Nadja Nestler

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.

A Prospective Multicentre Study to Improve Postoperative Pain: Identification of Potentialities and Problems

Many studies still indicate insufficient pain management after surgery, e.g., in patients after small- or medium-size operations. Yet it is still uncertain if postoperative pain based on patient-related outcomes can be improved by implementing guideline-related programmes in a multicentre approach. Adult patients in six hospitals in one German city were included in this prospective study. Data collection took place twice in each hospital, once before and once after implementation of concepts and in-house training. Pain and pain-related aspects were assessed one day after surgery and compared between the pre- and post-test group including subgroup analysis of certain surgical procedures by using Student’s t-tests, Mann-Whitney U tests and chi-square tests (alphatwo-tailed = 0.05). Overall, pain at rest and during movement was slightly lower after the intervention. Significant changes were observed after thoracic surgery, small joint surgery and other minor surgical procedures. The rather moderate decrease in pain likely relates to a reasonable pre-existing pain management and to detached improvements in certain patient subgroups. Interestingly, specific analyses revealed significantly lower post-test pain as compared to pre-test pain only in patients without pre-existing chronic pain. Side effects related to pain medication were significantly lower after intervention. Our data show, for the first time, benefits of a perioperative teaching programme in a multicentre approach. Pain ratings improved mainly in specific subgroups of patients, e.g., small surgical procedures and patients without preoperative pain. Thus, general improvement is possible but special attention should be paid to the group of patients with preoperative pain.

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.

Emerging Standards of Care in Pain Management in Germany

ABSTRACT A research project addressing roles of nurses in pain management is described. The role of specialized pain management nurses is discussed. Standards, communication, and multidisciplinary care, as well as roles of nurses in hospitals, nursing homes, and home care are described. Specialization is discussed including training and certification. The German National Expert Standard for Pain Management in Nursing is described. This report is adapted from paineurope 2013; Issue 3, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication.

Schmerzen besser im Griff

Mehr als 700.000 Menschen in Deutschland leben im Pflegeheim. Schmerzen gehören dort vielfach zum Alltag. Doch mit einem abgestimmten Schmerzmanagement lässt sich bei vielen Bewohnern eine gute Schmerzlinderung und bestmögliche Lebensqualität erreichen. Im Fokus der Pflegekräfte stehen Schmerzerfassung, das Umsetzen der verordneten medikamentösen Therapie sowie nichtmedikamentöse Maßnahmen.

Pain management in patients with cancer. Perspectives of various network participants

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.

Schmerzmanagement bei Menschen mit Tumorerkrankung@@@Pain management in patients with cancer: Die Sicht einzelner Netzwerkakteure@@@Perspectives of various network participants

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.

Schmerz in der Chirurgie

Die internationale Gesellschaft zur Erforschung des Schmerzes IASP (International Association for the Study of Pain) definiert Schmerz als ein unangenehmes Sinnes- oder Gefühlserlebnis, das mit tatsächlicher oder potentieller Gewebeschädigung einhergeht oder von betroffenen Personen in einer Weise beschrieben wird, als wäre eine solche Gewebeschädigung die Ursache. Schmerz – welcher Ursache auch immer – beeinträchtigt die Lebensqualität bzw. führt zu verzögerten Heilungsprozessen. Schmerz ist eine Tatsache des medizinischen Alltages, welche aufgrund neuer Medikamente und Applikationsformen (Schmerzpumpen) heute eigentlich kein Problem in der Behandlung darstellen sollte (1,2). Trotzdem wurde dem Schmerz in Hinblick auf Selbst- und Fremdwahrnehmung, Dokumentation und Therapie sowohl seitens konservativer als auch invasiv-chirurgischer Fächer bisher zu wenig Bedeutung beigemessen, wie Erhebungen der vergangenen Jahre in österreichischen und deutschen Krankenhäusern zeigen (3,4). Dabei stellte sich heraus, dass eine suffiziente, mit entsprechender Patientenzufriedenheit verbundene Schmerztherapie nach wie vor nicht selbstverständlich ist.

Pflegerische Aspekte der Schmerztherapie – Eine Übersicht

Schmerz ist ein die Pflege taglich begleitendes Phanomen. In allen Versorgungsbereichen tritt Schmerz bei Patienten auf. Pflegende mussen sich mit diesen Schmerzen, die aufgrund der vorliegenden Erkrankung, aber auch durch medizinische wie pflegerische Interventionen auftreten, auseinandersetzen und ihnen durch gezielte Aktionen begegnen. Sowohl in Krankenhausern, Einrichtungen der stationaren Altenhilfe, Hospizen, wie auch im ambulanten Setting ist ein spezifisches Schmerzmanagement in Abstimmung aller beteiligten Berufsgruppen notwendig. Leitend dabei sind die Menschen, die einer Unterstutzung in der Auseinandersetzung und Behandlung ihrer Schmerzen bedurfen.