Challenge of improving postoperative pain management: case studies of three acute pain services in the UK National Health Service.

BACKGROUND: Previous national survey research has shown significant deficits in routine postoperative pain management in the UK. This study used an organizational change perspective to explore in detail the organizational challenges faced by three acute pain services in improving postoperative pain management. METHODS: Case studies were conducted comprising documentary review and semi-structured interviews (71) with anaesthetists, surgeons, nurses, other health professionals, and managers working in and around three broadly typical acute pain services. RESULTS: Although the precise details differed to some degree, the three acute pain services all faced the same broad range of inter-related challenges identified in the organizational change literature (i.e. structural, political, cultural, educational, emotional, and physical/technological challenges). The services were largely isolated from wider organizational objectives and activities and struggled to engage other health professionals in improving postoperative pain management against a background of limited resources, turbulent organizational change, and inter- and intra-professional politics. Despite considerable efforts they struggled to address these challenges effectively. CONCLUSIONS: The literature on organizational change and quality improvement in health care suggests that it is only by addressing the multiple challenges in a comprehensive way across all levels of the organization and health-care system that sustained improvements in patient care can be secured. This helps to explain why the hard work and commitment of acute pain services over the years have not always resulted in significant improvements in routine postoperative pain management for all surgical patients. Using this literature and adopting a whole-organization quality improvement approach tailored to local circumstances may produce a step-change in the quality of routine postoperative pain management.

A randomized comparative crossover study to assess the affect on circuit life of varying pre-dilution volume associated with CVVH and CVVHDF.

OBJECTIVE: To determine if circuit life is influenced by a higher pre-dilution volume used in CVVH when compared with a lower pre-dilution volume approach in CVVHDF. DESIGN: A comparative crossover study. Cases were randomized to receive either CVVH or CVVHDF followed by the alternative treatment. SUBJECTS: All patients >or= 18 yrs of age who required CRRT while in ICU were eligible to participate, but excluded if coagulopathic, thrombocytopenic or unable to receive heparin. Based on an intention-to-treat, 45 patients were randomized to receive either CVVH or CVVHDF followed by the alternative treatment. SETTING: A 24-bed, tertiary, medical and surgical adult intensive care unit (ICU). INTERVENTION: Blood flow rate, vascular access device and insertion site, hemofilter, anticoagulation and machine hardware were standardized. An ultrafiltrate dose of 35 ml/ kg/h delivered pre-filter was used for CVVH. A fixed pre-dilution volume of 600 mls/h with a dialysate dose of 1 L was used for CVVHDF. RESULTS: Thirty-one patients received CVVH or CVVHDF out of 45 participants followed by the alternative technique. There was a significant increase in circuit life in favor of CVVHDF (median=16 h 5 min, range=40 h 23 min) compared with CVVH (median=6 h 35 min, range=30 h 45 min). A Mann-Whitney U test was performed to compare circuit life between the two different CRRT modes (Z=-3.478, p<0.001). Measurements of circuit life on the 93 circuits which survived to clotting (50 CVVH and 43 CVVHDF) were log transformed prior to under taking a standard multiple regression analysis. None of the independent variables - activated prothrombin time (aPTT), platelet count, heparin dose, patient hematocrit or urea - had a coefficient partial correlation >0.09 (coefficient of the determination=0.117) or a linear relationship which could be associated with circuit life (p=0.228). CONCLUSION: Pre-diluted CVVHDF appeared to have a longer circuit life when compared to high volume pre-diluted CVVH. The choice of CRRT mode may be an important independent determinant of circuit life.

Exploring the relationship between senior management team culture and hospital performance.

The purpose of this study was to explore relationships between senior management team culture and organizational performance in English hospital organizations (NHS trusts [National Health Service]). We used an established culture-rating instrument, the Competing Values Framework, to assess senior management team culture. Organizational performance was assessed using a wide variety of routinely collected measures. Data were gathered from all English NHS acute hospital trusts, a total of 197 organizations. Multivariate econometric analyses were used to explore the associations between measures of culture and measures of performance using regressions, ANOVA, multinomial logit, and ordered probit. Organizational culture varied across hospital organizations, and at least some of this variation was associated in consistent and predictable ways with a variety of organizational characteristics and measures of performance. The findings provide particular support for a contingent relationship between culture and performance.

Do Hospital Boards matter for better, safer, patient care?

Manifest failings in healthcare quality and safety in many countries have focused attention on the role of hospital Boards. While a growing literature has drawn attention to the potential impacts of Board composition and Board processes, little work has yet been carried out to examine the influence of Board competencies. In this work, we first validate the structure of an established 'Board competencies' self-assessment instrument in the English NHS (the Board Self-Assessment Questionnaire, or BSAQ). This tool is then used to explore in English acute hospitals the relationships between (a) Board competencies and staff perceptions about how well their organisation deals with quality and safety issues; and (b) Board competencies and a raft of patient safety and quality measures at organisation level. National survey data from 95 hospitals (334 Board members) confirmed the factor structure of the BSAQ, validating it for use in the English NHS. Moreover, better Board competencies were correlated in consistent ways with beneficial staff attitudes to the reporting and handling of quality and safety issues (using routinely collected data from the NHS National Staff Survey). However, relationships between Board competencies and aggregate outcomes for a variety of quality and safety measures showed largely inconsistent and non-significant relationships. Overall, these data suggest that Boards may be able to impact on important staff perceptions. Further work is required to unpack the impact of Board attributes on organisational aggregate outcomes.

Cultural characteristics of "high" and "low" performing hospitals.

PURPOSE: To compare and contrast the cultural characteristics of "high" and "low" performing hospitals in the UK National Health Service (NHS). DESIGN/METHODOLOGY/APPROACH: A multiple case study design incorporating a purposeful sample of "low" and "high" performing acute hospital Trusts, as assessed by the star performance rating system. FINDINGS: These case studies suggest that "high" and "low" performing acute hospital organisations may be very different environments in which to work. Although each case possessed its own unique character, significant patternings were observed within cases grouped by performance to suggest considerable cultural divergence. The key points of divergence can be grouped under four main headings: leadership and management orientation; accountability and information systems; human resources policies; and relationships within the local health economy. PRACTICAL IMPLICATIONS: As with any study, interpretation of findings should be tempered with a degree of caution because of methodological considerations. First, there are the limitations of case study which proceeds on the basis of theoretical rather than quantitative generalisation. Second, organisational culture was assessed by exploring the views of middle and senior managers. While one should in no way suggest that such an approach can capture all important cultural characteristics of organisations, it is believed that it may be at least partially justified, given the agenda-setting powers and influence of the senior management team. Finally "star" performance measures are far from a perfect measure of organisational performance. Despite such reservations, the findings indicate that organisational culture is associated in a variety of non-trivial ways with the measured performance of hospital organisations. ORIGINALITY/VALUE: Highlights considerable cultural divergence within UK NHS hospitals.

Diminishing returns or appropriate treatment strategy?--an analysis of short-term outcomes after pain clinic treatment.

In the United Kingdom patients with chronic pain are frequently managed in anaesthetist-led outpatient pain clinics. In many of these clinics the emphasis is on medical therapies (analgesics and psychotropic drugs, TENS, acupuncture and nerve blocks) with patients trying a series of different therapies until relief is achieved or further attempts at physical treatments are discontinued. The sequential trial of different treatment modalities presents clinicians with a problem. Patients who receive little benefit from (say) the first three treatments tried might be expected to be less likely to gain benefit from the next treatment modality. The presence or absence of such 'diminishing returns' from treatment will influence when therapeutic efforts based on the medical model of pain should be abandoned. This study examined basic outcome data on 1912 patients seen in a single Scottish pain clinic between 1987 and 1994. The data were analysed to assess whether the success of treatment modalities depended on whether they were used as a first-choice treatment or were given after previous therapeutic attempts had failed. Diminution in success rates was generally not large although this varied between therapies. No fall-off in success rates was seen for antidepressants, acupuncture or sympathetic nerve blocks. However, the other nerve blocks all showed falling success rates when they were used as fourth- or fifth-line treatments. That little diminution of success rates was seen warrants further investigation. Pain clinics need good information on the success or otherwise of late treatment so that they can devise rational pain management strategies covering multiple therapies and appropriate criteria for ending medical interventions. These findings suggest that allowing patients access to multiple pain therapies may well be an appropriate management strategy.

Cut and thrust: antecedent surgery and trauma among patients attending a chronic pain clinic.

Surgery and trauma are recognised as important causes of chronic pain, although their overall contribution has not been systematically studied. This paper reports on the contribution of surgery and trauma to chronic pain among 5130 patients attending 10 outpatient clinics located throughout North Britain. Surgery contributed to pain in 22.5% of patients, and was particularly associated with the development of pain in the abdomen and with anal, perineal and genital pain. Trauma was a cause of pain in 18.7% of patients, and was most common in pain in the upper limb, the spine and the lower limb. Patients with chronic pain associated with trauma are on average younger than those with chronic post-surgical pain. Further, and unusually for pain conditions, the trauma patients show an excess of males over females. These findings indicate that it can be unhelpful for pain classification systems to combine surgery and trauma in a single category. The results also point to areas for potentially fruitful research into the aetiology of chronic pain. In particular, studies are needed to identify the operative procedures associated with the development of pain so that preventive measures can be implemented.

Unlearning in health care.

Learning in health care is essential if healthcare organisations are to tackle a challenging quality of care agenda. Yet while we know a reasonable amount about the nature of learning, how learning occurs, the forms it can take, and the routines that encourage it to happen within organisations, we know very little about the nature and processes of unlearning. We review the literature addressing issues pivotal to unlearning (what it is, why it is important, and why it is often neglected), and go further to explore the conditions under which unlearning is likely to be encouraged. There is a difference between routine unlearning (and subsequent re-learning) and deep unlearning--unlearning that requires a substantive break with previous modes of understanding, doing, and being. We argue that routine unlearning merely requires the establishment of new habits, whereas deep unlearning is a sudden, potentially painful, confrontation of the inadequacy in our substantive view of the world and our capacity to cope with that world competently.

Using routine comparative data to assess the quality of health care: understanding and avoiding common pitfalls.

Measuring the quality of health care has become a major concern for funders and providers of health services in recent decades. One of the ways in which quality of care is currently assessed is by taking routinely collected data and analysing them quantitatively. The use of routine data has many advantages but there are also some important pitfalls. Collating numerical data in this way means that comparisons can be made--whether over time, with benchmarks, or with other healthcare providers (at individual or institutional levels of aggregation). Inevitably, such comparisons reveal variations. The natural inclination is then to assume that such variations imply rankings: that the measures reflect quality and that variations in the measures reflect variations in quality. This paper identifies reasons why these assumptions need to be applied with care, and illustrates the pitfalls with examples from recent empirical work. It is intended to guide not only those who wish to interpret comparative quality data, but also those who wish to develop systems for such analyses themselves.

Shaping attitudes to postoperative pain relief: the role of the acute pain team.

Postoperative pain relief is often inadequate. Ignorance and misconceptions about opioids by ward staff contribute to this poor management. The introduction of acute pain teams has done much to improve pain relief for patients. It may also have contributed to changes in attitudes and knowledge of medical and nursing staff. We questioned 48 doctors and nurses on their knowledge and beliefs about postoperative pain relief. Staff members were questioned on two units, one with access to an acute pain team and one without. Over half those on the unit using traditional postoperative care thought patients did not receive adequate pain relief (58%). In comparison, only one respondent from the unit with the pain team thought this was the case (P < 0.001). More staff members that had experience of patient-controlled analgesia (PCA) were optimistic about its benefits than those in the unit with no experience; they were also less concerned about possible side effects. Only one respondent on the unit using PCA thought it carried a risk of drug dependence, compared to over half (55%) of those on the unit with no experience in this technique (P < 0.001). Over two-thirds of staff familiar with PCA thought nursing workload had decreased. Acute pain teams have an important role in educating ward staff. The impact of establishing such teams on staff knowledge and attitudes needs further study to ensure that they can carry out this role most effectively.

Diagnosis and management of osteomyelitis. Decision analytic and pharmacoeconomic considerations.

Osteomyelitis, or bone infection, is becoming more common, largely because of increases in the use of implanted prosthetic devices in the management of arthritis or fractures. The clinical management of osteomyelitis requires accurate microbiological diagnosis that will identify appropriate antibacterials to which the pathogenic organisms are sensitive. Therapy will largely depend on the type of bacteria, the route by which the bacteria reach the bone, the presence of any orthopaedic devices and the patient's ability to mount an immune response. Consequently, therapy often requires a combination of medical and surgical management. The aim of this review is primarily to assess the impact of different drug regimens on the total cost and to clarify the implications of various treatment options for patients with osteomyelitis. Thus, the review examines the link between the main categories of osteomyelitis and common pathogens, and provides additional comments on the aetiology and epidemiology of the condition. At present, there is a real shortage of high quality evidence to guide the decision-maker through the range of available options. One way to deal with the complexity and uncertainty surrounding the management of osteomyelitis is to develop treatment protocols leading to decision trees which will in turn systematically analyse the options available for treating patients with osteomyelitis. Consequently, we have developed a number of decision trees to show the range of options available and have applied these to the relatively simple problem of route of administration of antibacterials. However, even here the available data allow only relatively crude estimations of the costs and consequences of alternative regimens. Thus, the aim has been to provide structures that may help to set priorities for research based on the expected value of new information. In the absence of evidence, there are broadly 2 alternatives. One is based on selection of the least expensive regimen in the absence of evidence to prove that more expensive options are more effective; patients with multiply resistant staphylococci, for which no effective oral regimen is available, should be treated with intravenous therapy. This is consistent with the UK legal system, which is founded on the so-called Bolam test. The alternative is providing the maximum available treatment; in the US, it is more likely that a doctor will be held negligent for not providing the maximum available treatment, and most standard texts recommend routine use of intravenous therapy for osteomyelitis.

A rapidly expanding lesion in the neck: unusual presentation of Castleman's disease.

We report a painless but rapidly enlarging 9 cm x 4 cm lobulated hard neck mass. CT scanning suggested lymphoid tissue that was not confirmed by cytopathology. Histopathological analysis of the excision specimen detected Castleman's disease, extending to the resection margin. Postoperative radiotherapy was administered. The patient remains disease-free after 44 months.

Combined latissimus dorsi-serratus anterior/rib composite free flap in mandibular reconstruction.

The serratus anterior/rib composite flap can be used alone or in combination with a latissimus dorsi myocutaneous flap in mandibular reconstruction. The combined flap is particularly useful in reconstructing large anterior mandibular defects, and 4 cases are described which illustrate its use both as a pedicled flap and as a free tissue transfer.

Public release of performance data and quality improvement: internal responses to external data by US health care providers.

Health policy in many countries emphasises the public release of comparative data on clinical performance as one way of improving the quality of health care. Evidence to date is that it is health care providers (hospitals and the staff within them) that are most likely to respond to such data, yet little is known about how health care providers view and use these data. Case studies of six US hospitals were studied (two academic medical centres, two private not-for-profit medical centres, a group model health maintenance organisation hospital, and an inner city public provider "safety net" hospital) using semi-structured interviews followed by a broad thematic analysis located within an interpretive paradigm. Within these settings, 35 interviews were held with 31 individuals (chief executive officer, chief of staff, chief of cardiology, senior nurse, senior quality managers, and front line staff). The results showed that key stakeholders in these providers were often (but not always) antipathetic towards publicly released comparative data. Such data were seen as lacking in legitimacy and their meanings were disputed. Nonetheless, the public nature of these data did lead to some actions in response, more so when the data showed that local performance was poor. There was little integration between internal and external data systems. These findings suggest that the public release of comparative data may help to ensure that greater attention is paid to the quality agenda within health care providers, but greater efforts are needed both to develop internal systems of quality improvement and to integrate these more effectively with external data systems.

Trust in performance indicators?

The 1980s and 90s have seen the proliferation of all forms of performance indicators as part of attempts to command and control health services. The latest area to receive attention is health outcomes. Published league tables of mortality and other health outcomes have been available in the United States for some time and in Scotland since the early 1990s; they have now been developed for England and Wales. Publication of these data has proceeded despite warnings as to their limited meaningfulness and usefulness. The time has come to ask whether the remedy is worse than the malady: are published health outcomes contributing to quality efforts or subverting more constructive approaches? This paper argues that attempts to force improvements through publishing health outcomes can be counterproductive, and outlines an alternative approach which involves fostering greater trust in professionalism as a basis for quality enhancements.

Reviewing audit: barriers and facilitating factors for effective clinical audit.

OBJECTIVE: To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process. DESIGN: A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of "audit", "audit of audits", and "evaluation of audits" and a handsearch of the indexes of relevant journals for key papers. RESULTS: Findings from 93 publications were reviewed. These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care. The studies reviewed incorporated the experiences of a wide variety of clinicians, from medical consultants to professionals allied to medicine and from those involved in unidisciplinary and multidisciplinary ventures. Perceived benefits of audit included improved communication among colleagues and other professional groups, improved patient care, increased professional satisfaction, and better administration. Some disadvantages of audit were perceived as diminished clinical ownership, fear of litigation, hierarchical and territorial suspicions, and professional isolation. The main barriers to clinical audit can be classified under five main headings. These are lack of resources, lack of expertise or advice in project design and analysis, problems between groups and group members, lack of an overall plan for audit, and organisational impediments. Key facilitating factors to audit were also identified: they included modern medical records systems, effective training, dedicated staff, protected time, structured programmes, and a shared dialogue between purchasers and providers. CONCLUSIONS: Clinical audit can be a valuable assistance to any programme which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at nurturing effective audits, valuable opportunities will be lost. Paying careful attention to the professional attitudes highlighted in this review may help audit to deliver on some of its promise.

Performance management using health outcomes: in search of instrumentality.

The past decade has seen the growing use of performance data in the hope of bringing about quality improvements in health care. Most recently, an emphasis on health outcomes (and especially mortality rates) has led to much activity around collecting and publishing such data. Two major problems intervene. What meanings can be ascribed to reported health outcomes? And what impacts are they likely to have on clinical performance? Much empirical work supports the assertion that reported outcomes may be poor indicators of service quality. In addition, the impact of these data may be small or even detrimental unless great care is made to connect the reporting with explicit quality-improving actions.

Exploring the pathology of quality failings: measuring quality is not the problem--changing it is.

The USA can boast a long history of investigation into quality failings in health care. From Ernest Codman and Abraham Flexner in the opening decades of this century through to the intense activity of the 1980s and 1990s, much careful study has exposed extraordinary and at times scandalous deficiencies in the quality of care (Millenson 1997; Chassin & Galvin 1998; Schuster et al. 1998). Yet we are still far from developing 'industrial strength' quality in health care: in all but a few isolated areas, such as general anaesthesia, 'six sigma quality' (i.e. a handful of errors per million) seems wishful thinking (Chassin 1998). Pockets of excellence and innovation notwithstanding, the dominant experience of the past two decades has been an increasing ability to document quality failings and a seeming inability to mobilize effective action (Coye & Detmer 1998). The rich literature on health-care quality that has sprung up over the past few decades has largely failed to provide a clear direction for quality improvement activity. This paper analyses some of the reasons why this might be so. Contrasting the relative absence of progress on health-care quality with the relative success of disease epidemiology provides some illuminating parallels. In essence, study of the quality of care has focused largely on providing a 'descriptive epidemiology'. Much more work is needed yet to unravel the underlying pathology of quality failings, in order to empower development of an 'aetiological epidemiology' of quality in health care. Such understanding is essential as a precursor to targeted and effective preventative and remedial action.

Public trust and accountability for clinical performance: lessons from the national press reportage of the Bristol hearing.

The General Medical Council hearing into events at the Bristol Royal Infirmary resulted in verdicts of serious professional misconduct against three senior doctors. After the longest-running hearing in the GMC's history the press response was fierce. This paper reviews the reporting of the Bristol case (and issues arising from it) in the main broadsheet and tabloid national newspapers (dailies and Sundays) in the 5-week period around the GMC's delivery of the verdicts and subsequent sentencing. The aim was to describe the main themes emerging from the press coverage and to assess the implications for future debates over clinical performance and accountability. Media interest in the Bristol case was intense (184 published items in 5 weeks). The reporting was emotive and largely hostile, raising doubts about not just isolated lapses of care but also the possibility of more systematic failings. Diminished trust and reduced public confidence were recurrent themes, powerfully expressed. Professional self-regulation received scathing criticism, with calls for more public access to individual performance data. Future debates about clinical governance will need to take account of the new public context in the wake of Bristol. Arguments about the relative merits of self-regulation or data-driven performance management systems now need to be played out for a knowing and openly sceptical print media.

Interpreting health outcomes.

Interest in outcomes is universal. To patients, good outcomes represent their highest hopes for therapy; to health care professionals, good outcomes are the desired end-point of a complex web of care. More recently, politicians and health care managers too have shifted their emphasis away from health service activity and towards what is termed 'health gain'. The rise of the outcomes movement appears irresistible. However, the difficulties in interpreting outcomes data will not go away. Outcomes measured using routine data are subject to numerous biases and many practical difficulties. Despite recent statistical, methodological and technological advances, comparisons of outcomes at best provide us with weak evidence of either the effectiveness or the quality of health care. And sometimes they may frankly mislead. The apparent intuitiveness of outcomes monitoring has broad public appeal. But enthusiasm for outcomes needs to be tempered with a clear understanding of their limitations.