Patient satisfaction with pre-operative analgesia in acute trauma

R. MORGAN-JONES, L. CUTLER, S. KAUL and K. SMITH
Department of Orthopaedics and Trauma, North Staffordshire Royal Infirmary, Stoke-on-Trent, U.K.

Introduction

Method

Results

Discussion

Conclusion

References

We performed a prospective study of 100 consecutive patients admitted to the Orthopaedic and Trauma Unit at the North Staffordshire Royal Infirmary following acute injury. We assessed the patient's level of pain and perception of pain relief in the period from their admission to hospital and surgery, or the first 24 hours as an inpatient using a questionnaire. We found that 54% of patients described their pain as 'severe' or 'the worst possible pain'. Significantly, 36% of patients would have liked more analgesia. We conclude that patients are not receiving the analgesia they require following acute injury.

Keywords: Analgesia, patients' perception, pre-operative, trauma

J.R.Coll.Surg.Edinb., 45, December 2000, 371-372 

INTRODUCTION

Inadequate patient analgesia for acute conditions, both in the Accident and Emergency department and following admission have previously been documented. 1,2,3,4 However, it has not previously been documented whether patients themselves feel that they require more analgesia in the pre-operative period following acute admission. This article attempts to address this clinically important question.

METHOD

We prospectively studied 100 consecutive patients admitted with acute injuries requiring orthopaedic intervention. Non-acute injuries, head injury, drug or alcohol intoxication or confusion were exclusion criteria from the study. The period investigated was from admission to theatre, or the first 24 hours of admission, whichever was the shorter.

Patients were asked to complete a post-operative questionnaire within 48 hours of admission. This addressed the severity of the pain, 5 point scale perception of pain relief and other measures e.g splintage, elevation etc which reduced pain. It is likely that the patients' perception and memories of pain diminish with time. We believed that completion of the questionnaire within 48 hours of admission was a reasonable time at which to minimise possible underreporting of preoperative pain. The severity of their pain was assessed using a visual analogue scale 0 = no pain to 100 = the worst possible pain and by selecting appropriately from a choice of responses describing their pain. They were also asked if their pain was bearable without analgesia, and if they would have liked more analgesia.

RESULTS

Of the 100 patients, 63 were male, and 37 female, with a mean age of 47.3 years range 19-84 years . Mean pain score, recorded on a visual analogue scale, was 62 range 1-100. Sixty-three percent found the pre-operative pain unbearable without analgesia. Thirty-six percent would have liked more analgesia before their operation. Patients were asked to choose which of five responses best described their pain, from 'no pain' to 'the worst possible pain'. Only two patients said they had no pain, whereas 54 patients described their pain as 'severe' or the 'worst possible pain'. When asked whether any adjuvant treatment helped their pain, 39% of patients found splintage and 29% found elevation helpful.

DISCUSSION

In our study we did not assess how much analgesia patients actually received as we had previously studied this aspect.1 However, it has been previously demonstrated that many patients are receiving inadequate analgesia in acutely painful conditions, both in the Accident and Emergency department and following admission.1,2,3.4 It is unknown to what extent inadequate pre-operative analgesia has on adverse effects in clinical outcome in trauma but pain and analgesia do modulate the metabolic response to trauma.

To the best of our knowledge, it has not previously been documented whether patients admitted with acute trauma feel that they require more analgesia. We have demonstrated that 63% of patients have pain that is unbearable without analgesia, and 36% of patients would have liked more preoperative analgesia.

Possible reasons for reluctance to give analgesia have been suggested5,6 such as patient refusal, worry of masking injuries and complications such as compartment syndrome, fear of side effects and fear of dependence.

Patient refusal was not the reason, as 36% of patients in our study who would have liked more analgesia. Although one would expect side-effects to be more common in elderly patients some studies have shown analgesics can be used, as frequently in this group of patients, without problems.6,7 Drug dependence is not an issue with acute pain;8 and we know of no evidence that adequate analgesia in the mentally alert patient masks significant occult injury.

Failure to perceive the degree of pain associated with acute musculoskeletal trauma1,9 is the main reason for patients not receiving adequate analgesia. This can be addressed with improved information and education for both medical and nursing staff who may be making value judgements regarding the need for analgesics.

An acute pain service has an important role to play in training and supervising acute pain management in the post-operative period,10,11 and this role could be extended to include preoperative analgesia. Pain and analgesic side-effects should regularly be assessed; for example using pain charts12 and doses titrated, accordingly.

Intravenous opiates are the most effective analgesia in acute trauma.13 However, alternative methods of analgesia can also be used where appropriate, including local/regional techniques as well as physical methods such as ice, elevation and splinting. Epidural infusions have a role to play in major lower limb trauma. Patient controlled analgesia, although mostly used post-operatively, can also be used pre-operatively in the acutely injured patient.

CONCLUSION

This study has demonstrated that a large number of patients (36%) perceive they are not receiving adequate pre-operative analgesia following injury, despite having severe pain. It is important to address our prescribing and administration of analgesia well as the use of adjuvant treatment measures so patients receive the analgesia that they require in the preoperative period. Education of medical and nursing staff and review of analgesic prescribing policies may help to improve the current situation.

REFERENCES

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  2. Reichl M. and Bodiwala CG. Use of analgesia in severe pain in the accident and emergency department. Arch Emerg Med 1987; 4: 25
  3. Wilson JE and Pendleton JM. Oligoanalgesia in the Emergency Department. Ann J Emerg Med 1989; 7:620
  4. Fung ASY and Bentley TM. Pre-operative analgesia for acute surgical patients: no place for complacency. Ann R Coll Surg Engl 1994; 76 Suppl. 11
  5. Perry SW and Millman RB. Pain in the Emergency Department. In: Callahan ML Ed : Current Therapy in Emergency Medicine. Philadelphia, PA Decker 1987, P327
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  8. Porter J and Jick H. Addiction rare in patients treated with narcotics. N Engl J Med 1980; 302: 123
  9. McQuay H, Moore A and Justins D. Treating acute pain in hospital. BMJ 1997; 314: 1531
  10. Rawal N and Beggren L. Organisation of acute pain services: a low cost model. Pain 1994; 57: 117
  11. Gould TH, Crosby DL et al. Policy for controlling pain after surgery: effect of sequential changes in management. BMJ 1992; 305: 1187
  12. Burford Nursing Development Unit. Nurses and pain. Nursing Times 1984: 18: 94
  13. Smee WO and Crochard A. Trauma Care. London: Academic,1981

Copyright date: 27 October 2000

ACKNOWLEDGEMENTS

We gratefully acknowledge the help and support of Professor J. Templeton, Mr P.B.M. Thomas, Mr N.C.Neal, Mr J.S.M.Dwyer, Mr M.F.Brown, Mr D.Griffiths and Mr D.J.McBride, Consultants in Orthopaedics and Trauma at the North Staffordshire Royal Infirmary during the writing of this article.

Correspondence: Mr R.L. Morgan-Jones, Laurel House, Tetchill, Ellesmere SY12 9AP, U.K.

©2000 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb. 45, 6: 371-372