Acute pain therapy

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Pain therapy should be an indicator of quality

After an operation, many patients complain of pain and inadequate therapy. Patient satisfaction varies from hospital to hospital. That investing in well-thought-out treatment actually does pay off is no foreign concept to doctor and MBA Dr. Joachim Erlenwein.

Dr. Erlenwein, in April at the surgical convention in Munich, you calculated the return on investment (ROI) of acute pain therapy. Is that necessary?

Hospitals deal with flat rates every day. This means they not only heal patients, they treat them efficiently as well. This includes acute pain therapy after operations, since they facilitate better and faster rehabilitation, there are fewer complications and patients regain mobility faster after, say, a joint operation.

A model calculation by colleagues at the Dresden University Hospital based on a prostatectomy study shows that patients who are given effective acute pain therapy can be discharged considerably faster, and it can save the hospital a lot of money and even bring in more revenue. It's worth it to invest. Even though you have to be a little careful with model calculations, it still suggests that no DAX stock can achieve this kind of ROI.

While acute pain therapy is no longer controversial, it still has significant deficiencies in quality.  Why is it worthwhile?

There are a lot of reasons for doctors to rely on acute pain therapy. For one, the ethical aspects that forbid them to let people suffer, which is also reflected in the professional code. Patients also have a right to adequate pain therapy. Medically, the effect is clear: Pain causes the body to release stress hormones that put a strain on the body and on healing.

There are more complications, the blood clots more easily, which increases the risk of thromboses and pulmonary embolisms, blood glucose goes off the rails faster, wound healing can be disrupted and the risk of infection increases. Atelectasis and pneumonia are more frequent, since patients recovering from major surgery on the chest or abdomen can't breathe deeply or cough up mucus out of the lungs because of the pain. This is also why the goal should always be keeping pain bearable. If this doesn't happen, there's also a risk of developing chronic postoperative pain that can last over six months.

How should acute pain therapy be provided?

When there's a new patient, it's important not only to discuss the operation but also to note any risk factors for severe pain from their pain history. After the operation, it's necessary to use standardized metrics to regularly ask the patient how much pain they're in on a scale from one to ten—not least to have a clear indicator for administering appropriate medications. Treatment standards establish in advance when analgesics should be administered in the ward and how pain management overall should look. For a stomach operation, this can be a peridural catheter or a perineural catheter after a knee operation.

At the hospital, there should at least be a standard for treatment with a severe amount of pain that makes the ward staff capable of acting. When transferring patients to another ward or discharging them into the further care of a primary care physician, the subsequent treatment of pain should be coordinated between these points of contact and regulated by standards. My gut tells me there are substantial deficiencies at these points and the risk of pain increases. It should be a topic in discharge management—which the Joint Federal Committee has currently put on their agenda, by the way.

Why is acute pain therapy often not taken seriously?

I see three causes. The first is organizational: Pain therapy has to go to the patient. There need to be set rules. Also, pain therapy takes a lot of resources, which takes time, so, for example, there needs to be staff on hand for if there's acute pain. It's also often that different pain management approaches are used in succession on the path from the ER to the ICU, to the regular ward, to the primary care physician and then to the rehab clinic. There are frequently no global concepts within the clinics or control over these interdepartmental treatment processes as there are in, say, transfusion medicine or hospital hygiene.

The second is lack of interest: Workers are often not interested in pain therapy. The third is a lack of knowledge about the medical consequences or improper or inadequate pain therapy or treatment approaches.

What really needs to change for acute pain therapy to become established?

Pain therapy should be centrally controlled like transfusion medicine or hospital hygiene. The treatment of pain should also be introduced as an indicator of the quality of care at hospitals. While 80 percent of the hospitals in Germany have an acute pain service, there's no standard for what procedure, what equipment and what staff make up these services. In the Netherlands, acute pain services are required by law. Additionally, awareness of the topic needs to be much higher. Some hospitals have more technicians for repairing and maintaining elevators than staff for acute pain service.

This interview was conducted by Andreas Schmitz.

State of emergency in German hospitals

More than every other patient reports being unsatisfied with pain therapy, found Dr. Christoph Maier from the Bergmannsheil University Hospital. Patients given particularly conservative treatment complained about not receiving adequate therapy (almost 46 percent). After an operation, almost every third patient (30 percent) reported feeling left high and dry.

20 to 40 percent of patients experienced severe pain following surgery at German hospitals, found Dr. Hans-Jürgen Gerbershagen from the Marienhospital in Gelsenkirchen in an analysis of more than 110,000 patients. It was also found that, in addition to complicated operations on the spine or feet, comparably simple operations like removing an appendix or inflamed tonsils have so far been underestimated. "Especially operations that are dismissed as minor often cause a lot of pain," explained Freys. With major operations - in the chest area, for example—it has been obvious for years that every opportunity to avoid pain is taken, from peridural and nerve block catheters to an epidural.

A study published in the German medical magazine "Ärzteblatt" decried the massive difference in pain experienced, restricted mobility and satisfaction in patients across hospitals in Germany. University hospitals in particular stood out as not taking the topic of pain seriously enough. "Wherever patients were well-informed, patients were more satisfied," concluded Freys from the results. "In hospitals with a greater depth of care, there were clear deficiencies compared to those that are active in basic care and are literally more in touch with the patient."


Andreas Schmitz