reported on the patients’ opinion about the medical practice, and only one study reported on scores of atelectases.
The overall results of the systemic review suggest that the patient controlled analgesia appeared to be more effective in comparison with the traditional analgesia. The pain management with different preparations, such as morphine, pethidine, piritramide, nalbuphine, and tramadol was observed. Interestingly, in all cases the level of patients’ satisfaction proved to be much higher when using the PCA. Among the articles selected for our paper, one work is devoted to the pain management after cardiac surgery. Similarly to the results of the systemic review, the article reports about the significant pain relief using the PCA during the first 24 hours after the operation (Martin, Bainbridge, and Cheng, 2005).
In addition, according to the studies used in the review, the risk of pulmonary complications is also dependant on the analgesia method: the average scores of atelectases are considerably lower with PCA compared with NCA. These data were also supported by one of the articles. The pulmonary complications in PCA proved to be twice less possible than in the usual care (Gust, Pecher, and Gust, 2002). The investigation of pain level showed that its intensity is the greatest during the first day after operation.
The pain management proved to be nearly two times more efficient using the patient controlled analgesia compared to the convectional nurse controlled analgesia. One of the selected articles also warns about the seriousness of possible adverse effects. They are likely to occur in cases when people are prescribed the PCA without the special education about the therapy (Maddox, Williams, and Fields, 2004). All the reported adverse effects, including nausea, bradypnoea, hypoxia, sedation, pruritus, and urinary retention proved to appear both in PCA and NCA methods.
The presented results of the systemic review can be considered as reliable, as all the studies are methodologically valid. The strict criteria for reports selection suggest that the analyzed data is secure. The review considers a number of studies, each of them working with large groups of people. The overall quantity of analyzed patients is nearly 2, 5 thousands. Therefore, it can be stated that the results of the review are relatively precise. However, on the other hand, this number of people can be insufficient when the statistical data is being formed. The articles selected for the paper also dealt with a limited number of patients (Gust, Pecher, and Gust, 2002). In other words, on the local level the results of overview can be secure, but on the level of a country or on the international level, more research needs to be conducted.
Apply the Results to Patient Care
Having analyzed the systemic review, we got acquainted to the current situation in the post operational pain management. The feelings and needs of the patients are of paramount importance, as pain relief is essential for a successful treatment. One of the key features of every study is the possibility to apply its results in the real life conditions. Therefore, we need to consider the results of the overview in order to apply them in the medical practice.
For instance, we need to define some points that were common for all the reports included in the review and consider them when working with patients in the post operational setting. As a rule, the patients admitted the patient controlled analgesia to be more effective for pain management than the traditional control. PCA also proved to have better volumes of cumulative opioid consumption, pain scores, and duration of hospital stay. Therefore, it is sensible to take this fact into consideration. Knowing that the PCA is preferred by patients, we can apply it more often, or offer it to those who are not familiar with this method yet. In addition, if there is a risk of pulmonary complications, we can avoid in case of using the PCA. This knowledge is also derived from the review and can be applied for the patients.
The review managed to study all the possible outcomes of the therapy. Both the advantages of the PCA and possible risks were analyzed. The authors considered such patient-important factors, as cumulative opioid consumption period, pain scores, duration of hospital stay, possible pulmonary complications, patients’ preferences etc. However, only the outcomes for the current group of people were studied; the children and young people often need some help and can barely be trusted to do the PCA for themselves. Thus, it can be said that the specialization of the review is rather narrow, and is focused on a certain type of patients.
As it was mentioned before, PCA was concluded to have a multitude of advantages for the patients. However, there are also some adverse effects, which often occur in patients. Thus, it is important to compare the benefits with the costs and risks of the therapy to define whether it is valid.
The growing popularity of PCA suggests that the modern hospitals need to be equipped with the PCA devices. This demands financial resources, as the new technology is rather expensive. On the other hand, the PCA therapy is proved to shorten the period of the hospital stay, which means that some money can be economized by these means. Concerning the adverse effects of the PCA, the studies have proved that these effects are likely to occur both with the patient controlled analgesia and with the usual nurse controlled analgesia. That is why, we can confidently state that the benefits of the therapy are worth the costs and potential risks.
List of Recommendation for Practice Change
The practice change is a multistage process, which demands proper planning and gradual implementation. The area of practice to be changed is pain management for patients who underwent surgery. Our aim is to offer the patient controlled analgesia as a common practice instead of the traditional nurse controlled analgesia. First of all, in order to adopt the idea about the implementation of some changes in the practice, there has to be a clear evidence of the need for the changes (Daly, Speedy, and Jackson, 2004).
For instance, in case with the pain management in the post operational setting we can observe the need for some therapy which could help the patients quickly and effectively. In addition, the existing methods are not always satisfactory enough. Next, there has to be a leader and a team who would drive the practice changes. In case with PCA implementation the team would consist of the doctors who would prescribe PCA to patients, and of patients, who would accept this method of analgesia. The leaders can be the head of the hospital or even the head of Health Ministry of the country. Finally, we need a detailed plan of the changes which are to be implemented.
In our opinion, the main steps for the practice change implementation are:
- Prepare all the workers for the change and involve every worker into it. This stage is of a paramount importance, as cooperation is the key element of every successful system work. For this purpose, the special meetings have to be held, where the stuff would explain to the workers the new work strategy and give instructions.
- Prepare the patients to the innovation. As far as I case of PCA the patient is the only person who is responsible for dosage and frequency of the injections, they have to be educated about how to use the PCA device properly. The inadequate use of the method an be hazardous for the patient’s health. Thus, the patients have to be warned about possible risks and taught how to operate the process. The fact that the patients just underwent surgery and are in an instable state also should be taken into consideration (Doyle, Harper, and Morton, 1993).
- Evaluate the statistical data and provide the hospitals with special equipment. This step suggests that all the prior studies have to be reviewed, and the average number of PCA devices to be bought defined. The hospitals need to buy the equipment, in order to be able to practice the patient controlled analgesia.
- Widely implement the PCA. At this level, the doctors should prescribe the PCA to the patients who underwent surgery. It should be remembered, that the doctor’s confidence and authority is of a vital importance for the patients.
- Monitor the results. This stage is also extremely important, as the implemented change has to be effective. Assessment of the effectiveness can be realized through monitoring the results and analyzing the possible improvements. The results of the practice have to be evaluated objectively; all the further changes have to be aimed at serving for the good of the patients.
Besides the adequate planning of the change implementation, there are also other factors which need to be considered. For instance, the implementation of the change has to be realistic, which means that not only the benefits, but also the costs and risks of the innovation have to be considered. Another important point is the involvement of all the stakeholders, which means that the implementation of the change has to be agreed among the members of the team.
Furthermore, any change means something new both for medics and patients; for this reason, there should always be the consultation available for both sides. With this purpose, some seminars or support centers have to be organized. In addition, throughout the process of change implementation, some unexpected problems may occur. In order to detect the drawbacks and correct them immediately, it is necessary to regularly organize the meetings of the team involved in the change.
Table of Divers, Barriers and Strategies for Practice Change
In order to make sure that the implemented changes are realistic and viable, we need to consider the drivers and the problems that may occur in the change process. What is more, we need to develop strategies for optimizing the drivers of the project and overcoming the possible barriers. For this purpose, we will present a table.
Conclusion
In conclusion it can be said, that the best practice for managing pain for the patients in a post operative setting is the patient-controlled analgesia. In comparison with the traditional nurse-controlled analgesia, the method performed better in the respect of patient-reported level of pain, amount of analgesia used, duration of the hospital stay, and risks connected to the possible pulmonary complications. The method was also preferred by the patients who tried both the PCA and NCA. Therefore, it can be stated that the wide implementation of patient controlled analgesia for the patients who underwent surgery is justified.
Having developed a plan for practice change implementation, we also considered the barriers and drivers of the project. We have come to conclusion that patient controlled analgesia is worth implementing. All in all, PCA is a very promising innovation, which gives a lot of benefits both for the doctors and patients.
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