Chapter 11: Guidelines for the Provision of Anaesthesia Services for Inpatient Pain Management 2021
Inpatient pain services (IPS) consist of a multidisciplinary team including appropriately trained acute pain physicians and anaesthetists along with nurses specialised in pain management. Other allied health professionals such as applied psychologists, addiction medicine specialists, physiotherapists and pharmacists may also be part of the IPS team.
After the publication of the joint working party of the Royal College of Surgeons and Royal College of Anaesthetists report ‘Pain after surgery’ document in 1990, the provision of IPS in UK hospitals expanded rapidly.1 The percentage of UK hospitals with an IPS increased from 44% in 1995 to >80% in 2004. However, further progress has been difficult to sustain, particularly in terms of quality and consistency.2,3 Recent UK and European surveys of IPS demonstrate a wide variation in service provision, with many IPSs not meeting minimal quality standards (for example, 45% of German IPSs met the specified standards in 2016).4,5 A British survey in 2004 revealed that 69% of respondents thought that IPSs were ‘struggling’ or ‘non-existent’.3 Clinicians agree that most of the reasons for the failure of IPSs to meet standards are organisational rather than technical; financial constraints were cited as being the major reason for failure in 53% of cases.2,3 It has proved difficult to implement early recommendations despite support from the Chief Medical Officer in his report of 2009.6
The Faculty of Pain Medicine (FPM) of the Royal College of Anaesthetists produced the document Core Standards for Pain Management Services in the UK in 2015 (CSPMSUK).7 This chapter should be read with reference to CSPMSUK, which informs part of the requirements detailed below. CSPMSUK provides a detailed model for IPSs to emulate. Recent national audit has revealed that most IPSs do not meet the standards recommended in CSPMSUK in terms of staffing provision.8
Where benchmarking against national standards has identified shortcomings, organisational change is difficult to achieve in most UK hospitals. The particular challenges faced by IPSs have been investigated in three case studies and include: ‘doubts and disagreements about the nature of the changes required to improve inpatient pain management; challenging local organisational contexts; and the beliefs, attitudes and responses of health professionals and managers’.9 In order to provide an adequate IPS these, challenges need to be addressed simultaneously at a local level. Embracing continuous quality improvement as a core value of the IPS and utilising change management techniques may increase the likelihood of success in the longer term.3
The relief of acute pain is primarily a humanitarian matter, but effective pain management may also result in improved clinical outcomes and reduced complication rates, particularly in high risk patients undergoing major surgery.10
Providing safe and effective analgesia for an increasingly elderly surgical patient population with complex medical problems is a significant challenge for IPSs.
Patients’ expectations of surgical outcome and pain relief are high, and it is difficult to meet these expectations with limited IPS resources.
Advances in minimally invasive surgery have resulted in a significant reduction in post surgical pain in some cases. However, these new surgical techniques present challenges of their own, particularly when combined with enhanced recovery after surgery (ERAS) programmes in which the expectation is of early mobilisation and accelerated discharge from hospital.11,12 Meeting the goals of ERAS has led to rapid and significant changes in pain management techniques, which must be supported by well trained and informed IPSs.13,14 However, it is important that we recognise that ERAS protocols are not a replacement for IPSs.15 Patients with complex medical problems, opioid tolerance or chronic pain account for 20-30% of all inpatients and cannot be effectively managed using rigid post surgical pain management protocols.16 There is evidence from a Danish survey to suggest that a steady rise in the adoption of ERAS protocols from 40% of all hospitals in 2000 to 80% in 2009 was paralleled by the almost complete loss of IPSs outside teaching hospitals over the same period.17
The traditional role of IPSs was to manage acute pain after surgery. This remit is expanding in many hospitals to include the care of medical inpatients and patients with complex pain problems such as acute-on-chronic pain or opioid misuse.18
As part of a growing emphasis on perioperative medicine by anaesthetists in the UK, IPSs are increasingly involved at all stages of the patient pathway, from the decision to operate to full recovery after discharge from hospital. The potential for preoperative optimisation of pain management, both in terms of analgesic drugs and pain coping strategies, is being evaluated as part of wider prehabilitation programmes.19,20 Preassessment programmes now include preoperative prediction of those who are likely to suffer severe acute pain and those at risk of developing persistent post surgical pain (PPSP).21,22 IPSs may be involved in developing these programmes and devising enhanced analgesic strategies for high risk patients.23,24 The use of opioid -sparing techniques for peri-operative pain management, for example using analgesic adjuncts (such as magnesium and ketamine) and continuous regional anaesthesia may help reduce the need for opioids post-operatively.25
IPSs therefore have the potential to evolve into Transitional Pain Services involving acute pain physicians, applied psychologists, physiotherapists and occupational therapists to identify risk factors for persistent pain, implement preventative strategies and avoid potential opioid dependency.26,27 The use of opioid risk scores such as the Opioid Risk Tool should be considered to assess risk of opioid abuse when continuing opioid therapy beyond the immediate postoperative period.
There is a need to foster a culture of responsible opioid prescribing as described by The Faculty of Pain Medicine in its Opioids Aware guidelines.28 Liberal opioid prescribing, especially in the United States, has led to addiction, misuse and increased mortality. There is a 44% increase in risk of opioid misuse for every week of repeat prescription after discharge.29 Other clinical problems arise from the perioperative use of opioids, including opioid induced ventilatory impairment (OIVI), acute tolerance and opioid-induced hyperalgesia.29 Patients that are not opioid naïve are also at higher risk of having pain that is difficult to control in the acute setting.29 To reduce the prevalence of these complications, NHS hospital trusts need to work with primary care providers to reduce pre-operative opioid use and step down opioid use after discharge.
The development of risk stratification tools for PPSP and opioid dependence, together with improved communication with surgical teams and primary care have the potential to reduce the risk of developing inappropriate long term opioid use. This intervention should be led by IPSs and has the potential to prevent an ‘opioid crisis’ occurring in the UK. IPSs can help to develop and support analgesic techniques to minimise opioid use without worsening post surgical pain and without increasing the risk of developing PPSP.30
The combination of IPSs with other teams, such as critical care outreach, is taking place in some hospitals, and there is evidence that this approach may reduce adverse events and improve analgesia in complex patients, albeit at the expense of an increased workload.12,31 However, there is also a risk of dilution of pain management skills and the loss of highly trained clinical nurse specialists in pain management.
1. Staffing requirements
Inpatient pain services (IPS) should be staffed by multidisciplinary teams led by appropriately trained consultant or SAS anaesthetists. The minimum training requirement for new appointments to IPS lead roles is Royal College of Anaesthetists higher pain training.32 Advanced pain training, or its equivalent, should be considered optimal.
Anaesthetists in an IPS post need to demonstrate an ongoing significant interest in acute pain management by involvement in continuing professional development (CPD), appraisal and job planning.
Adequate time should be made available for IPS provision in job plans. Two clinical sessions for the lead(s) and one session for all other anaesthetists involved in the IPS is recommended per week.
Adequate staff and systems should be in place to provide timely pain management to all inpatients. Out of usual working hours, this may be delivered by appropriately trained IPS nursing staff or anaesthetic staff (having received intermediate pain training as a minimum standard). A clear point of contact for expert advice should be available at all times.
Patients under the care of an IPS should be reviewed by the IPS regularly, with patients receiving epidural analgesia or other continuous local anaesthetic infusions being seen at least once daily.
Adequate numbers of clinical nurse specialists in pain medicine should be available to fulfil the following roles within working hours:
- review of patients in pain with appropriate frequency to provide a safe and effective service
- provision of advice to ward staff and other healthcare teams regarding all aspects of pain management
- liaise with an appropriate pain medicine specialist to highlight clinical or systematic problems
- ensuring that systems are in place to support non-specialist healthcare staff to safely and effectively manage acute pain overnight and at weekends if the IPS is not immediately available.
The IPS should aim to provide multidisciplinary assessment and management of pain where needed. This should involve collaborative working with allied health professionals including pharmacists, physiotherapists, applied psychologists, liaison psychiatrists and addiction medicine specialists.
Outpatient (chronic) pain management teams should be available to provide advice to the IPS during working hours. This activity should be supported through job planning. If possible, the inpatient and outpatient (chronic) pain services should be integrated, with team members working in both environments, to ensure coordinated care for patients with complex pain while in hospital and also for those recently discharged to the community.
2. Equipment, services and facilities
- infusion pumps for neuraxial analgesia (epidural infusion/patient controlled epidural analgesia (PCEA) and potentially intrathecal infusions)33
- infusion pumps for use with continuous regional analgesia catheters
- patient controlled analgesia infusion pumps
- infusion pumps for other analgesic drugs
- disposables for the above, including neuraxial and regional block devices e.g. NRFit.
Ultrasound scanning, nerve stimulators and all equipment and drugs necessary to perform local and regional analgesic techniques should be available.34
Clinical areas caring for patients receiving analgesic techniques which may result in cardiovascular, respiratory or neurological impairment should have appropriate facilities and adequately trained staff to provide appropriate monitoring.46
Drugs and equipment for the management of the complications associated with analgesic techniques should be readily available.46
There should be adequate office space, informatics and administrative support for the IPS.
There should be appropriate storage facilities for analgesic devices and drugs.
3. Areas of special requirement
Recommendations on the provision of anaesthesia services for children are comprehensively described in chapter 10.
The standard of care for neonates, infants, children and young people should be the same as that for adults, with specific arrangements made for the management of pain in neonates, infants, children and young people.47
The service should be delivered by an appropriately trained team, with specific skills in paediatric pain management and paediatric anaesthesia. Paediatric pain management services may be provided by paediatricians or anaesthetists.
All tertiary paediatric centres should have access to paediatric chronic pain services to assist in managing complex cases. Other centres should develop a network to provide access to paediatric chronic pain services for advice and guidance.
Specialist acute pain management advice and intervention should be available in the emergency department (ED).
Inpatient pain services should also provide assistance in developing management plans for groups or individuals who attend ED frequently with pain. This should be in the context of a wider multidisciplinary team including chronic pain services, primary care and clinical psychology.
Other patient groups
Specific arrangements and guidelines should be available, where applicable, for the management of subgroups of vulnerable adult patients, including:
- critically ill patients
- elderly and/or frail patients48,49
- non-native English speakers
- patients with chronic pain
- patients with coexisting mental health problems
- patients with dementia
- patients with multiple trauma or significant blunt chest wall trauma
- patients with opioid tolerance50
- patients with physical or learning disability
- patients with problem drug and alcohol use51
- patients with significant organ dysfunction
- pregnant and breastfeeding patients.
Patients receiving high dose opioids should be identified in the pre-operative period and referred to specialist services to reduce their opioid use and manage their pre-existing pain issues.52
Discharge prescriptions for opioids should be for a maximum of 5 days. After this, a primary care physician must review the patient before re-prescribing these drugs.52
Communication with Primary Care Providers is recommended when discharging a patient on opioids especially modified release (MR ) preparations (which should generally be avoided in acute pain management).53
There should be clear discussion with all patients started on opioids, especially MR preparations, on the risks of opioids with a clear agreed and documented plan to de-escalate and stop them when the acute pain phase is over.
The service should have access to Chronic Pain Outpatient Clinics that specialise in opioid de-escalation.
4. Training and education
Inpatient pain services should actively contribute to a hospital environment in which education, training and staffing levels ensure the safe care of patients being treated for pain.
Inpatient pain services should provide education delivered by appropriately trained individuals.54 Training should include the recognition, assessment and treatment of pain, this includes using a management plan.
Training should be provided as part of employment induction and repeated regularly thereafter for anaesthetists, ward staff, doctors in training and allied health professionals.
All staff should know how to obtain expert advice when required. This includes being able to access guidelines and protocols.
Members of the IPS should have access to internal and external CPD appropriate to their roles. Funding and time should be available for staff to attend this training.55
Training for anaesthetists to attain basic, intermediate and higher level competencies in pain medicine, as specified by the Faculty of Pain Medicine of the Royal College of Anaesthetists, should be provided. Where higher or advanced pain training is not feasible within an individual hospital, it should be available within the region.56
Inpatient pain nurse specialists providing education on the wards should have dedicated time for this role distinct from direct clinical duties.
Training should include consideration of the use of simulation where feasible. For example role play with the pain team simulating a patient with a failed epidural.
Members of the IPS should engage in outpatient (chronic) pain CPD.
5. Organisation and administration
Clear lines of communication and close working with other services such as surgical and medical colleagues, outpatient (chronic) pain, palliative care, emergency medicine and primary care should be in place.
Advice for the management of step down analgesia should be provided for primary care doctors, where required.
Inpatient pain services should engage with critical incident reporting, root cause analysis and mortality and morbidity meetings as part of the local hospital reporting structure.57
There should be processes in place for learning from critical incidents and from excellent care.
There should be mechanisms to disseminate national safety alerts from groups such as the Safe Anaesthesia Liaison Group (SALG).58
All guidelines should be dated and regularly reviewed. All guidelines should have a clearly documented author and review date and be published in line with local clinical governance policies with appropriate oversight.
Guidelines for the management of specific patients groups (as listed in 3.6) should be available.
Guidelines for the management of side effects and complications including inadequate analgesia should be available.
Where good evidence exists, consideration should be given to procedure specific analgesic techniques.
Where possible, guidelines should be shared locally, between hospitals and nationally.
Assessment and record keeping
Pain and its management should be regularly recorded in the patient notes and/or observation chart using validated tools for each clinical setting. Consistent tools should be used throughout the patient pathway.
6. Financial considerations
Part of the methodology used in this chapter in making recommendations is a consideration of the financial impact for each of the recommendations. Very few of the literature sources from which these recommendations have been drawn have included financial analysis.
The vast majority of the recommendations are not new recommendations, but are a synthesis of already existing recommendations. The current compliance rates with many of the recommendations are unknown, and so it is not possible to calculate the financial impact of the recommendations in this chapter being widely accepted into future practice. It is impossible to make an overall assessment of the financial impact of these recommendations with the currently available information.
7. Research, audit and quality improvement
Where possible, the IPS should encourage engagement in research in acute pain medicine, including recruitment into well designed national and international multicentre studies.67
8. Implementation Support
The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, aims to provide support for departments of anaesthesia to implement the recommendations contained in the GPAS chapters. The scheme provides a set of standards, and asks departments of anaesthesia to benchmark themselves against these using a self-assessment form available on the RCoA website. Every standard in ACSA is based on recommendation(s) contained in GPAS. The ACSA standards are reviewed annually and republished approximately four months after GPAS review and republication, to ensure that they reflect current GPAS recommendations. ACSA standards include links to the relevant GPAS recommendations, so that departments can refer to them while working through their gap analyses.
Departments of anaesthesia can subscribe to the ACSA process for an appropriate fee. Once subscribed, departments are provided with a ‘college guide’ (a member of the RCoA working group that oversees the process), or an experienced reviewer to assist them with identifying actions required to meet the standards. Departments must demonstrate adherence to all ‘priority one’ standards listed in the document to receive accreditation from the RCoA. This is confirmed during a visit to the department by a group of four ACSA reviewers (two clinical reviewers, a lay reviewer and an administrator), who submit a report back to the ACSA committee.
The ACSA committee has committed to building a ‘good practice library’, which will be used to collect and share documentation such as policies and checklists, as well as case studies of how departments have overcome barriers to implementation of the standards, or have implemented the standards in innovative ways.
One of the outcomes of the ACSA process is to test the standards, and by extension the GPAS recommendations, to ensure that they can be implemented by departments of anaesthesia and to consider any difficulties that may result from implementation. The ACSA committee has committed to measuring and reporting feedback of this type from departments engaging in the scheme back to the CDGs updating the guidance via the GPAS technical team.
9. Patient Information
The Royal College of Anaesthetists have developed a range of Trusted Information Creator Kitemark accredited patient information resources that can be accessed from our website. Our main leaflets are now translated into more than 20 languages, including Welsh.
Recommendations for the provision of patient information and obtaining consent are comprehensively described in chapter 2. Specific recommendations for inpatient pain services are listed below.
Patient information leaflets should be made available to provide information on analgesia in general, and on specialised analgesic techniques such as epidural analgesia, nerve blocks, specialist drug infusions and patient controlled analgesia.68
Patient information should be available in formats that take into account the information needs of patients listed in 3.6 and they should be accessible electronically.
Leaflets should explain pain management after discharge, including a step down analgesic plan and how further supplies of medicine can be obtained. Patient information should emphasise the need to avoid harm from long term strong opioid use and give clear advice on the impact of analgesics on driving, acknowledging the current DVLA guidance.69,70
Patient education regarding expectation of pain and analgesia after surgery should be given to all patients in the preoperative period.
Areas for future development
Following the systematic review of the evidence, the following areas of research are suggested:
- transitional pain management73
- psychological interventions74,75
- establish a national database (organisational and patient level data)
- opioid minimisation and long term abuse
- persistent post surgical pain
- pre-emptive and preventive analgesic strategies
- safe analgesia for older people and those with cognitive dysfunction
Clinical lead - Staff grade, associate specialist and specialty (SAS) doctors undertaking lead roles should be autonomously practicing doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues. They should usually have experience in teaching and education relevant to the role and they should participate in quality improvement and CPD activities. Individuals should be fully supported by their clinical director and be provided with adequate time and resources to allow them to effectively undertake the lead role.