Christine Leo Swenne

Why is pain still not being assessed adequately? Results of a pain prevalence study in a university hospital in Sweden.

AIM The aim of this study was to investigate the prevalence of pain and pain assessment among inpatients in a university hospital. BACKGROUND Pain management could be considered an indicator of quality of care. Few studies report on prevalence measures including all inpatients. DESIGN Quantitative and explorative. METHOD Survey. RESULTS Of the inpatients at the hospital who answered the survey, 494 (65%) reported having experienced pain during the preceding 24 hours. Of the patients who reported having experienced pain during the preceding 24 hours, 81% rated their pain >3 and 42.1% rated their pain >7. Of the patients who reported having experienced pain during the preceding 24 hours, 38.7% had been asked to self-assess their pain using a Numeric Rating Scale (NRS); 29.6% of the patients were completely satisfied, and 11.5% were not at all satisfied with their participation in pain management. CONCLUSIONS The result showed that too many patients are still suffering from pain and that the NRS is not used to the extent it should be. Efforts to overcome under-implementation of pain assessment are required, particularly on wards where pain is not obvious, e.g., wards that do not deal with surgery patients. Work to improve pain management must be carried out through collaboration across professional groups. RELEVANCE TO CLINICAL PRACTICE Using a pain assessment tool such as the NRS could help patients express their pain and improve communication between nurses and patients in relation to pain as well as allow patients to participate in their own care. Carrying out prevalence pain measures similar to those used here could be helpful in performing quality improvement work in the area of pain management.

Serum MMP-9 and TIMP-1 concentrations and MMP-9 activity during surgery-induced inflammation in humans.

Abstract Background: Matrix metalloproteinase 9 (MMP-9) and the endogenous inhibitor to MMP-9, tissue inhibitor of metalloproteinase 1 (TIMP-1), have important roles in tissue remodelling and are implicated in a number of diseases related to inflammation. The time course in activation and formation of MMPs and TIMPs during an inflammatory reaction is not fully known. This study investigates MMP-9 and TIMP-1 concentrations and MMP-9 activity at different time points after major surgery when a state of noticeable inflammation is expected. Methods: Serum MMP-9 and TIMP-1 concentrations and MMP-9 activity were analysed preoperatively and 4 and 30 days postoperatively in patients undergoing elective surgery (coronary artery bypass n=21; orthopaedic surgery, n=29). Results: Serum TIMP-1 and MMP-9 activity increased significantly 4 days after surgery (p<0.05 and p<0.01, respectively) and decreased again 30 days after surgery (p<0.01, respectively, compared to 4 days after surgery). Serum MMP-9 increased significantly 4 days after surgery (p<0.05) and was still high 30 days after surgery (p<0.01 compared to before surgery). The calculated MMP-9/TIMP-1 ratio was increased 30 days after surgery compared to before surgery (p<0.01). Conclusions: The inflammatory state induced by elective surgery is associated with increased TIMP-1 response and MMP-9 activity in serum within a few days which may be of importance for the postoperative heeling process. The further increase in MMP-9 concentrations at day 30 postoperative did not result in increased MMP-9 activity. Serum MMP-9 concentrations or the calculated MMP-9/TIMP-1 ratio do not entirely represent MMP-9 activity during surgery-induced inflammation.

Patients' experiences of mediastinitis after coronary artery bypass graft procedure

Few studies have focussed on patients’ experiences of and suffering due to mediastinitis following Coronary Artery by-pass Graft (CABG). Mediastinitis creates a complex and invasive experience for the patient with prolonged hospitalisation, and would be expected to be a significant stressor. The aim of the present study was to capture patients’ experiences of the medical and nursing care they received for mediastinitis following CABG. Content analysis revealed three themes with regard to how the patients coped with the stress and threats of mediastinitis and its treatment and how they thought it would influence their future life. A first theme centred on physical and psychological discomfort and impact on autonomy. The staffs medical knowledge and the quality of nursing care as well as the patients’ understanding of the situation influenced their experience. A second theme was how patients dealt with perceived danger and stress. Coping strategies such as problem solving, information seeking, dissociation, distraction, minimisation and expression of emotion were used to handle the situations. The third theme comprised the patients’ belief that the mediastinitis would not affect the outcome of the CABG procedure, even though their confidence in this was influenced by uncertainty about the rehabilitation process.

Surgical team members’ compliance with and knowledge of basic hand hygiene guidelines and intraoperative hygiene:

The aim of the present study was to observe surgical team members’ compliance with basic hand hygiene and intraoperative hygiene guidelines during the anaesthetic and surgical procedure. A secondary aim was to investigate the team members’ knowledge and attitudes toward these guidelines. A structured observation schedule was designed to capture observational data on compliance with hygiene guidelines. A questionnaire was also designed to elicit written responses on attitudes, beliefs and knowledge about hygiene routines. The results showed that the clinical procedures for basic hand hygiene and intraoperative hygiene were flawed in three areas. Hand disinfection before and after direct patient contact was incomplete. Secondly, the team members used gloves in an incorrect way. Thirdly, the scrub nurse did not always change sterile gloves after intraoperative skin disinfection before handling sterile instruments. The quantity of 0.5% chlorhexidine with 70% ethanol used varied and the mechanical performance of skin disinfection varied. Knowledge of hand hygiene routines and intraoperative hygiene routines among surgical team members is incomplete and adherence needs to improve. Regular routine observations and continuous feedback to all staff may be necessary to improve compliance and avoid deterioration of practice.