1. Emergency Laparotomy Cymru
Improving pain management for Emergency Laparotomy patients
Charlotte Oliver, Anaesthetic ST5; Margaret Coakley, Anaesthetic consultant; Gemma Roberts,
Acute pain specialist nurse, University Hospital Wales
Context and Problem
Effects of Changes
A service evaluation was completed following concerns raised by the surgical National Emergency Laparotomy Audit (NELA) lead and Acute Pain nurses that patients undergoing emergency laparotomy had higher pain levels postoperatively than elective patients.
Between February and June cases of emergency laparotomy were reviewed. 3 patients died, 17 were ventilated post-op and 41 had incomplete data and so were excluded. The remaining 72 patients were included in an audit, 70% reported their pain as moderate to severe one day post procedure (figure 1). This audit also highlighted that there was a lack of a standardised approach to analgesia with a wide range of techniques being used and the most effective options being used least often.
Patient’s Pain Scores 1 day post procedure
Fig.1
Type of pain relief given to patients post procedure
Fig. 2
Pre
Intervention 1
Post
Intervention
Pre
Interventio n
Intervention
Commenced
Strategy for Change
Post
Intervention
An improvement project set out to improve post operative pain management for patients undergoing emergency laparotomy through the development of a guideline for pain management. This required a training programme for anaesthetic and surgical staff on how to insert and use rectus sheath catheters.
First period of intervention
A guideline was introduced to try and help with some of the human factors involved in the decision making process. It had an algorhythmic structure, directing the user to decision outcomes. It also contained information useful for informing decisions, reducing the cognitive load for the user. Here are the steps involved:
1. Literature review to establish evidence base for guideline
2. Draft guideline written
3. Draft approved by anaesthetic consultant NELA lead
4. Draft circulated to CEPOD anaesthetists group and acute pain nurses
5. Draft presented at anaesthetic department audit meeting
6. Final guideline produced following feedback
7. Guideline distributed via to anaesthetic department.
8. Guideline printed, laminated and displayed in CEPOD theatre
9. Guideline presented at teaching session for rectus sheath catheters for
anaesthetists
10. Guideline presented to new anaesthetic trainees at departmental induction.
Training staff on the insertion and use of rectus sheath catheters
1. Presentation to surgical audit meeting about rectus sheath catheters
2. Training morning for anaesthetic trainees and consultants on how to insert
and use rectus sheath catheters.
3. Ongoing quality improvement project by another team regarding rectus sheath catheters.
Second period of intervention
1. Presentation to anaesthetic audit meeting
2. Display of the outcomes of the service re-evaluation outside CEPOD theatre.
3. Presentation at trainee induction
4. Publication of the analgesia guideline in the University Hospital Wales
anaesthetic department guidelines (online).
This project succeeded in both reducing the pain experienced by patients and increasing the utilisation of an appropriate regional technique.
Figure 1 shows the results of both the initial and two further sevice evaluations carried out after the intervention periods. It demonstrates that post introduction of pain guidelines, patients reporting moderate to severe pain has reduced from 70% of all patients to 39%. This equates to a 45% reduction in the number of patients categorising their pain as moderate to severe. The third evaluation shows that there has been a slight increase in the number with severe pain. This shows the importance and challenge of ensuring a change is sustained.
Figure 2 shows that there has been a significant increase in the use of rectus sheath catheters and epidurals over the observation period. Whilst the use of intra-thaecal diamorphine alone has decreased the use of intra-thaecal diamorphine combined with rectus sheath catheters has not flourished as we would hope. As these patients have similar pain scores to those with an epidural we are hoping uptake will increase as we emphasise the benefits of simultaneous intra-thaecal diamorphine and rectus sheath catheters. Over all, by the end of the observation period the number of patients receiving a regional technique had increased from 55% to 90%.
Lessons Learned
Feedback to clinicians: More timely feedback on the results of the project would possibly have given positive reinforcement which would have created more sustainability within the project
A mechanism to deliver timely feedback on the results of the project would have increased early buy-in.
Data analysis was labour intensive: there were problems with access and collection and if this had been addressed earlier in the project it would have saved time a made the roles of others easier.
Sustainability: Having rotated to another hospital and although handing the project over to another trainee, it has been a challenge to maintain the momentum of the project.
Acknowledgements: I would like to thank the acute pain specialist nurses for their contribution towards data collection
Measurement of Improvement
Data was already being collected by the acute pain team and consists of an electronic database of cases and their associated pain management.
Measures
1. Patient reported pain score (0-10) day one post-op (outcome measure)
2. Mode of analgesia used (process measure)
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