Acute Pain Services – how effective are we?

The report ‘Pain after Surgery’ in 1990 [1] recommended the formation of acute pain teams to manage postoperative analgesia, and by 2000, some 88% of hospital trusts had created such teams [2]. There is no national (or international) consensus on the optimal structure or responsibilities that an acute pain service should adopt, and unsurprisingly the exact format, resourcing and responsibilities of these teams varies. We have analysed the performance of 14 hospitals' acute pain services, varying in size from small district general hospitals through to large teaching hospitals. Each adopted a standard data collection system and definitions, and collected their data at identical time intervals. In the first instance, we looked only at the performance of epidurals sited for postoperative analgesia. On day 1 postoperatively, an average of 18.5% of patients with epidural analgesia had experienced ‘significant pain’ (defined as pain scores of 2 or 3 out of 3 for two consecutive data collection periods). This figure masked a range throughout the hospitals of between 6.9% and 37.6%. There was no striking association with infusion drugs, mode of delivery or type of surgery. The situation was even more extreme when ‘epidural failure’ was considered. An epidural failure was defined as any incident that resulted in a need to change analgesia modality, and so included organisational difficulties as well as clinical problems. The mean failure rate during the entire period of use was 19.3%, but the range this time was from 6.4% to 57.8%. The reasons for the apparent variation in performance are unclear, but are likely to be multifactorial. They clearly warrant closer attention, and we will be attempting to establish whether these differences are related to resources, working practices or simply a reflection of local surgical workload variation. Acute pain provision services are now over 10 years old and 60% of hospitals perform continuous internal audit [3]. Isn't it time to produce national standards against which performance can be judged? In our opinion, this can be facilitated by the adoption of more effective, national audit rather than focusing on internal audits that do not allow multicentre comparisons. National audit could then provide data for the formation of appropriate standards against which we could audit locally.