Delegation ärztlicher Tätigkeiten in der Akutschmerztherapie

Acute pain management is an interprofessional and interdisciplinary task and requires a good and trustful cooperation between stakeholders. Despite provisions in Germany according to which medical treatment can only be rendered by a formally qualified physician (“Arztvorbehalt”), a physician does not have to carry out every medical activity in person. Under certain conditions, some medical activities can be delegated to medical auxiliary personnel but they need to be (1) instructed, (2) supervised and (3) checked by the physician himself; however, medical history, diagnostic assessment and evaluation, indications, therapy planning (e.g. selection, dosage), therapeutic decisions (e.?g. modification or termination of therapy) and obtaining informed consent cannot be delegated. With respect to drug therapy, monitoring of the therapy remains the personal responsibility of the physician, while the actual application of medication can be delegated. From a legal perspective, the current practice needs to be stressed about what is within the mandatory requirements and what is not when medical activities are delegated to non-medical staff. The use of standards of care improves treatment quality but like any medical treatment it must be based on the physician’s individual assessment and indications for each patient and requires personal contact between physician and patient. Delegation on the ward and in acute pain therapy requires the authorization of the delegator to give instructions in the respective setting. The transfer of non-delegable duties to non-medical personnel is regarded as medical malpractice.     

Vorbestehender Schmerz als Komorbidität im postoperativen Akutschmerzdienst

Background

Pre-existing or chronic pain is a relevant risk factor for severe postoperative pain. The prevalence of pre-existing and chronic pain in hospital depends on the time definition used and is approximately 44 % and 33?%, at 3 or 6 months, respectively. The aim of this study was to determine the prevalence and importance of pre-existing pain in patients treated by a postoperative acute pain service (APS) and to evaluate the requirements for treatment and resources as well as its quality in this context.

Material and methods

This study involved an evaluation of all visits by the APS of the University Hospital in Göttingen over an 8-week period including patient subjective quality assessment on the basis of the quality improvement in postoperative pain therapy (QUIPS) questionnaire. Pre-existing pain (>?12 weeks) was assessed by recording patients history of pain by members of the APS. The results from patients with and without pre-existing pain were compared.

Results

A total of 128 patients (38?% female, 62?% male, aged 15-88 years old, mean age 59.8?±?14.4 years) were seen by the APS on 633 occasions. Of these patients 91?% had been admitted to hospital for surgery (66?% for tumor surgery, 8?% joint replacement, 9?% other joint surgery and 16?% other interventions), 50?% had acute postoperative pain without pre-existing pain, 50?% had had pre-existing pain for at least 12 weeks, 31?% had chronic non-cancer pain and 19?% pain possibly related to cancer. Patients with pre-existing pain showed no significant differences in the treatment requirements (e.g. adjustment of medication), use of resources (e.g. number of visits to the APS and time spent in hospital) and quality of care (e.g. pain intensity, functional aspects, side effects and complications) in the setting of the APS. However, there was an additional subsequent support by chronic pain and palliative care services.

Conclusion

Pre-existing pain is a common comorbidity in surgery patients treated by the APS. There were no significant differences in treatment requirements and quality of care between the patients. This is in contrast to other studies of postoperative pain management which showed that patients with pre-existing postoperative pain had higher pain intensity. This indicates indirectly that the presence of pre-existing pain should be further evaluated as a potentially useful indication for the support by an APS. However there is an urgent need for further studies to clarify whether this indirect effect can be replicated at other hospitals or in other patient collectives. Also it has to be clarified what benefits pain patients have from this kind of treatment: if they benefit from the APS in general or from the special technique, if there is a long-term effect lasting beyond treatment in the APS or if this group of patients would benefit in general from multiprofessional and non-invasive concepts of acute pain treatment.     

Erratum zu: Management von Patienten mit chronischen Schmerzen in der Akut- und perioperativen Medizin

Die Anaesthesiologie - Im Abschnitt „Medikamentöse Strategie“ des veröffentlichten Beitrags kam es zu einem Umrechnungsfehler. Bitte beachten Sie den korrigierten Text: Es...     

Sicherheit und Monitoring der patientenkontrollierten intravenösen Analgesie

Die Anaesthesiologie - Die patientenkontrollierte intravenöse Analgesie („patient controlled intravenous analgesia“, PCIA) ist als Verfahren in der Akutschmerztherapie etabliert....     

Qualitätsverbesserung im konservativen Schmerzmanagement (QUIKS)

Nationale und internationale Erhebungen zeigen, dass die Qualität der Schmerztherapie im Krankenhaus, insbesondere auch in den nichtoperativen Fachbereichen, Defizite aufweist. Ziel war es, analog zu dem auf die operative Schmerztherapie ausgerichteten Qualitätssicherungsinstrument QUIPS (Qualitätsverbesserung in der postoperativen Schmerztherapie) ein Modul für Ergebnis- und Prozessparameter für Patienten im Rahmen einer konservativen Krankenhausbehandlung zu entwickeln und klinisch zu validieren. In einem 4‑stufigen Vorgehen erfolgte die Adaption des QUIPS-Ergebnis- und Prozessbogens des QUIPS-Moduls an Gegebenheiten der konservativen Medizin. Es erfolgten eine systematische Testung und klinische Validierung bei Patienten der inneren Medizin, Neurologie und Dermatologie. 973 Patienten wurden eingeschlossen (Einschlussquote 74 %; n = 403 innere Medizin, n = 401 Neurologie, n = 169 Dermatologie). Der Großteil füllte den Fragebogen eigenständig aus, 33 % der Patienten benötigten Unterstützung, meist in Form eines Interviews. Die meisten Fragen zur Schmerzintensität und Funktion wurden vollständig erfasst; wenige Fehlwerte lagen vor. Schwierig zeigte sich die Bewertung des Outcomes, da viele Patienten unabhängig von einer Schmerztherapie keine Schmerzen hatten. Da zum Befragungszeitpunkt oft keine abschließende Diagnose bestand, wurden im Vergleich zu der bei QUIPS verwendeten OPS-Codierung organbezogene Krankheitsgruppen mit Wortdiagnosen entwickelt. In Ergänzung zu den operativen Modulen von QUIPS steht nun mit QUICKS (Qualitätsverbesserung im konservativen Schmerzmanagement) ein Instrument zur Qualitätssicherung der Schmerzbehandlung bei Patienten in konservativen Fachbereichen zur Verfügung.     

Metamizol

Background

Dipyrone (metamizole) is a non-opioid analgesic commonly used in Germany, which can, in very rare cases, cause life-threatening agranulocytosis. The prescribing information calls for regular monitoring of the differential blood count in cases of long-term treatment. However, there is uncertainty about how this testing should be handled in practice.

Objectives

Which recommendations can be derived from the published literature for evaluating blood cell counts during treatment with metamizole and which other options for monitoring exist?

Methods

Data from recent epidemiological studies, reviews, and spontaneously reported cases were evaluated.

Results

Agranulocytosis can emerge at highly variable intervals ranging from the first day of metamizole treatment to months after treatment has begun. As a result, there is no conclusive, evidence-based recommendation for the time intervals at which blood cell counts should be tested. Therefore, the onset of clinical symptoms should be used as trigger for monitoring blood cell counts to enable early diagnosis and avoid agranulocytosis-related complications. In addition to general symptoms like fever, sore throat, fatigue, and muscle pain, mucosal ulcerations, severe angina, and systemic infections leading to sepsis are typical of agranulocytosis.

Conclusions

Providing patients and medical staff with better information about early symptoms of agranulocytosis could be a sensible way to prevent complications. Any suspicion of agranulocytosis should immediately lead to a differential blood count and to the withdrawal of all drugs possibly associated with agranulocytosis. Patients should be monitored and treated according to the severity of their symptoms.

     

Vereinbarung zur Organisation der Schmerztherapie chirurgischer Patienten des Berufsverbandes Deutscher Anästhesisten und des Berufsverbandes der Deutschen Chirurgen (Neufassung 2019)

Die Unfallchirurgie - Die Therapie möglicher ursächlicher, prozedurenspezifischer und/oder -begleitender Akutschmerzen ist ein essenzielles Qualitätsmerkmal in jedem chirurgischen...