CLINICAL AUDIT

PAIN MANAGEMENT IN TOTAL KNEE

REPLACEMENT
AADHAR HOSPITAL
JANUARY –JULY 2018
 AIM
• TO ASSESS OUR PAIN MANAGEMENT
PRACTICE AND IMPROVE TO THE
INTERNATIONAL STANDARDS BY IMPLEMENTING
CHANGES
 PURPOSE
• TO IMPROVE PATIENT CARE AND
SATISFACTION BY AVOIDING PAIN DURING THE
COURSE OF HOSPITAL
 SCOPE
• PATIENT UNDERWENT TOTAL KNEE
REPLACEMENT
• CRITERIA • STANDARD

• MAXIMUM PAIN SCORE • IT SHOULD BE 3 OR LESS

DURING POST THAN 3 TO HAVE
OPERATIVE HOSPITAL BETTER PATIENT
STAY SATISFACTION AND
OUTCOME
 AUDITORS

DR RAMESHWAR LODHA : ANAESTHESIOLOGIST

DR HARIPAL MALIK : CLINICAL ASSISSTANT (ORTHOPAEDICS )

MR.NAVDEEP GAURI : NURSING SUPERINTENDENT

MISS SONIA : CLINICAL NURSING SPECIALIST

MR YOGESH KAPIL : QUALITY OFFICER

 DURATION OF AUDIT

4 MOTNTH March to june -july 2018

 METHOD AND DESIGN

IT’S A RETROSPECTIVE SINGLE CENTER STUDY

The detailed baseline audit was done for pain management effectiveness
on all the patients operatedFor total knee replacement
including retrospective and current files from march to may 2018 using a checklist.

On basis of audit findings guidelines and recommendation were

Issued and implemented to improve pain management ptactice
in these these subgroups of patient. Patients files were reaudited
To check the compliance and improvement in the month of june and july2018
 S.No.
Name
IPD

Maximum Pain Score

Post-Operative

Day of Maximum Pain

Score

Epidural Analgesia
Dose

Started within
CHECKLIST
Clinical Audit - Pain Management

IV Analgesics Given
Doses/Schedule

Reserve Analgesics
Given

Possible reasons of
Pain management
failure
MONTH ___________________________
FINDINGS
 Number of cases of total knee
replacement (Month wise)
Total No. of TKR Cases
40

35

30

25

20

15

10

0
March April May June
Total No. of TKR Cases
Month wise patient having maximum
pain score <3 or =3 in postoperative
period
% OF PATIENT HAVING MAXIMUM
PAIN SCORE LESS THAN OR EQUAL
TO 3
% of patient taking pain score less than or equal to 3

75%
40%
33%
25%
20%

10/34

12/30
6/30

3/12

9/12
MARCH APRIL MAY JUNE JULY
Possible reasons for failure of pain
management
Inadequate dosing of epidural 100%

Inadequate management of epidural 10%

Opioid Tolerance 1%

Inadequate patient communication 50%

Inadequate discontinuation of epidural without any 60%

step down analgesic prescription

 OBSERVATION
On audit it was found epidural analgesic doses were
 DISCUSSION
Studies indicate that treatment of acute pain remains
suboptimal due to attitudes and educational barriers
on the part of both physicians and patients,
as well as the intrinsic limitations of available therapies.

Under-treatment of pain is a focus of growing concern to

the medical community
.
Poorly controlled postoperative pain leads to undesirable
outcomes, including immobility, stiffness, myocardial
ischemia, atelectasis, pneumonia, deep venous
thrombosis, anxiety, depression, and chronic pain.
 DISCUSSION

Recent years have seen an increased awareness regarding the importance of pain
management, with the congress declaring the 10-year period beginning in 2001
as the “Decade of Pain.”
 Barriers to Pain Management

Not having consistent way of assessing and managing the pain

Not having policies ,procedures guidelines that contribute to

knowledge of acceptable best practices

Not having documented approach for pain assessment,pain treatment,

available alternate methods, and not having a dedicated person or team

Phusician lack of knowledge and reluctance to give analgesics in adequate dose

 Inadequate Acute Pain Management Has
Substantial Consequences for Patients

REDUCED QUALITY OF LIFE

IMPAIRED SLEEP

IMPAIRED PHYSICAL FUNCTION

HIGH ECONOMIC COST

PHYSIOLOGICAL AND PSYCHOLOGICAL CONSEQUENCES

CHRONIC PAIN
POST TRAUMATIC STRESS DISORDER
 RECOMMENDATIONS
1: Development of clinical guidelines and protocols for post operative pain management

2: guidelines for post operative epidural analgesia

3: Guidelines for step down analgesics should be framed

4: Patient with previous opioid exposure must be treated by multidisciplinary team

having addiction physician as core member

5: Designated team should be formed for providing acute pain services hospital wide
even in out of hours

6)Registered nurses made aware of subjective nature of pain, and various pain assessment
tools. After initial assessment susequent assessment should be carried out as advised
EPIDURAL SUBSCRIPTION FORM
 STEP DOWN FROM EPIDURAL

Epidural is usually discontinued after 2-3 days and earlier if appropriate

Transition from epidural should be planned in advanvce and in consultation
with patient.
Some patient will require opioid analgesia following discontinuation of epidural.
If possible, the step down analgesia should be planned to avoid pain and problems

FOLLOWING REGIMENS ARE RECOMMENDED.

A: PATIENT TAKING ORALLY

Oral paracetamol Igm qid
Oral NSAID (if not contraindicated)
Oral . TRAMADOL (IF PAIN SCORE MORE THAN 3)

B: PATIENT UNABLE TO TAKE ORALLY

I.V. PARACETAMOL 1 GM QID
I.V. NSAID
I.V. TRAMADOL (IF PAIN SCORE MORE THAN 3)
 IMPLEMENTING GUIDELINES

ACUTE PAIN SERVICE team formed to improve acute pain management

in surgical and medical patients .Team includes:

DR MOHAR SINGH M.D. ANAESTHESIA

DR HARIPAL MALIK (CLINICAL ASSISSTANT)
Mrs. MUKESH ( CLINICAL NURSING SPECIALIST)

Team will be responsible for providing acute pain service even in out hours

Team will teach and implement the guidelines for pain management
hospital wide

Team has the responsibilty for surviellance and future data collection
regarding pain management.
 REAUDIT

For the month of june and july 40 patient files of total knee replacement
were audited .

Out of 40 patients 30 patient had maximum pain score of 3 during post operative
course which was signifiantly improved( 75%) after implementing the changes
Recommended.

We will continue our focussed efforts to improve and implement the changes
hospital wide ijn all group of patients.