Jürgen Osterbrink

The Quality of Pain Management in German Hospitals

BACKGROUND The Pain-Free Hospital Project was initiated in 2003 with the aim of improving pain management throughout Germany. We assessed the current state of pain management in German hospitals. METHODS From 2004 to 2006, data were obtained anonymously from 2252 patients who had undergone surgery, and 999 who had been treated non-surgically, in a total of 25 hospitals. They were interviewed about the intensity of pain they had experienced and about the effectiveness of its treatment. RESULTS No pain at all was reported by 12.4% of patients who had undergone surgery and by 16.7% of the non-surgically treated patients. Moderate to severe pain at rest was reported by 29.5% of the surgical group and 36.8% of the non-surgical group. More than 50% of the overall group reported pain on movement. 55% of the surgical group, and 57% of the non-surgical group, were dissatisfied with their pain management. Peak pain tended to occur outside normal working hours. No analgesic treatment at all was given to 39% of patients in the non-surgical group, even though they were in pain; the corresponding figure for the surgical group was 15% (a significant difference, p<0.001). Inadequately effective pain management was reported by 45.6% of patients in the non-surgical group and 29.6% in the operative group (again, a significant difference. Cancer patients were treated more often with potent opioids. CONCLUSION Severe postoperative pain is still too common among hospitalized patients, particularly pain that is induced by movement. Patients being treated on non-surgical wards also often suffer severe pain needlessly. Pain management seems to be worse for non-surgical patients (cancer patients excepted) than for surgical patients: waiting times for medication are longer, and ineffective medications are given more often. On the other hand, a number of hospitals provide positive examples of the potential effectiveness of pain management for both surgical and non-surgical patients.

Assessment and management of persistent (chronic) and total wound pain

Persistent (chronic) wound‐related pain is a common experience that requires appropriate assessment and treatment. It is no longer adequate for health care professionals to concentrate on the acute (temporary) pain during dressing change alone. The study provides useful recommendations and statements for assessing and managing total wound‐related pain for patients, health care professionals and other policymakers. The recommendations have been developed with the involvement of an interprofessional panel of health care professionals from around the world.

Managing painful chronic wounds: the Wound Pain Management Model.

Chronic wound pain is not well understood and the literature is limited. Six of 10 patients venous leg ulcer experience pain with their ulcer, and similar trends are observed for other chronic wounds. Chronic wound pain can lead to depression and the feeling of constant tiredness. Pain related to the wound should be handled as one of the main priorities in chronic wound management together with addressing the cause. Management of pain in chronic wounds depends on proper assessment, reporting and documenting patient experiences of pain. Assessment should be based on six critical dimensions of the pain experience: location, duration, intensity, quality, onset and impact on activities of daily living. Holistic management must be based on a safe and effective mix of psychosocial approaches together with local and systemic pain management. It is no longer acceptable to ignore or inadequately document persistent wound pain and not to develop a treatment and monitoring strategy to improve the lives of persons with chronic wounds. Unless wound pain is optimally managed, patient suffering and costs to health care systems will increase.

Why combine a foam dressing with ibuprofen for wound pain and moist wound healing

Six out of ten patients with chronic wounds suffer from persistent wound pain (1). A novel dressing combination has been formulated to provide pain relief and moisture balance at the local wound site (ibuprofen-foam, Biatain-Ibu foam dressing, Coloplast A/S). Foam dressings with polyurethane cells have been known to absorb moisture and provide moisture balance. These second generation foams have the ability to partially retain some fluids and to exchange other fluid, providing moisture balance to the wound surface. This type of foam is less likely to cause maceration of the periwound skin (2). Healing wounds requires five initial important components: debridement, prevention of bacterial damage, pain and prolonged inflammation and maintaining moisture balance. Painful wounds take longer time to heal, and some patients cannot tolerate the treatment of wounds and some can become immobile, which in turn can lead to social isolation, depression and feelings of hopelessness (3). Non steroidal anti-inflammatory drugs (NSAIDs) are excellent pain-reducing agents, but when administered systemically in the elderly patients, they may cause side effects such as gastrointestinal bleeding, decreased renal function and even deaths. To overcome the safety concern, very small doses of ibuprofen can have an excellent local effect on the superficial wound compartment, without detectable systemic levels. The equivalent of a quarter tablet (50 mg, 1010-cm dressing) of ibuprofen can exert adequate anti-inflammatory and pain-reducing effects up to 7 days. Conceptually, we have a safe combination of moisture-balancing foams with continuousrelease, low-dose ibuprofen to exert a local pain-reducing effect.

Qualitätskriterien von Assessmentinstrumenten – Cohen's Kappa als Maß der Interrater-Reliabilität (Teil 1)

Eine weit verbreitete Kenngrose zur Quantifizierung der Interrater-Reliabilitat von Assessmentinstrumenten bzw. -verfahren ist das zufallskorrigierte Ubereinstimmungsmas Cohens Kappa. Obwohl oder ...

[Opioid-induced bowel dysfunction: a literature analysis on pathophysiology and treatment].

SummaryBowel dysfunction is a frequent and serious side effect of opioid analgetics. In spite of its common occurrence, in the course of clinical routine, it is frequently ignored or underestimated. Authors of the analysed literature widely agree that a prophylactic and routine pharmacotherapy is necessary. For this purpose, laxatives, enemas and suppositories, prokinetic agents and opioid antagonists can be considered. Bulk-forming laxatives did not prove to be effective, since the quantity of fluid intake required for the action usually cannot be provided. Furthermore, the benefit of emollient agents is doubted. As a monotherapy they are not sufficient. By contrast, stimulant and osmotic laxatives proved to be active. Prokinetic drugs are not recommended because of their serious side effects. Effective abatement of opioid-induced obstipation by opioid antagonists has been proven in numerous studies. However, the loss of analgesia and opioid withdrawal symptoms were described as adverse effects. Development of quaternary opioid antagonists such as methylnaltrexone was allowed for mitigating these adverse effects.ZusammenfassungObstipation ist eine häufige und schwerwiegende Nebenwirkung von Opioidanalgetika. Trotz ihres gehäuften Auftretens wird sie im klinischen Alltag vielfach übersehen oder unterschätzt. In der analysierten Literatur herrscht Einigkeit darüber, dass eine prophylaktische und routinemäßige medikamentöse Therapie vonnöten ist. Hierfür kommen Laxantien, rektale Entleerungshilfen, prokinetische Medikamente und Opioidantagonisten in Betracht. Unter den Laxantien haben sich Füll- und Quellstoffe nicht bewährt, weil die Zufuhr der für die Wirkung notwendigen Flüssigkeitsmenge meist nicht gewährleistet werden kann. Auch der Nutzen von Weichmachern ist umstritten und als Monotherapie nicht ausreichend. Dagegen haben sich Stimulantien und osmotisch wirksame Laxantien bewährt. Prokinetische Medikamente sind wegen ihrer schwerwiegenden Nebenwirkungen nicht zu empfehlen. Die effektive Linderung der opioidinduzierten Obstipation durch Opioidantagonisten wurde in zahlreichen Studien belegt. Als nachteilige Wirkungen wurden Analgesieverlust und Entzugssymptomatika beschrieben. Durch die Entwicklung der quartären Opioidantagonisten wie Methylnaltrexon konnten diese nachteiligen Effekte entschärft werden.

Opioidinduzierte Obstipation: Literaturanalyse zu Pathophysiologie und Behandlung

SummaryBowel dysfunction is a frequent and serious side effect of opioid analgetics. In spite of its common occurrence, in the course of clinical routine, it is frequently ignored or underestimated. Authors of the analysed literature widely agree that a prophylactic and routine pharmacotherapy is necessary. For this purpose, laxatives, enemas and suppositories, prokinetic agents and opioid antagonists can be considered. Bulk-forming laxatives did not prove to be effective, since the quantity of fluid intake required for the action usually cannot be provided. Furthermore, the benefit of emollient agents is doubted. As a monotherapy they are not sufficient. By contrast, stimulant and osmotic laxatives proved to be active. Prokinetic drugs are not recommended because of their serious side effects. Effective abatement of opioid-induced obstipation by opioid antagonists has been proven in numerous studies. However, the loss of analgesia and opioid withdrawal symptoms were described as adverse effects. Development of quaternary opioid antagonists such as methylnaltrexone was allowed for mitigating these adverse effects.ZusammenfassungObstipation ist eine häufige und schwerwiegende Nebenwirkung von Opioidanalgetika. Trotz ihres gehäuften Auftretens wird sie im klinischen Alltag vielfach übersehen oder unterschätzt. In der analysierten Literatur herrscht Einigkeit darüber, dass eine prophylaktische und routinemäßige medikamentöse Therapie vonnöten ist. Hierfür kommen Laxantien, rektale Entleerungshilfen, prokinetische Medikamente und Opioidantagonisten in Betracht. Unter den Laxantien haben sich Füll- und Quellstoffe nicht bewährt, weil die Zufuhr der für die Wirkung notwendigen Flüssigkeitsmenge meist nicht gewährleistet werden kann. Auch der Nutzen von Weichmachern ist umstritten und als Monotherapie nicht ausreichend. Dagegen haben sich Stimulantien und osmotisch wirksame Laxantien bewährt. Prokinetische Medikamente sind wegen ihrer schwerwiegenden Nebenwirkungen nicht zu empfehlen. Die effektive Linderung der opioidinduzierten Obstipation durch Opioidantagonisten wurde in zahlreichen Studien belegt. Als nachteilige Wirkungen wurden Analgesieverlust und Entzugssymptomatika beschrieben. Durch die Entwicklung der quartären Opioidantagonisten wie Methylnaltrexon konnten diese nachteiligen Effekte entschärft werden.

Polypharmacy, potentially inappropriate medication and cognitive status in Austrian nursing home residents: results from the OSiA study.

SummaryThere is little research investigating polypharmacy and potentially inappropriate medications (PIM) in connection with cognitive status in residents of Austrian nursing homes. Our findings result from a cross-sectional survey of 425 residents (315 women, 110 men, mean 83.6 years) from 12 Austrian nursing homes. The number of systemically administered permanent prescription drugs was 8.99 ± 3.9 and decreased significantly with increasing cognitive impairment. Irrespective of cognitive status, polypharmacy (> 5 individual substances) was present in approximately 75 % of the residents. Hyper-polypharmacy (> 10 individual substances) was present among almost 50 % of the cognitively intact residents, and hence, significantly more frequent as compared with the group with the lowest cognitive performance (23.4 %). At least one PIM was found in 72.4 % of residents regardless of cognitive status. Predominantly, PIMs consisted of tranquilizers, antipsychotics, osmotic laxatives, non-steroidal anti-inflammatory drugs (NSAIDs) and anticholinergics, where only the number of NSAIDs decreased significantly with increasing cognitive impairment. In summary, our study shows a continued high prevalence of polypharmacy and PIM in long-term care institutions in Austria.ZusammenfassungDie Datenlage zu Polypharmazie und potentiell inappropriaten Medikamenten (PIM) bei Bewohnern von österreichischen Langzeitpflegeeinrichtungen in Abhängigkeit vom kognitiven Status ist unzureichend. Unsere Ergebnisse resultieren aus einer Querschnitterhebung von 425 Bewohnern (315 Frauen, 110 Männer, mean 83,6 Jahre) in 12 österreichischen Altenpflegeheimen. Die Zahl der systemisch verabreichten Dauermedikamente betrug 9,0 ± 3,9 und sank mit zunehmender kognitiver Beeinträchtigung signifikant. Polypharmazie (> 5 Einzelsubstanzen) fand sich unabhängig vom kognitiven Status bei etwa 75 % der Bewohner. Hyperpolypharmazie (> 10 Einzelsubstanzen) war mit knapp 50 % bei den kognitiv leistungsfähigeren Bewohnern signifikant häufiger als in der Gruppe mit der geringsten kognitiven Leistungsfähigkeit (23,4 %). Mindestens 1 PIM fand sich bei 72,4 % der Bewohner ohne signifikante Unterschiede in Bezug auf den kognitiven Status. Unter den PIM dominierten Tranquilizer, Antipsychotika, osmotische Laxantien, nicht steroidale Antirheumatika (NSAID) und Anticholinergika., wobei lediglich die Zahl der NSAID mit zunehmender kognitiver Beeinträchtigung signifikant abnahm. Zusammenfassend zeigt unsere Studie eine anhaltend hohe Prävalenz von Polypharmazie und PIM in Einrichtungen der Langzeitpflege in Österreich.

Schmerzmanagement bei Menschen mit Tumorerkrankung

BACKGROUND High healthcare needs are evident for pain caused by cancer. Those affected are not only looking for help in acute inpatient structures but also for a much larger part in outpatient care structures. To avoid mistreatment, undertreatment or overtreatment of pain in people with cancer, it is necessary to differentiate the tasks and roles of different providers while highlighting the specific aspects of pain management within the given network structures. MATERIALS AND METHODS Aspects, such as pain assessment and the necessary scope of action in pain treatment are illustrated from the perspective of nurses from home care services, primary physicians as well as the general or special ambulatory palliative care (AAPV or SAPV) on the basis of initial survey results and a documentation analysis. RESULTS Ambulatory care nurses (93 %) and primary caregivers (64 %) use pain assessment scales. The kind of scales used varies. The ability to provide adequate pain care for patients in the immediate care situation is reported as given by more than half of the nurses (56.6 %). CONCLUSIONS In order to ensure an adequate pain therapy targeted interprofessional coordination is required between outpatient and primary physicians with respect to aspects of pain assessment, scope of action and accessibility.ZusammenfassungHintergrundSchmerzen infolge einer Tumorerkrankung zeigen einen großen Versorgungsbedarf. Betroffene suchen nicht nur in akut stationären, sondern zum wesentlich größeren Anteil auch in ambulanten Versorgungsstrukturen Hilfe. Um schmerztherapeutische Fehl-, Unter- oder Überversorgung bei Menschen mit Tumorerkrankung zu vermeiden, ist es erforderlich, die Aufgaben und Rollen der Akteure in einem Netzwerk differenziert mit Blick auf spezifische Aspekte des Schmerzmanagements zu beleuchten.Material und MethodenAspekte wie die Schmerzeinschätzung und der in der Schmerzbehandlung für notwendig erachtete Handlungsspielraum werden aus der Perspektive von Pflegenden, Haus- und Fachärzten sowie der allgemeinen (AAPV) bzw. speziellen ambulanten Palliativversorgung (SAPV) anhand von Befragungsergebnissen und einer Dokumentationsanalyse beleuchtet.ErgebnisseAmbulant tätige Pflegende (93 %) sowie Haus- und Fachärzte (64 %) nutzen Skalen zur Schmerzerfassung. Welche Skalen genutzt werden, erweist sich als heterogen. Ein Handlungsspielraum in der schmerztherapeutischen Versorgung beim Patienten, also in der direkten Versorgungssituation, wird von über der Hälfte der Pflegenden (56,6 %) genannt.SchlussfolgerungZur Sicherung einer adäquaten schmerztherapeutischen Versorgung bedarf es gezielter interprofessioneller Abstimmungen zwischen ambulant tätigen Pflegenden sowie Haus- und Fachärzten hinsichtlich der Aspekte Schmerzerfassung, Handlungsspielräume und Erreichbarkeit.AbstractBackgroundHigh healthcare needs are evident for pain caused by cancer. Those affected are not only looking for help in acute inpatient structures but also for a much larger part in outpatient care structures. To avoid mistreatment, undertreatment or overtreatment of pain in people with cancer, it is necessary to differentiate the tasks and roles of different providers while highlighting the specific aspects of pain management within the given network structures.Materials and methodsAspects, such as pain assessment and the necessary scope of action in pain treatment are illustrated from the perspective of nurses from home care services, primary physicians as well as the general or special ambulatory palliative care (AAPV or SAPV) on the basis of initial survey results and a documentation analysis.ResultsAmbulatory care nurses (93 %) and primary caregivers (64 %) use pain assessment scales. The kind of scales used varies. The ability to provide adequate pain care for patients in the immediate care situation is reported as given by more than half of the nurses (56.6 %).ConclusionsIn order to ensure an adequate pain therapy targeted interprofessional coordination is required between outpatient and primary physicians with respect to aspects of pain assessment, scope of action and accessibility.

Management of acute pain in the postoperative setting: the importance of quality indicators

Abstract Despite the introduction of evidence-based recommendations for postoperative pain management (POPM), the consensus is that pain control remains suboptimal. Barriers to achieving patient-satisfactory analgesia include deficient knowledge regarding POPM among staff, lack of instructions, insufficient pain assessments and sub-optimal treatment. Effective monitoring of POPM is essential to enable policy makers and healthcare providers to improve the quality of care. Quality indicators (QIs) are quantitative measures of clinical practice that can monitor, evaluate and guide the quality of care provided to patients. QIs can be used to assess various aspects relating to the care process and they have proven useful in improving health outcomes in diseases such as myocardial infarction. In this commentary we critically analyze the evidence regarding the use of QIs in acute POPM based upon the experience of pain specialists from Europe and the USA who are members of the Change Pain Advisory Board. We also undertook a literature review to see what has been published on QIs in acute pain with the goal of assessing which QIs have been developed and used, and which ones have been successful/unsuccessful. In the hospital sector the development and implementation of QIs is complex. The nature of POPM requires a highly trained, multidisciplinary team and it is at this level that major improvements can be made. Greater involvement of patients regarding pain management is also seen as a priority area for improving clinical outcomes. Changes in structure and processes to deliver high-level quality care need to be regularly audited to ensure translation into better outcomes. QIs can help drive this process by providing an indicator of current levels of performance. In addition, outcomes QIs can be used to benchmark levels of performance between different healthcare providers.