Quality management in postoperative pain therapy

Background. Deficits in quality of postoperative pain management are not caused by the complexity of the medical problem or shortage of suitable drugs but by difficulties in organization and hospital structures. Moreover, there is no consensus on how to measure the quality of pain management. Quality management programs consist of strategies to overcome such difficulties and to increase quality continuously. This study reports the implementation of a quality management program to improve postoperative pain management at a university hospital. Methods. An interdisciplinary task force consisting of nursing staff, anesthesiologists, surgeons, and members of the hospital pharmacy was set up. This task force interviewed patients and performed an analysis of current deficits (phase 1). Then, primary and secondary outcome parameters were defined to measure quality of pain management, and strategies were defined to implement improvements (phase 2). These referred to aspects of organization, standardization,and responsibility. One of the main intentions was the involvement of nursing staff. After implementation (phase 3), a second analysis was performed (phase 4). This was followed by a continuous assessment of parameters indicating quality of procedures and results which were fed back to all participants (phase 5). Results. After implementation of the program (phase 4), significantly more patients reported no or mild (NRS <4) postoperative pain (40.2% vs 30.1%) compared to phase 1. Also, patients' satisfaction with pain therapy improved significantly. The proportion of patients without pain treatment decreased by one-third. Opioids were given more frequently and more often intravenously. In contrast, the proportion of i.m. injections decreased from 20% to 5%. Continuous assessment of up to now more than 4,900 patients helped to identify possible reasons for problems and to maintain overall quality of pain management. Discussion. Tools of quality management consisting of deficit analysis, definition of outcome parameters, implementation of improving strategies, post-intervention analysis and continuous feed-back may be successfully used to improve postoperative pain therapy. Changes in organization of medical management seem to be more important than medical or technical aspects. Similar strategies might be used to increase quality of other medical procedures.