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How audit can improve provision of in-patient pain services

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Kate Lawler, BSc (Hons) Nursing, RN, DipN.

Clinical Nurse Specialist, Pain Management, James Cook University Hospital, Middlesbrough

Auditing the work of a pain service is difficult because of the lack of guidance and nationally agreed standards.

Auditing the work of a pain service is difficult because of the lack of guidance and nationally agreed standards.

However, reliable information is essential for:

- Identifying areas for improvement

- Ensuring that planned improvements bring about the desired outcomes

- Making comparisons between a service and its counterparts elsewhere

- Providing information to the public

- Monitoring adverse outcomes of care.

The Royal College of Anaesthetists has produced a series of guidelines for all anaesthetic practices, including acute and chronic pain (RCA, 2000). The guidelines are not, however, intended to be statements of recommended practice and, as such, they lack definition.

The Clinical Standards Advisory Group report Services for Patients in Pain (2000) offers recommendations but no standards of practice. Databases created specifically for auditing pain service activity rely on having information technology and time for data collection.

Most in-patient pain services make local decisions about the data to be collected and the means to do so. Pain teams vary in terms of numbers of personnel and clinical activity, with many still in the development phase. A rationale for the collection of data is needed, and the value of the exercise must be established (Table 1).

It is also important to take into consideration the fact that pain scores do not indicate whether analgesia was given promptly or even willingly, or how many times a patient might have been openly disbelieved when reporting pain. Neither do they give any indication of how pain assessment is carried out by ward staff. O'Neill (2001) describes patients as 'experts in receiving care' and their experiences as essential to shaping services. As it is hard to do justice to patient satisfaction within routine data collection, separate in-depth surveys are more valuable.

There is a tendency to stop collecting data when advanced analgesic techniques, such as epidurals and patient-controlled analgesia (PCA), are discontinued. At this point patients are likely to fall into the 'analgesic gap' as ward teams take over responsibility for pain management (Smith and Power, 1998). It could be argued that audit should continue up to and beyond discharge.

Finally, there is the question of how we audit our effectiveness as educators. The bedside team should be educated as first-line pain managers, and outcome indicators of the effectiveness of education provided should be sought and measured to ensure that any problems are identified and addressed and the provision of pain services meets patients' needs.

CSAG. (2000)Services for Patients in Pain. London: The Stationery Office.

O'Neill, S. (2001)Why ask patients what they think? Professional Nurse 16: 5 (suppl), S2.

RCA. (2000)Raising the Standard. London: RCA. Smith, G., Power, I. (1998) Audit and bridging the analgesic gap. Anaesthesia 53: 521-522.

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