05 CLINICAL AUDIT-ORTHO done at a peripheral.pptx

Clinical audit on pain management done at peripheral health centre

1. CLINICAL AUDIT PAIN MANAGEMENT IN LOWER LIMB SURGERIES IN ORTHOPAEDICS (Mar To May 2022)

2. AIM TO ASSESS OUR PAIN MANAGEMENT PRACTICES AND IMPROVE TO THE INTERNATIONAL STANDARDS BY IMPLEMENTING CHANGES

3. PURPOSE TO IMPROVE PATIENT CARE AND SATISFACTION BY REDUCING PAIN DURING THE COURSE OF HOSPITALIZATION.

4. SCOPE PATIENT WHO UNDERWENT LOWER LIMB SURGERIES IN ORTHOPAEDICS

5. CRITERIA MAXIMUM PAIN SCORE DURING POST OPERATIVE HOSPITAL STAY STANDARD IT SHOULD BE 4 OR LESS THAN 4 TO HAVE BETTER PATIENT SATISFACTION AND OUTCOME

6. AUDITORS DR. Sidharth Baheti : CONSULTANT ORTHOPAEDICS DR. Shrey Sharma : ANAESTHESIOLOGIST MR. Sumt : ANESTHETIST ASSISTANT Dr. Pawan Kumar : QUALITY MANAGER

7. DURATION OF AUDIT 3 MONTHS (Mar 2022 to May 2022)

8. METHOD AND DESIGN IT ’ S A PROSPECTIVE SINGLE CENTER STUDY The detailed baseline audit was done for pain management effectiveness on all the patients operated for Lower Limb Surgeries in Orthopedics from Mar to May . 2022 using a checklist. On basis of audit findings guidelines and recommendation were Issued and implemented to improve pain management practice in these subgroups of patient.

9. CHECKLIST CLINICAL AUDIT-PAIN MANAGEMENT S.No . Name UHID/IPD No. Maximum Pain Score-Post Operative Day of Maximim Pain Score Epidural Analgesia Conc. Started Within IV Analgesics given Doses/ Schedule Reserve Analgesics Given Possible Reasons of Pain management Failure                                                                                                                                                                                                                                                

10. FINDINGS

11. Number of cases of Lower Limb Surgeries (Month wise)

12. Month wise patient having maximum pain score <3 or =3 in postoperative period   Mar-22 Apr-22 May-22 Total No. Lower Limb Surgeries 08 11 05 Total no. of patients having pain score =4 or <4 01 03 02 % of patients having Pain score = 4 or < 4 12.5 27.2 40

13. Possible reasons for failure of pain management in patients Inadequate dosing of epidural 1 Inadequate management Opioid and NSAID 5

14. OBSERVATION On basis of audit it was found that In 1 patients epidural analgesic infusion doses was inadequate and the dose was not given as per the patient requirement, hence leading to failure in pain management. In five of the case where NSAID & Opioid was given inadequate management was noticed,

15. DISCUSSION 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 . 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.” 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.

16. 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 Physician lack of knowledge and reluctance to give analgesics in adequate dose

17. 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

18. RECOMMENDATIONS 1: Development of clinical guidelines and protocols for post operative pain management included in pain management sheet. 2: Guidelines for step down analgesics should be framed 3: Patient with opioid addition must be treated by multidisciplinary team having additional physician as core member 4: Team should be formed for providing acute pain services In the hospital 24*7. 5. Registered nurses made aware of subjective nature of pain, and various pain assessment tools. After initial assessment subsequent assessment should be carried out as advised.

19. STEP DOWN FROM EPIDURAL Epidural is usually discontinued after 2-3 days and earlier if appropriate Transition from epidural should be planned in advance 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 NSAIDs (if not contraindicated) Oral . TRAMADOL (IF PAIN SCORE MORE THAN 3) B: PATIENT UNABLE TO TAKE ORALLY I.V. NSAIDs I.V. TRAMADOL (IF PAIN SCORE MORE THAN 3)

20. ACUTE PAIN SERVICE team formed to improve acute pain management in surgical patients . Team includes: DR. Sidharth Baheti (CONSULTANT ORTHOPAEDICS) DR. Shrey Sharma (ANAESTHESIOLOGIST) Mr. Kamini Puri ( NURSING SUPERINTENDENT) 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 responsibility for surveillance and future data collection r egarding pain management. IMPLEMENTING GUIDELINES

21. Result A total of 8 patients in march, 11 Patients in April and 5 patients in May were taken for the audit. The results were as: in Mar to May 18 patients had VAS Score =4 or <4 out of 25 patients respectively.

22. REAUDIT We will continue our focused efforts to improve and implement the changes in coming months.