Does an acute pain service improve postoperative outcome?

P ain relief after surgical procedures continues to be a major medical challenge. Alleviation of pain has been given a high priority by the medical profession and the health authorities. Improvement in perioperative analgesia not only is desirable for humanitarian reasons, but is also essential for its potential to reduce postoperative morbidity (1–4) and mortality (2). Inadequacies in postoperative pain relief have been evident for decades (5,6). The importance of establishing an organization for the management of postoperative pain relief, with special attention to a team approach, was proposed more than 40 yr ago (7). Although several editorials (8–10) from 1976 to 1980 again advocated the introduction of an analgesia team to supervise and administer pain relief and to take responsibility for teaching and training in postoperative pain management, almost a decade passed before a specialized in-hospital postoperative pain service emerged. Thus, in 1985 the first acute pain services (APSs) were introduced in the United States (11,12) and in Germany (13). Immediate and sustained formal support and authoritative recommendations from various medical and health care organizations promoted a widespread introduction of APSs (14–22). One document explicitly stated “that this service should be introduced in all major hospitals performing surgery in the UK” (15); this is in agreement with recommendations from the Agency for Health Care Policy and Research (United States) and the National Health and Medical Research Council (Australia), which state that all major acute care centers should have an APS (14,18). Furthermore, provision of an APS is presently a prerequisite for accreditation for training by the Royal College of Anaesthetists (23) and the Australian and New Zealand College of Anaesthetists. A Canadian survey from 1991, including 47 university-affiliated teaching hospitals, showed that 25 hospitals (53%) operated an APS and that an additional 17 (35%) were attempting to organize one (24) (Table 1). A survey in Australia and New Zealand in 1992–1993 from 111 larger institutions showed that 37 (33%) had an APS and 58 (53%) would have liked to or had plans to implement the service (25). Repeated surveys in 1994 and 1996 from New Zealand indicated in 22 larger institutions an increase from 12 to 17 APSs (29). In a European survey from 1993, including 105 representative hospitals from 17 countries, 34% of the hospitals had a formal APS (26). Forty-two percent to 73% of US hospitals, depending on size and academic affiliation, had an APS in 1995 (31,32). In the United Kingdom, the number of hospitals providing APSs increased from 3% in 1990 to 43% in 1994 (27,28,36), to 47% in 1996 (37), and to 49% in 1999 (35). In a recent survey from Germany, 36% of hospitals operated an APS, but the quality of criteria for the service was very variable (34). The introduction of APSs has led to an increase in the use of specialized pain relief methods, such as patient-controlled analgesia (PCA) and epidural infusions of local anesthetic/opioid mixtures, in surgical wards. Implementation of these methods may represent real advances in improving patient well-being and in reducing postoperative morbidity (38). However, a pertinent question is whether the extensive resources allocated to these commitments have been successful and cost-effective. The objective of this study, therefore, was to critically review the literature on APSs regarding outcome: pain relief, side effects of the postoperative pain treatment, patient satisfaction, therapy-related adverse events, morbidity, hospital stay, and cost issues.