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Objective of the campaign
The appropriate relief of pain of patients in general and of hospital patients in particular is on the agenda in many institutions. To be sure, carers have always tried to relieve the pain of their patients, including through the use of morphine and related drugs.
We nevertheless have to state that progress remains to be made. Recent studies have clearly indicated that the situation has not much changed regarding the five main types of pain: childbirth, postoperative, chronic, cancerous, acute.
Indeed according to numerous WHO reports, only 40 to 50% of hospitalised patients consider that their pain is relieved adequately, and this is in spite of new therapeutic approaches which should permit relief in 90 or 95% of cases.
By way of example, the pain experienced by children has only recently been recognised, and more particularly that of very small children. A 1987 article by KJS Anand noted that 70% of premature babies are operated under simple sedation and without a genuine anaesthetic.
The same holds good for aged patients who are thought, often wrongly, to feel less pain, and from this ensues an inadequate treatment. In the final year of life old people often experience pain which is inadequately relieved. The same goes for pain caused by investigations and treatment.
It may happen that patients refuse to continue a treatment or do not dare to speak of their pain for fear of having to undergo further investigations. Modern methods such as those which enable a patient to control his or her own postoperative analgesic (PCA) or carers to make painless injections (Emla paste) should be much more widely employed.
In spite of marked improvements especially in the use of analgesics and in the recognition of the patient who is in pain or approaching death, the net result has in general not greatly changed.
There are several reasons for this state of affairs:
- the notion which is still widely held that pain is a natural phenomenon and that it even has redeeming or expiatory value
- the reticence of certain carers, whether medical or paramedical, when faced with a responsibility which calls into question the power of the carer in regard to his ability to take account of the “needs” of the patient
- the different levels of training of medical staff within the hospital and hence the difficulty of conducting joint training sessions
- the lack of any systematic therapeutic approach in the use of analgesics
- the renewal and rapid turnover of this medical staff, which necessitates constant repetition
- the fact that this problem is generally handled at the interface between assistant and medical staff
A concrete programme to deal with this problem began in 1992 at the Hospital St.Luc in Montreal under the aegis of WHO. It subsequently spread to Geneva, to the Rhône-Alpes region of France and is now expanding towards the North of France and Spain. More recently programmes have also been undertaken in English-speaking countries.
The concrete measures which have been taken in these institutions have generally comprised the following elements:
- an initial evaluation of the amount of agreement between the pain as felt by the patient and the perception of it by the medical staff (an inquiry made of the patients in hospital and of the staff providing them with medical care)
- measuring the annual consumption of analgesics by the hospital pharmacy, and analysing it by the different types of analgesic and the different services of the hospital
- an awareness campaign (kiosk, posters, leaflets) amongst the patients, those around them and all the medical staff of the hospital.
- application of the WHO scheme of analgesic treatment
- partners in the programme: voluntary medical services, nursing department, administration, etc.
- a fresh evaluation after three months
- overall length of the campaign: three months
Organisation of the campaign
1. Evaluation of Days Zero and 90
This evaluation is simple and is carried out by student nurses under the supervision of the head nurse. (The conduct of this inquiry by student nurses is perfectly well accepted by the medical staff). It consists in meeting every patient of the medical services which volunteer and asking them the following questions :
1.1. At this very moment, are you in pain?
1.2. If yes, can you tell me how much pain you have (showing a visual analogue scale from 1 to 10)
2. After this visit, the medical staff is asked the following questions :
2.1. When I saw the patient, do you think he or she was experiencing pain?
2.2. If yes, how much on the visual scale?
2.3. Are analgesics administered? Which ones?
2.4. Situations:
2.4.1 Post operative? Date of operation?
2.4.2. Cancer?
2.4.3. Other?
3. Comparison of the results obtained
4. Evaluation of the consumption of analgesics within the service according to the type (see WHO classification below).
WHO Plan of Analgesic Treatment
1. Non-morphine based antalgic medications
1.1 Paracetamol : 2-4 gr/day (e.g. 500 mg/4 hours)
1.2 Acetylsalicylic acid: 2-3 gr/day
1.3 Diclofenac: 150-200 mg/day
1.4 Ibuprofen: 1200 – 1800 mg/day
2. Weak morphone-based painkillers
2.1 Codeine: 30-135 mg/day or dextropropoxyphen +/- level one painkiller
3. Strong morphine based painkillers
3.1 Agonist/antagonist (cannot be associated with morphine!) opioids e.g. buprenorphine
3.2 Oral morphine solution
Peak action one hour, duration 4-6 hours
Initial dose: 10 mg/4 hours ( to reduce to 5 mg if general state is considerably altered)
Adapt doses by 30% each time if required to obtain satisfactory pain reduction
3.3 Long acting morphine
3.4 Parenteral morphine (subcutaneously every 4 hours) – 30-50% of the oral dose
4. Associated measures
4.1 Laxative: indispensable to counteract the constipating effect of opioids
4.2 Anti-emetics: metoclopramide (e.g. 40 mg/day)
Organisation of the campaign
1. Meeting of a working group
1.1 Composition
1.1.1 Coordination: Dr Patrick Rutten, Claude Colle
1.1.2 Nurses: Christiane Belche, Christaine Goffin, L-Marie Jadoul, Viviane Chardome, R. LAssence, N. Courtois
1.1.3 Physicians : Dr Ferrant, Dr Magotteaux, Dr Gérard F. ; Dr M-L Herman and a physician from each of the following services: gynaecology, internal medicine, paediatrics
1.2 Mission
1.2.1 Call for services to volunteer for participation in the campaign
1.2.2 Organisation of the campaign
1.2.3 Verification against WHO pain treatment recommendations et possible adaptation of the recommendations
2. Evaluation and spreading of the information within the services
2.1. Day Zero; week of 10 January
2.2. Gathering and analysis of the results of the evaluation
2.3. Distribution of the results to the services, as well as the outline of how the analgesics are being used
2.4. Organisation of an information meeting within each service and explanation of how the analgesics are being used
2.5. Inclusion of the measure of the pain (EVA) in the ?? of the patient and application of the programme of analgesics
3. Campaign for the public
3.1. Production of an information leaflet
3.2. Distribution of this to the patients, their families and the hospital staff (kiosk at the entrance of the hospital)
3.3. Organisation of a brief press conference, March 1998
4. Further evaluation at the end of the campaign on Day 90 (end of March 1998)
For additional information :
Dr Patrick RUTTEN (Medical management)
Or communicate :
Monsieur Claude COLLE (Nurse management)
Centre Hospitalier de l'Ardenne
Avenue d'Houffalize
B-6800 LIBRAMONT
Belgium
Phone : (32) 61 238.111
Fax : (32) 61 238.540
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Last updated : 01-01-2006
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