081 Impact of a clinical pathway for pain management in total knee arthroplasty patients (CHC, Liege - Belgium)

Abstract

Background and objectivesThe Centre Hospitalier Chrétien (CHC) Liège (Belgium) consists of six clinics (1051 acute care beds, 30 psychiatric beds, 564 beds in the network for elderly patients). These clinics implement Clinical Pathways (CP) using a methodology for 30 activities adapted from the Deming Wheel. The methodology is taught in the CP network of which CHC is part since the creation of the network in December 2003. The CP for Total Knee Arthroplasty (TKA) on the St-Joseph site was the first CP to be implemented by CHC (since December 4, 2004). In 5 years, 448 patients have followed this CP.Pain is a key clinical indicator in all types of surgery. However, before the introduction of CPs, pain assessment was not performed in the surgical unit performing TKAs. An objective of our CP was to achieve a pain score < or=3 on a numerical scale ranging from 1 to 10 on transition to oral analgesia (ie, on the 3rd postoperative day).Programme description, implementation, and follow-upThe following steps were implemented with regard to pain management: (i) Information and training of the multidisciplinary team in pain scoring (principles, myths, value, etc), (ii) Introduction of pain assessment at rest and during mobilisation throughout the patient's hospital stay (minimum 3 times/24 h, (iii) Development of an evidence-based protocol for pre-, peri- and postoperative medical care (15% patient controlled analgesia (PCA), 85% patient-controlled peripheral nerve block (PCPNA) during postoperative care), (iv) Implementation of the CP, (v) Inclusion of information on pain management in the patient CP brochure.ResultsAt 1 year, use of pain scoring was optimal in our unit and the objective seemed to have been reached when considering average pain scores. The average score out of 10 for PCA was 2.33 [3.5]* on D3 during rest and 1.67 (2.5) on D3 during mobilisation (*(P75)). The average score for PCPNA was 1.97 (2.75) on D3 during rest and 2.74 (4) during mobilisation. However, the pain score remained > 3 in 25% of the patients (P75). A multidisciplinary discussion of the findings thus took place. The care protocol was reviewed and improved. Patient information was also improved by producing a brochure on management of acute pain.In terms of clinical impact, we then observed:More active patient participation in pain assessment and managementObjective achieved at 4 years and maintained ever since. The mean pain scores (out of 10) at 5 years were:PCA: D3 at rest=0.11 (0) D3 during mobilisation=0.46 (0)PCPNA: D3 at rest=0.37 (0) D3 during mobilisation=1.05 (2)Increased patient and team satisfaction according to satisfaction surveys.Discussion and conclusionPain management requires that all health care professionals increase their awareness of pain, change their attitude, and invest themselves at all times. The use of pain scores is essential in order to encourage teams to move forward and in order to provide visibility to the rest of the institution. Our CP procedure was rapidly adopted for all patients regardless of the indicatio...