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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 36  |  Issue : 2  |  Page : 70-74

Ideal pain-free hospital – A step forward


Institute of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission09-Jul-2021
Date of Decision15-Nov-2021
Date of Acceptance19-Dec-2021
Date of Web Publication25-Aug-2022

Correspondence Address:
Dr. Pradeep Jain
Institute of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_59_21

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  Abstract 


Pain is the most common and distressing symptom which a patient fears when admitted to the hospital for medical or surgical reasons. Well-managed pain relief improves the quality of life, lessens complications, shortens hospital stay, and decreases health-care expenses. Inadequate control of pain has consequences that go beyond suffering: Insomnia, mood swings, decreased gut motility, reduced mobility, increased risk of deep-vein thrombosis, and respiratory and cardiac morbidity to name a few. The harsh reality is that postoperative pain is inadequately addressed worldwide, and many patients both inpatients and outpatients go home where they cannot manage their pain effectively. This is not necessarily the result of the absence of effective pain relief measures but is the outcome of inappropriate management for postoperative pain relief. The ideal pain-free hospital (PFH) is achievable by putting together a multidisciplinary team of pain physicians, pain nurses, physiotherapists, and other medical professionals. Education of the patient through counseling and printed handouts with information about postoperative pain and the techniques to manage it reduces anxiety. The PFH team is founded on the tenets of thorough preoperative assessment, better-educated pain-relieving staff along all the updated facilities. The pain education incorporates all teaching gadgets for medical and paramedical staff. Round-the-clock super-specialist pain relief services along with the preplanning of proper pain management, upgraded minimally invasive and daycare surgeries make the patient pain-free up to the maximum extent.

Keywords: Education and training, pain management, pain-free hospital, postoperative


How to cite this article:
Jain P, Dua N, Sood J, Sahai C, Yadav P, Sharma A. Ideal pain-free hospital – A step forward. Indian J Pain 2022;36:70-4

How to cite this URL:
Jain P, Dua N, Sood J, Sahai C, Yadav P, Sharma A. Ideal pain-free hospital – A step forward. Indian J Pain [serial online] 2022 [cited 2022 Sep 29];36:70-4. Available from: https://www.indianjpain.org/text.asp?2022/36/2/70/354722



Pain is a more terrible lord of mankind than even death itself.”

-Albert Schweitzer

Aristotle believed that pain was due to evil spirits that entered the body through an injury. Hippocrates believed that pain was caused by an imbalance in the vital fluids of a human. René Descartes theorized that the body was more similar to a machine and that pain was a disturbance that passed down along nerve fibers until the disturbance reached the brain.[1]

In 1975, the International Association for the Study of Pain sought a consensus definition for pain, finalizing “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” as the final definition.[2]

Pain is among the most common and distressing symptoms experienced by a large number of inpatients. Untreated pain results in physical, mental, and spiritual suffering directly or indirectly. Despite the progress in better understanding of the pathophysiology of pain and newer safe analgesic drugs with novel routes of administration, the majority of patients in hospitals all over the world experience unrelieved pain. The establishment of safe pain-free hospitals (PFHs) is the new norm.

Most patients are unaware that a PFH stay is their basic right. The gray area of poor pain management results from inadequate training and substandard knowledge of the treating physician regarding analgesic selection with suboptimal doses. The parcity of cost-effective analgesic drugs is another limiting factor for pain medicine success.[3] As clinicians, it is our ethical and moral responsibility toward our patients to make them pain-free and propagate the concept of a PFH. The pain management unit at Sir Ganga Ram Hospital has applied the model of a PFH to provide integrative and multidisciplinary treatment to lessen the pain experienced by our patients.[4] The cornerstone of our pain management service includes documentation, better communication, educating staff and patients regarding pain awareness, and provision of multimodal therapy.

Since the implementation of pain as the fifth vital sign in 2008 and the concept of PFHs in 2011, SGRH has been providing pain relief to all patients using a multidisciplinary team approach, incorporating advancements in surgical and anesthetic techniques and using both pharmacological and nonpharmacological methods in alleviating pain.

Our hospital is committed to provide:

  1. Acute pain services include preoperative pain relief planning; psychological counseling, perioperative pain relief, labor analgesia and trauma services
  2. Pain relief clinics in general and private outpatient departments (OPDs)
  3. Multidisciplinary palliative pain medicine unit as a supporting unit of the pain relief unit
  4. Appointment of dedicated trained nurses for pain relief services
  5. Pain education for all paramedical staff and nurses of the hospital
  6. Training pain specialists by providing certified courses and fellowships in pain management
  7. Organizing camps, radio talks, TV programs, seminars, workshops, and conferences to increase the awareness about pain relief among medical, paramedical personnel, and the public.



  Why a Pain-Free Hospital? Top


The requirement for a PFH is the need of the hour as it reduces hospital stay and decreases health care burden. In earlier days, less priority was given to pain management because of the lack of proper concepts, evolving medical sciences, and more priority to radical and curative surgical treatment. Nowadays, with evolving patient rights and logical reasoning, comprehensive pain management is the need of the hour.[5]

The main causes of poor pain management are as follows:[6]

  • Inadequate clinician awareness for effective pain management
  • Lack of preoperative counseling and plans for total pain relief
  • Treating physician's conscious ignorance of the patient's complaint of pain
  • Improper routes for analgesia, as where epidural is most appropriate, intravenous or intramuscular were chosen
  • Unified doses of analgesic drugs irrespective of age, body weight, height, and ethnic variation.


Time delay by nursing staffs to receive and follow commands due to communication failure, evaluation, and drug preparation – “action after distress.”

Steps taken by SGRH to achieve the goal of a PFH are:

  • Implementation of pain as the fifth vital sign
  • Educating health-care staff about pain assessment tools and treatment
  • Regular assessment and monitoring of pain
  • Psychological and therapeutic counseling for optimal pain management
  • Prompt response by health-care providers to treat pain complaints
  • Information about pain and the modality of pain relief to be made available to all patients
  • Standardized protocols for providing pain relief for different types of acute pain such as postoperative pain and labor pain[7],[8]
  • Proper analgesic care to be provided to all patients
  • Promotion of ultrasound-guided regional analgesic techniques
  • Increased number of daycare surgeries with optimal postoperative pain control
  • Utilization of minimally invasive surgery
  • Using nonpharmacological techniques such as traditional and complementary medicine.



  Daycare and Minimally Invasive Surgery Top


To have a cost-effective beneficial outcome of surgeries, daycare and minimally invasive surgery is the best alternative. To provide the best pain relief, we follow the protocol procedure-specific postoperative pain management and use intraperitoneal instillation of local anesthetics (LA), transverse abdominis plane block, and local infiltration with LA and opioid mixture.[9] The number of daycare and minimally invasive surgeries in the last 5 years are tabulated to highlight the importance of daycare surgeries [Figure 1].
Figure 1: Annual daycare statistics

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At SGRH, the Institute of Anesthesiology, Pain and Perioperative Medicine and Palliative Care is involved in the management of both acute and chronic pain conditions. A wide spectrum of painful conditions comprising postoperative, ischemic, neurogenic, labor, trauma, and cancer pain are effectively managed at our institution. All patients are assessed and treated by physicians trained in pain management using an algorithm based on individually tailored analgesic drugs and techniques comprising pharmacological and nonpharmacological methods.

The PFH Initiative is a quality improvement program designed to integrate pain management into service delivery by educating patients and staff, raising motivation and awareness, documenting pain intensity, and improving communication impact.[4]

Our efforts in integrating modern evidence-based standard protocols of pain management into hospital-based services will serve as a model for other hospitals and will help us to chart a new path for patient care.[4]

Barriers to pain treatment in India include poor awareness and lack of proper knowledge by clinicians. The time lag in getting information about pain in a patient, obtaining the prescription, and procurement of pain medicines, remains a cumbersome process, consequently making the entire system of pain relief management ineffective.

“Pain as the 5th Vital Sign” was declared in 2008. The International Summit on Pain in 2010 announced: “Access to pain management as a basic human right.”[10] This initiative was followed by the “PFH” concept in 2011. “The PFH” concept emphasized holistic pain management by using a multidisciplinary team approach that includes anesthesia and analgesia, modern surgical techniques, and traditional and complementary medicine.[11]


  The Pain-Free Hospital Concept Has Three Main Pillars Top


To achieve pain relief as a basic human right, we used a low-cost model that could be implemented in any hospital, with the main components being education for health-care providers and patients, optimal utilization of existing facilities, developing standardized protocols, and a rigorous audit process to improve any shortfall at the earliest.[12]


  Pain Assessment Top


Pain assessment is important for both institution and patient, to evaluate the requirement of analgesic for the patient and assessing the effect in providing an effective approach to pain management.

We use standard tools for assessing the Numerical Rating Scale (NRS) pain scale for adults and Wong-Baker Pain Scale for children.[13],[14]

Numerical rating scale

This scale is often verbally administered with a range of 0–5 or 0–10. In some cases, the NRS is a visually presented scale with words and numbers along a vertical (or horizontal) line [Figure 2]a.
Figure 2: Pain assessment tools (a) Numerical Rating Scale (b) Wong and Baker Scale

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Faces pain scale by wong and baker

It consists of facial expressions range from a smiling face to a sad, crying face. A numerical rating is assigned to each face (from 0, “no hurt” to 10, “hurts worst”) of the Wong-Baker Face Scale [Figure 2]b.

There has been a tremendous increase in awareness about the importance of pain assessment, and pain management practices are changing slowly, but surely as nowadays, patients demand a pain-free post surgical period.

Providing services in the area of pain management includes the establishment of:

Acute and chronic pain services

In our hospital, we have established two teams: Acute and chronic pain management services in 1993. From the preoperative counseling extending to a hospital stay, we manage acute pain with the help stand of protocol-based pain management ranging from epidural catheter placement, transdermal drug delivery patches to closed-loop automated patient control analgesia pumps. Every day in dedicated pain relief (OPD) services, we provide consultation for chronic pain patients and the appropriate intervention procedures are done in a dedicated pain-relieving procedure operation theatre. We have a proper standard of protocol for acute and chronic pain management, respectively [Figure 3] and [Figure 4].
Figure 3: Automated pump-assisted pain relief delivery

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Figure 4: Chronic pain management blocks

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Labor pain management using analgesics is one of our aims to provide safe and pain-free motherhood to women who have to face intense pain problems during childbirth [Figure 5].
Figure 5: Obstetric pain management

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Education and training

To propagate awareness and knowledge of good pain management in a hospital setup, the pain physician began educating physicians, nurses and other paramedical staff with day-to-day lectures, bedside training and 15 days and 3 months dedicated fellowship programmes. These were established in 2000 and continue till date.[Table 1]. The pain fellowship program comprises basic and advanced lecture series with hands-on experience. All the fellows have to be orientated beforehand on a mannequin. Paramedical staff training includes mainly basic lecture series with bedside learning.
Table 1: Training of pain specialists

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Palliative care clinic

The palliative care clinic was launched in 2017 and provides multidisciplinary clinical management in palliative medicine to all patients with chronic life-limiting conditions in terminal stages. The palliative team comprises physicians from all specialities. Over 600 patients in need of end-of-life care have been admitted under this clinic since its establishment, and many have been discharged after getting supportive advice for home-care-based palliative management approach and the dying with dignity approach [Figure 6].
Figure 6: Palliative care

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In the “Pain-Free” hospital concept, sometimes it is not possible to achieve a completely pain-free state in all cases. However, we have been successful in providing a pain-free experience to >90% of patients and emphasize our pledge as outlined in our PFH Patient Charter which states that “Our healthcare professionals will enquire about your pain and care about your comfort throughout your hospital stay.” We are sure that any patient would be thrilled to hear these words, as suffering pain is one of the biggest fears of patients going to a hospital for surgery or treatment of any condition. Apart from patient comfort, we also aim to enable patients to have a faster recovery from surgery and return to normal activity as soon as possible.

The beneficial effects of providing good analgesia and a pain-free postoperative period for patients is:

  1. More comfortable and a shorter hospital stay (for daycare admission patients)
  2. Less risk of nosocomial infection
  3. Decreased anxiety and stress
  4. The decreased burden on the health-care infrastructure as there is easy bed availability in the hospital.


Benefits for the hospital:

  • Better customer satisfaction
  • Optimal use of ambulatory care centers by promoting the use of daycare surgery and minimally invasive surgery
  • Cost-effective
  • Reducing the health burden.



  Hospital Strategies Top


The management of pain in a PFH must work in a stepwise manner:[15]

  1. Education: Pain should be included as an integral part of all professional training for medical and paramedical staff
  2. Empowerment: People should be supported to understand and plan about their pain and treatment
  3. Collaboration between different specialities: To make joint patient strategies to speed fruitful response
  4. Early access to prevent acute pain becoming chronic pain
  5. Measurement of pain as the “Vth vital sign”.



  Conclusion Top


To sum up, some issues need to be addressed to make an institution pain-free. Not all patients are alike and pain manifestations come in myriad forms which are related to the disease, comorbidities, surgery, and the psychological makeup of an individual. Forging relationships between the patient and the members of the team of specialists treating pain will go a long way in achieving satisfactory outcomes. Although it is not possible to achieve 100% freedom from pain, properly trained medical and paramedical professionals with effective drug delivery systems can make patients happy, pain-free, and satisfied.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Linton S. Models of pain perception. In: Understanding Pain for Better Clinical Practice. 1st ed. Edinburgh; New York: Elsevier; 2005.  Back to cited text no. 1
    
2.
Ronco M, Iona L, Fabbro C, Bulfone G, Palese A. Patient education outcomes in surgery: A systematic review from 2004 to 2010. Int J Evid Based Healthc 2012;10:309-23.  Back to cited text no. 2
    
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Eldor J, Kotlovker V, Orkin D. Pain free hospital – Availability (24 hours) of anesthesiologists. J Anesth Clin Sci 2013;2:17.  Back to cited text no. 3
    
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The Pain-Free Hospital Initiative in India; 2012. Available from: https://ehospice.com/internationalposts/the-pain-free-hospital-initiative-in-india. [Last accessed on 2021 Jan 23].  Back to cited text no. 4
    
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Bertini L. Pain free hospital: Organisation aspects. Minerva Anestesiol 2001;67:181-6.  Back to cited text no. 5
    
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Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008.  Back to cited text no. 6
    
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Lehmkuhl D, Meissner W, Neugebauer EA. Evaluation der “initiative schmerzfreie klinik” zur qualitätsverbesserung in der postoperativen schmerztherapie. Eine prospektive kontrollierte studie [Evaluation of the “initiative pain-free clinic” for quality improvement in postoperative pain management. A prospective controlled study]. Schmerz 2011;25:508-15.  Back to cited text no. 7
    
8.
Practice guidelines for acute pain management in the perioperative setting. A report by the American Society of Anesthesiologists Task Force on Pain Management, acute pain section. Anesthesiology 1995;82:1071-81.  Back to cited text no. 8
    
9.
Roofthooft E, Joshi GP, Rawal N, Van de Velde M; PROSPECT Working Group* of the European Society of Regional Anaesthesia and Pain Therapy and supported by the Obstetric Anaesthetists' Association. PROSPECT guideline for elective caesarean section: Updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021;76:665-80.  Back to cited text no. 9
    
10.
Declaration of Montréal; 2010. Available from: https://www.iasp-pain.org/advocacy/iasp-statements/access-to-pain-management-declaration-of-montreal/. [Last accessed on 2021 Jan 23].  Back to cited text no. 10
    
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Visentin M. Towards a pain-free hospital: A project to improve the approach to the patient in pain. J Headache Pain 2002;3:59-6.  Back to cited text no. 11
    
12.
Milewska MM, Horosz B, Ladyko AR. Pain – Free hospital: Recommendations for the acute pain management in Poland. J Pain Relief 2013;02:1000120.  Back to cited text no. 12
    
13.
Numeric Rating Scale (NRS); 2017. Available from: https://www.painscale.com/article/numeric-rating-scale-nrs. [Last accessed on 2021 Nov 10].  Back to cited text no. 13
    
14.
Wong-Baker Faces Foundation; 2016. Available from: https://wongbakerfaces.org/. [Last accessed on 2021 Nov 10].  Back to cited text no. 14
    
15.
Sinatra R. A stepwise approach to pain management. In: Sinatra R, Jahr J, Watkins-Pitchford J, editors. The Essence of Analgesia and Analgesics. Cambridge: Cambridge University Press; 2010.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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Abstract
Why a Pain-Free ...
Daycare and Mini...
The Pain-Free Ho...
Pain Assessment
Hospital Strategies
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