Page 96 Acute Pain Management

some institutions, the APS will assume responsibility for managing more advanced methods of
pain relief such as PCA and epidural analgesia.
3.2.1 General requirements

Guidelines that aim to enhance patient outcomes and standardise analgesic techniques
(eg drug and drug concentrations, dose, dose intervals), monitoring requirements, equipment
used, and responses to inadequate or excessive analgesic doses and other complications,
may lead to consistency of practice and potentially improved patient safety and analgesic
efficacy, regardless of technique used (Macintyre & Schug, 2007; Counsell et al, 2008; Macintyre
& Scott, 2009).
Marked improvements in conventional methods of pain relief have followed the introduction
of guidelines for intramuscular (IM) opioid administration (Gould et al, 1992 Level III‐3; Humphries
et al, 1997 Level III‐3). However, implementation of guidelines and not their development
remains the greatest obstacle to their use. Compliance with available guidelines is highly
variable and may be better in larger institutions (Carr et al, 1998 Level IV). Resource availability,
particularly staff with pain management expertise, and the existence of formal quality
CHAPTER 3 guidelines (Jiang et al, 2001 Level IV).
assurance programs to monitor pain management are positive predictors of compliance with

Professional bodies in a number of countries have issued guidelines for the management of
acute pain (Carr et al, 1992; ANZCA & FPM, 2003; ASA, 2004; RCA et al, 2004; ANZCA & FPM, 2007).

3.2.2 Acute pain services

Many institutions would now say that they have an APS. However, there is a very wide
diversity of APS structures, no consensus as to the best model, and no agreed definition of
what might constitute such a service (Counsell et al, 2008). Some are ‘low‐cost’ nurse‐based
(Shapiro et al, 2004; Rawal, 2005), others are anaesthetist‐led but rely primarily on APS nurses as
there may not be daily clinical participation by an anaesthetist (Harmer, 2001; Nagi, 2004), and
some are comprehensive and multidisciplinary services with APS nursing staff, sometimes
pharmacists or other staff, and daily clinical input from, and 24‐hour cover by, anaesthetists
(Ready et al, 1988; Macintyre et al, 1990; Schug & Haridas, 1993).
The degree of medical input varies enormously. In training hospitals in Australia, 91% of
hospitals accredited for anaesthetic training had an APS run from the department of
anaesthesia with daily input from medical staff, although consultant anaesthetist sessions (one
session is a half day) varied from zero in 27%, just one or two a week in a further 22%, four to
six per week in 22% and ten per week in 15% (Roberts, 2008). A survey in the United Kingdom
reported that while 90% of hospitals reported having an APS, dedicated medical staff sessions
did not exist in 37%, were limited to one or two per week in 40% and in only 4% were there
five or more sessions (Nagi, 2004).
Some APSs supervise primarily ‘high‐tech’ forms of pain relief while others have input into all
forms of acute pain management in an institution and will work towards optimising traditional
methods of pain relief so that all patients in that institution benefit (Macintyre & Schug, 2007;
Breivik, 2002; Counsell et al, 2008). Increasingly, APSs are also called on to deal with much more
complex pain management issues (eg acute‐on‐chronic pain, acute pain after spinal cord injury
and other major trauma, and acute pain resulting from a multitude of medical illnesses) and
much more complex patients (eg opioid‐tolerant patients, older patients) (Counsell et al, 2008).
Given the enormous heterogeneity of APS models and types of patients and pain treated, as
well as variation in the quality of published studies, it is not surprising that it is difficult to
come up with a meaningful analysis of the benefits or otherwise of an APS. Individual
48 Acute Pain Management: Scientific Evidence