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The First Comprehensive Survey of the Practice of Postoperative Pain Management in Hungarian Hospitals – a Descriptive Study

Open AccessPublished:January 13, 2023DOI:https://doi.org/10.1016/j.pmn.2022.12.001

      Abstract

      Background

      Pain management is a key issue in health care. Providers adopt promising technological developments, like Acute Pain Service, at differing speeds, with countries, such as the USA and Germany taking the lead. Where Hungary stands is unknown, as the practice of pain management has not yet been comprehensively reviewed in that country.

      Aim

      To explore the practice of postoperative pain management in Hungarian hospitals by addressing the questions of who is responsible for it, who measures pain and how, what kind of pain relief technologies are used, and who takes care of patients during duty hours.

      Methods

      We carried out a survey covering Hungarian hospitals with operational license for surgery, traumatology, orthopedics and anesthesiology between December 2019 and March 2020. The response rate was 72%, and we analyzed 135 questionnaires.

      Results

      We identified only 2 hospitals with an Acute Pain Service. In the majority of hospitals, the attending physician orders pain relief therapy. During duty hours the surgeon on duty takes care of pain management in 52.1% of the cases. Among pain relief therapies, intravenous infusions (74.1%) and oral medication (67.4%) are the most frequent. Ward nurses measure postoperative pain (77.8%) with unidimensional scales. According to 59.7% of the respondents, pain is not measured and documented at rest. Written protocols are available in 34.4% of the departments.

      Conclusions

      Compared with other countries, pain management in Hungary lags behind with significant room for improvement. Development and implementation of pain management protocols with appropriate education is the key intervention point.

      Keywords

      Postoperative pain management is a key issue in contemporary health care, and its significance is increasing with the increasing number of surgical interventions worldwide. In the United States, the estimated number of operations ranges from 48 to 100 million per year (
      • Coluzzi F.
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      Postoperative pain surveys in Italy from 2006 and 2012: (POPSI and POPSI-2).
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      • Habib A.S.
      • Miller T.E.
      • White W.
      • Apfelbaum J.L.
      Incidence, patient satisfaction, and perceptions of post-surgical pain: Results from a US national survey.
      ;
      • Petti E.
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      • Van Cleave J.H.
      • Reid M.C.
      Can multidimensional pain assessment tools help improve pain outcomes in the perianesthesia setting?.
      ;
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      Causes and consequences of inadequate management of acute pain.
      ;
      • Zaccagnino M.P.
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      • Sang C.N.
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      The perioperative surgical home: A new role for the acute pain service.
      ). In light of these high numbers, and their implications on health care organizations, resource use, quality of life, and productivity, it is not surprising that postoperative pain management is considered an important health, economic, and social issue (
      • Pozek J.J.
      • De Ruyter M.
      • Khan T.W.
      Comprehensive acute pain management in the perioperative surgical home.
      ).
      Postoperative pain is a common issue that poses a challenge to the health care staff caring for surgical patients (
      • Stamer U.M.
      • Mpasios N.
      • Stüber F.
      • Maier C.
      A survey of acute pain services in Germany and a discussion of international survey data.
      ;
      • Webb C.A.J.
      • Kim T.E.
      Establishing an acute pain service in private practice and updates on regional anesthesia billing.
      ). Several studies have already established that the bulk of patients experience medium level or severe pain after operations (
      • Gan T.J.
      • Habib A.S.
      • Miller T.E.
      • White W.
      • Apfelbaum J.L.
      Incidence, patient satisfaction, and perceptions of post-surgical pain: Results from a US national survey.
      ;
      • Park R.
      • Mohiuddin M.
      • Arellano R.
      • Pogatzki-Zahn E.
      • Klar G.
      • Gilron I.
      Prevalence of postoperative pain following hospital discharge: Protocol for a systematic review.
      ;
      • Rockett M.
      • Vanstone R.
      • Chand J.
      • Waeland D.
      A survey of acute pain services in the UK.
      ;
      • Sinatra R.
      Causes and consequences of inadequate management of acute pain.
      ;
      • van Boekel R.L.M.
      • Bronkhorst E.M.
      • Vloet L.
      • Steegers M.A.M.
      • Vissers K.C.P.
      Identification of preoperative predictors for acute postsurgical pain and for pain at three months after surgery: A prospective observational study.
      ;
      • Wikström L.
      • Nilsson M.
      • Eriksson K.
      The association of patients' daily summarized self-rated "real-time" pain scores with physical recovery after major surgery - A repeated measurement design.
      ;
      • Yazıcı G.
      • Yılmaz K.
      • Bulut H.
      • Ömer Kaşıkçı H.
      • Palteki T.
      • Karabulut A.B.
      • Memişoğlu K.
      The prevalence of pain in the first 24 hours after surgery: A multicenter study.
      ). A Dutch study estimated this to be over 75% (
      • van Boekel R.L.M.
      • Steegers M.A.H.
      • Verbeek-van Noord I.
      • van der Sande R.
      • Vissers K.C.P.
      Acute pain services and postsurgical pain management in the Netherlands: A survey.
      ), while another study found that over 70% of those patients, who had postoperative pain, experienced this as medium or grave (
      • Park R.
      • Mohiuddin M.
      • Arellano R.
      • Pogatzki-Zahn E.
      • Klar G.
      • Gilron I.
      Prevalence of postoperative pain following hospital discharge: Protocol for a systematic review.
      ). After certain procedures, such as thoracotomy, mastectomy, and coronary bypass, 30% to 50% of patients developed persistent, chronic pain (
      • Polanco-García M.
      • García-Lopez J.
      • Fàbregas N.
      • Meissner W.
      • Puig M.M.
      Postoperative pain management in Spanish hospitals: A cohort study using the PAIN-OUT Registry.
      ;
      • Rawal N.
      Current issues in postoperative pain management.
      ). Similar figures have been reported in a study of Asian patients, showing the prevalence of postoperative pain to be more than 80% (
      • Subramanian P.
      • Ramasamy S.
      • Ng K.H.
      • Chinna K.
      • Rosli R.
      Pain experience and satisfaction with postoperative pain control among surgical patients.
      ).
      Patients consider pain relief very important (
      • Le-Wendling L.G.W.
      • Tighe P
      Goals and objectives to optimize the value of an acute pain service in perioperative pain management.
      ). Postoperative pain detrimentally affects the quality of life of patients (
      • Fang H.
      • Liang J.
      • Hong Z.
      • Sugiyama K.
      • Nozaki T.
      • Kobayashi S.
      • Sameshima T.
      • Namba H.
      • Asakawa T.
      Psychometric evaluation of the Chinese version of the revised American Pain Society Patient Outcome Questionnaire concerning pain management in Chinese orthopedic patients.
      ), by, for example, reducing their mobility, which in turn has an adverse effect on respiration, decreases the oxygenation of the body, and may result in pneumonia (
      • Hayes K.
      • Gordon D.B.
      Delivering quality pain management: The challenge for nurses.
      ;
      • Park R.
      • Mohiuddin M.
      • Arellano R.
      • Pogatzki-Zahn E.
      • Klar G.
      • Gilron I.
      Prevalence of postoperative pain following hospital discharge: Protocol for a systematic review.
      ;
      • Petti E.
      • Scher C.
      • Meador L.
      • Van Cleave J.H.
      • Reid M.C.
      Can multidimensional pain assessment tools help improve pain outcomes in the perianesthesia setting?.
      ). Further problems may arise from the treatment of pain, or its lack thereof, such as the common side effects of nausea, tiredness, and drowsiness (
      • Meissner W.
      • Mescha S.
      • Rothaug J.
      • Zwacka S.
      • Goettermann A.
      • Ulrich K.
      • Schleppers A.
      Quality improvement in postoperative pain management: results from the QUIPS project.
      ), or chronic postoperative pain, which can be the result of inadequately managed pain (
      • Meissner W.
      • Mescha S.
      • Rothaug J.
      • Zwacka S.
      • Goettermann A.
      • Ulrich K.
      • Schleppers A.
      Quality improvement in postoperative pain management: results from the QUIPS project.
      ;
      • Park R.
      • Mohiuddin M.
      • Arellano R.
      • Pogatzki-Zahn E.
      • Klar G.
      • Gilron I.
      Prevalence of postoperative pain following hospital discharge: Protocol for a systematic review.
      ;
      • Pozek J.J.
      • De Ruyter M.
      • Khan T.W.
      Comprehensive acute pain management in the perioperative surgical home.
      ). In addition to its health effects, inadequate pain management also increases costs, for instance by longer length of stay and the high costs of treating complications (
      • Hayes K.
      • Gordon D.B.
      Delivering quality pain management: The challenge for nurses.
      ;
      • Meissner W.
      • Mescha S.
      • Rothaug J.
      • Zwacka S.
      • Goettermann A.
      • Ulrich K.
      • Schleppers A.
      Quality improvement in postoperative pain management: results from the QUIPS project.
      ;
      • Petti E.
      • Scher C.
      • Meador L.
      • Van Cleave J.H.
      • Reid M.C.
      Can multidimensional pain assessment tools help improve pain outcomes in the perianesthesia setting?.
      ;
      • Pozek J.J.
      • De Ruyter M.
      • Khan T.W.
      Comprehensive acute pain management in the perioperative surgical home.
      ;
      • Torabi Khah M.
      • Yousefi H.
      • Monazami Ansari A.H.
      • Musarezaie A.
      Prevalence of postoperative nausea and vomiting and pain in patients undergoing elective orthopaedic surgery in Iran.
      ).
      One of the reasons for the high prevalence of severe postoperative pain is the inadequacy of pain relief. According to a 2017 Croatian survey, one-third of traumatology patients were not involved in the assessment of their pain, and the pain of 40.4% of them wase measured only occasionally (
      • Farčić N.
      • Barać I.
      • Pačarić S.
      • Lovrić I.
      • Ilakovac V.
      Acute postoperative pain in trauma patients - The fifth vital sign.
      ). Furthermore, in Poland in 2018 pain was not regularly assessed using any validated scale (
      • Piotrkowska R.
      • Jarzynkowski P.
      • Mędrzycka-Dąbrowska W.
      • Terech-Skóra S.
      • Kobylarz A.
      • Książek J.
      Assessment of the quality of nursing care of postoperative pain in patients undergoing vascular procedures.
      ) in half of patients. The importance of using validated scales for pain assessment has been shown by a recent study, where 160 patients reported higher pain scores estimated by nurses (
      • Yang Y.E.
      • Xiong C.
      • Xia L.
      • Kang S.S.
      • Jian J.J.
      • Yang X.Q.
      • Chen L.
      • Wang Y.
      • Yu J.J.
      • Xu X.Z.
      Consistency of postoperative pain assessments between nurses and patients undergoing enhanced recovery after gynaecological surgery.
      ).
      One of the most important components of pain management is regular pain assessment and its documentation, in which nurses should play a key role (
      • Hoogervorst-Schilp J.
      • van Boekel R.L.
      • de Blok C.
      • Steegers M.A.
      • Spreeuwenberg P.
      • Wagner C.
      Postoperative pain assessment in hospitalised patients: National survey and secondary data analysis.
      ). Recent reports suggest that the documentation regarding pain assessment and treatment might be insufficient in some cases (
      • Rababa M.
      • Al-Sabbah S.
      • Hayajneh A.A.
      Nurses’ perceived barriers to and facilitators of pain assessment and management in critical care patients: A systematic review.
      ;
      • Shoqirat N.
      • Mahasneh D.
      • Dardas L.
      • Singh C.
      • Khresheh R.
      Nursing documentation of postoperative pain management: A documentary analysis.
      ), however these skills can be improved by training and education (
      • Dang H.
      • Stafseth S.K.
      Documentation for assessing pain in postoperative pain management pre- and post-intervention.
      ). Because documentation requirements are usually declared in pain treatment protocols, the presence of written protocols contribute to pain management efficacy (
      • Gonzales A.
      • Mari M.
      • Alloubani A.
      • Abusiam K.
      • Momani T.
      • Akhu-Zaheya L.
      The impact of a standard pain assessment protocol on pain levels and consumption of analgesia among postoperative orthopaedic patients.
      ).
      In Hungary adequate pain management is not only an ethical imperative for health professionals, but also a legal obligation defined by Article 98, section (2), point b) of Act CLIV on Health (
      • Hungarian National Assembly
      Act CLIV on Health.
      ). Most people, either as a patient or relative, face this problem at least once in their life. Unfortunately, we know very little about the topic, as no comprehensive survey has been carried out so far in Hungary about the practice of pain management in Hungarian health care providers.
      To explore, where Hungary stands in terms of postoperative pain management, first, we wanted to implement a comprehensive review of its practice by identifying which professionals are involved in the treatment of pain, who measures pain, how frequently, and with what pain measurement tools; what roles nurses play in the process; what kind of pain relief methods are in use; who takes care of patients during duty hours; as well as how much pain relief activities are regulated in the hospital. Second, we wanted to know, how many hospitals had actually adopted the Acute Pain Service (APS) technology to organize and operate pain relief, and what their main characteristics were regarding the number and composition of doctors and other health professionals in the pain team, the process and documentation of pain management, as well as the protocols, which are applied to guide their work. The review of the current situation can provide an excellent basis to identify both good practices that can be rolled out countrywide, and problems or shortcomings to be faced with and addressed.
      To answer these questions, we have carried out a survey among Hungarian hospitals from the end of 2019 to early 2020. Our findings regarding APS have already been published elsewhere (
      • Lovasi O.
      • Lam J.
      • Schutzmann R.
      • Gaal P.
      Acute Pain Service in Hungarian hospitals.
      ). Most importantly we have identified only two hospitals with a functioning APS, which reinforced our earlier impression that the technology has hardly been adopted in Hungary so far (
      • Lovasi O.
      • Lám J.
      • Kósik N.
      Az akutfájdalom-kezelő szolgálat szerepe a műtét utáni fájdalomcsillapításban.
      ). The objective of this paper is to provide a comprehensive review of postoperative pain management in Hungary in all hospitals regardless of whether or not they have an APS, since the fundamental questions about the process of pain management (who, what, how) apply to all institutions and departments, which have to care for patients experiencing postoperative pain. In this paper we first summarize the methodology of the survey, describe its results, and discuss them in the context of the international literature.

      Methods

      To meet our objectives, we designed and implemented a survey among Hungarian hospitals providing services in surgery, traumatology, orthopedics, and anesthesiology, regardless of their ownership or financing status. Given that on the basis of our earlier research we assumed that APS was not widespread in the Hungarian health system, it was important to include surgical specialties in addition to anesthesiology. The sampling frame was provided by the National Public Health Center, the authority responsible for issuing operational licenses to health care providers. We compiled the questionnaire on the basis of the literature, and after a pilot testing and ethical approval of our study, we sent it out to the identified hospitals. Participation in the survey was entirely voluntary and no financial compensation was paid to the respondents. The data collection period lasted from December 2019 to March 2020. The questionnaire covered three topics: (1) institution related data; (2) postoperative pain assessment, treatment, and documentation related data; and (3) postoperative pain management policy and protocol related data (Table 1). The questionnaire had to be filled out by a representative of the surgery, traumatology, orthopedics, and anesthesiology departments separately. This meant that we expected to receive minimum 2 and maximum 4 filled in questionnaires per hospital.
      Table 1The Structure and Main Topics of the Questionnaire
      TopicQuestionsOther information
      Institution related data
      • 1.
        Position of respondent professional
      Single-choice closed question
      Postoperative pain assessment, treatment, and documentation related data
      • 1.
        Methods used for postoperative pain treatment
      • 2.
        Person responsible for prescribing pain treatment for the first 24 hours
      • 3.
        Ward RNs allowed to administer IV-PCA boluses
      • 4.
        Ward RNs allowed to adjust IV-PCA boluses
      • 5.
        Ward RNs allowed to administer epidural boluses
      • 6.
        Ward RNs allowed to adjust epidural boluses
      • 7.
        Ward RNs allowed to administer peripheral nerve block pump boluses
      • 8.
        Person responsible for after-hours postoperative pain management
      • 9.
        Pain assessment tool
      • 10.
        Pain assessment person
      • 11.
        Pain assessment at rest
      • 12.
        Pain assessment with movement
      • 13.
        Frequency of postoperative pain assessment
      • 14.
        Documentation of pain assessment
      Multiple-choice closed question with free text option

      Multiple-choice closed question with free text option

      Single-choice closed question

      Single-choice closed question

      Single-choice closed question

      Single-choice closed question

      Single-choice closed question

      Multiple-choice closed question with free text option

      Multiple-choice closed question with free text option

      Multiple-choice closed question with free text option

      Yes-no question

      Yes-no question

      Multiple-choice closed question with free text option

      Single choice closed question
      Postoperative pain management policy and protocol related data
      • 1.
        Written protocol for postoperative pain management (presence and content)
      • 2.
        Hospital meetings or training courses on postoperative pain management
      • 3.
        Person providing instruction for the courses or meetings


      Yes-no questions

      Yes-no questions

      Multiple-choice closed question with free text option
      RN = registered nurse; IV-PCA = intravenous patient-controlled analgesia.
      The statistical analysis of the responses was carried out by the Statistical Package for the Social Sciences (SPSS) version 24.0 (IBM Corp., Armonk, NY, USA). The details of sampling, data collection and analysis can be found in another publication, which presented, analyzed, and discussed the findings of this survey regarding APS (
      • Lovasi O.
      • Lam J.
      • Schutzmann R.
      • Gaal P.
      Acute Pain Service in Hungarian hospitals.
      ).
      At the time of our survey there were 72 hospitals operating in Hungary, which met the inclusion criteria. Since most of these hospitals had more than one of the listed specialties covered, and we asked each hospital to fill in a separate questionnaire for each specialty, we got back 135 analyzable questionnaires from 52 hospitals. Our sample therefore covers 72.2% of institutions providing inpatient care in the listed surgical specialties. Unfortunately, not all questionnaires were 100% complete. Because of the missing answers, the number of responses that could be analyzed did not always add up to 135. The actual number of answers that could be included in the analysis is represented with “N” at each question. As far as the respondents are concerned, their distribution according to position is shown in Figure 1. Heads of departments constitute the largest part of our sample with 60.2%, followed by specialists, and head nurses, with 20.3% and 9%, respectively. We refer the reader to the aforementioned publication for further details on the composition of our sample (
      • Lovasi O.
      • Lam J.
      • Schutzmann R.
      • Gaal P.
      Acute Pain Service in Hungarian hospitals.
      ).
      Figure 1
      Figure 1The distribution of survey respondents according to position (N=133).

      Results

      In Hungary, out of the 52 responding hospitals, there are 2 hospitals, which have APS. The characteristics of these pain teams are described, analyzed, and discussed in detail elsewhere (
      • Lovasi O.
      • Lam J.
      • Schutzmann R.
      • Gaal P.
      Acute Pain Service in Hungarian hospitals.
      ). The analysis included all 52 hospitals and all the valid answers to the items of all the 135 questionnaires. As we will see, APS plays only a minor role, because of the limited number of hospitals, which have already adopted the method.

      Health Care Staff, who Administer Postoperative Pain Relief, and the Most Frequently Applied Methods

      According to our respondents it is the attending physician (73.3%) and the anesthesiologist (69.6%), who most frequently order pain therapy for the first 24 hours after an operation, while the APS pain team is mentioned least frequently with 1.5% (N = 135). In this case, multiple answers were allowed and 55.6% of our sample chose only one specialist (attending physician or anesthesiologist), while 44.4% chose two (attending physician and anesthesiologist) (Table 2).
      Table 2Who is responsible for postoperative pain management in the first 24 hours after the operation? (N = 135)
      Person Responsible for Postoperative Pain Management in the First 24 HoursNumber of Respondents% of Respondents (n = 135)
      Attending physician9973.3%
      Anesthesiologist9469.6%
      APS team21.5%
      APS = acute pain service.
      Regarding pain therapies, respondents could pick multiple answers, too (Table 3). The first three most frequently mentioned options are intravenous infusion (74.1%), oral medication (67.4%), and intravenous bolus (57.8%). On average 3.8 (±1.97 SD) methods are used by the hospital departments (N = 135).
      Table 3The Share of Pain Relief Methods Used (percentage, multiple answers were allowed N = 135)
      MethodProportion of Respondents Using the Method
      IV infusion74.1%
      Per os medicine67.4%
      IV bolus57.8%
      SC/IM. injection57.0%
      EDA perfusor50.4%
      IV bolus using EDA cannula32.6%
      PNB pump18.5%
      IV-PCA14.6%
      Other4.4%
      IV = intravenous; SC/IM = subcutaneous/intramuscular; EDA = epidural analgesia; PNB = peripheral nerve block; IV-PCA = intravenous patient-controlled analgesia.

      Responsibilities of Nursing Professionals

      To explore the role of nursing professionals we asked how much nurses were involved in certain pain relief therapies either independently or on doctors’ orders. The results are presented in Table 4. First, the relevant therapies are used by less than half of our sample. Epidural analgesia (EDA) is the most prevalent, both the setting of the pump (47.7%) and the administering of boluses into the pump (49.2%). It is followed by intravenous patient-controlled analgesia (IV-PCA) with 30.8% for administering boluses into the pump and 26.2% for setting the pump, while the administering of boluses into the pump of peripheral nerve blockade (PNB) is the last, with 21.5%. Second, when it comes to the involvement of nursing professionals, they are hardly allowed to make decisions independently (1.5%-4.6%), however, only a small number are fully excluded to apply these methods (0%-1.5%). Usually, nurses carry out the tasks based on doctors’ orders (20%-43.8%).
      Table 4Nursing Responsibilities in Administering Pain Relief Therapies (N = 130)
      MethodNot UsedPhysicians

      Order
      Decision by the NurseNot Allowed for Nurses
      IV-PCA bolus69.2%26.9%3.8%0%
      IV-PCA pump adjustment73.8%22.3%2.3%1.5%
      EDA bolus50.8%43.1%4.6%1.5%
      EDA pump adjustment52.3%43.8%3.8%0%
      PNB pump78.5%20%1.5%0%
      IV-PCA = intravenous patient-controlled analgesia; EDA = epidural analgesia; PNB = peripheral nerve block.

      Pain Relief During Duty Hours

      Next, we wanted to identify the health professionals who were involved in managing pain during out of hours and the weekend. Multiple options were available and the departmental representatives, who completed the questionnaire (N = 135), on average chose 1.7 (±0.89 SD) answers. Over one-third of the respondents picked one professional (35.6%), another 35.6% went for two, 21.5% chose three or more, while 7.3% did not answer. Among the respondents with a single answer, over half said that it was the doctor on duty (52.1%, n = 25), followed by the ward nurse with 16.7% (n = 8). Among the respondents with two choices, roughly half said that it was the combination of the surgeon on duty and the ward nurse (47.9%, n = 23), while according to the other half, it was the combination of the former and the anesthesiologist on telephone duty (43.8%, n = 21).

      Pain Assessment

      Next, we explored the pain measurement tools in use. The respondents chose 1.5 options (±0.86 SD) on average (N = 135). The subjective assessment of postoperative pain was indicated in 36.3% of the sample. The most frequently mentioned pain measurement tool was the Visual Analogue Scale (VAS) with 37.0% (Table 5).
      Table 5The Percentage Distribution of Scales to Measure Postoperative Pain According to Their Prevalence (N = 135)
      Pain Assessment MethodsNumber of Respondents% of Respondents (n = 135)
      Visual Analog Scale5037.0%
      Numeric Rating Scale3022.2%
      Verbal Descriptor Scale4433.6%
      Face Scale2317.0%
      Subjective assessment4936.3%
      According to 77.8% of the respondents, the ward nurse carries out the assessment of pain and 2.2% of the respondents indicated that the APS assesses pain (N = 135). In most of the departments, postoperative pain is not measured on a regular basis, either at rest (59.7%), or during activity (65.9%, N = 129). As far as the first 24 hours after the operation are concerned, we emphasize that 32.8% of our sample only occasionally assess the pain of patients (N = 130), while 9.9% gave other answers, such as ”it depends on the patient and the operation”, ”cases are decided on an individual basis”, or ”I do not know” (Fig 2).
      Figure 2
      Figure 2The frequency of pain measurement during the first 24 hours after the operation, percentage (N=130).
      We also addressed the question of recording the measured values. We found that the documentation was comprehensive in 23.7% of our sample, partial in 56.5%, while 19.8% did not record their findings at all (N = 131).

      The Internal Regulation of the Management of Postoperative Pain

      We found that a written protocol was available in 34.4% of the surveyed hospital departments, while 65.6% of the respondents claimed that their institution had no such document, which would guide the practice of pain management (N = 131). We asked the respondents to specify the content of the protocol if it was available. According to their answers, almost all of the documents include the options of pharmaceutical therapies (97%), and 90% designate the persons who prescribe the pain relief treatment. The frequency of pain measurement is determined in 77% of the protocols, and 70% define the threshold that warrants an intervention. The least frequently mentioned components were the enumeration of nonpharmaceutical treatment options (37.5%) and the education and training of staff members (17.5%).
      Professional training, including meetings and educational programs, are available in 28.9% of the responding departments (N = 128), which are almost exclusively led by anesthesiologists (91.9%, N = 37). The participants mostly consist of anesthesiologists, specialists of surgical departments, young doctors in residency training, and nurses.

      Discussion

      Our study is the first of its kind to comprehensively review the practice of postoperative pain management in Hungarian hospitals, according to the characteristics deemed important by the literature. We consider an important achievement that close to three-quarters of the relevant surgical inpatient care providers participated in the survey and that over 60% of the respondents were heads of departments, who actually filled in the questionnaire. We are convinced that their participation increases the validity of our findings, because they are responsible for the operation of their departments and have a comprehensive view, oversight and awareness of its activities. Further, such a response rate is especially remarkable in light of the chronic human resource shortages of the Hungarian health system, which makes every additional task over and above patient care increasingly difficult to undertake (
      • Gaál P.
      • Szigeti S.
      • Panteli D.
      • Gaskins M.
      • van Ginneken E.
      Major challenges ahead for Hungarian healthcare.
      ;
      • Girasek E.
      • Szócska M.
      • Kovács E.
      • Gaál P.
      The role of controllable lifestyle in the choice of specialisation among Hungarian medical doctors.
      ). The willingness of the health care staff to participate in our survey, thus might indirectly signify that they consider the topic of the study important, which in itself constitutes a good starting point on the basis of which the development of clinical practice can be built.

      Specialties Involved in Postoperative Pain Management

      Appropriate pain relief requires knowledge and understanding of the various types of pain, medications, and multimodal or regional anesthesia, which are possessed by anesthesiologists at best (
      • Le-Wendling L.G.W.
      • Tighe P
      Goals and objectives to optimize the value of an acute pain service in perioperative pain management.
      ). In addition, effective pain management is unimaginable without the regular measurement and documentation of pain scores, the education of patients on the benefits and side effects of pain relief technologies, and the measurement and documentation of patient satisfaction (
      • Sinatra R.
      Causes and consequences of inadequate management of acute pain.
      ). At the same time, the health professionals responsible for pain management should be in close cooperation with the surgical specialists, which is also a prerequisite to better monitor patient status and achieve better outcomes in terms of pain relief (
      • Boezaart A.P.
      • Munro A.P.
      • Tighe P.J.
      Acute pain medicine in anesthesiology.
      ). All these requirements are best met with the establishment of multidisciplinary pain teams, that is an APS, as has been demonstrated by several studies. An APS increases patient safety, patient satisfaction, and decreases length of stay (
      • Buckenmaier III, C.
      • Mahoney P.F.
      • Anton T.
      • Kwon N.
      • Polomano R.C
      Impact of an acute pain service on pain outcomes with combat-injured soldiers at Camp Bastion, Afghanistan.
      ;
      • Lee A.
      • Chan S.K.
      • Chen P.P.
      • Gin T.
      • Lau A.S.
      • Chiu C.H.
      The costs and benefits of extending the role of the acute pain service on clinical outcomes after major elective surgery.
      ;
      • Rawal N.
      Current issues in postoperative pain management.
      ;
      • Rockett M.
      • Vanstone R.
      • Chand J.
      • Waeland D.
      A survey of acute pain services in the UK.
      ;
      • van Boekel R.L.M.
      • Steegers M.A.H.
      • Verbeek-van Noord I.
      • van der Sande R.
      • Vissers K.C.P.
      Acute pain services and postsurgical pain management in the Netherlands: A survey.
      ;
      • Wheatley R.G.
      • Madej T.H.
      • Jackson I.J.
      • Hunter D.
      The first year's experience of an acute pain service.
      ). It has an important role to diminish the side effects of pain relief, such as nausea and vomiting (
      • Wheatley R.G.
      • Madej T.H.
      • Jackson I.J.
      • Hunter D.
      The first year's experience of an acute pain service.
      ), to increase pain management knowledge among health professionals by coordinating education and further training (
      • van Boekel R.L.M.
      • Steegers M.A.H.
      • Verbeek-van Noord I.
      • van der Sande R.
      • Vissers K.C.P.
      Acute pain services and postsurgical pain management in the Netherlands: A survey.
      ;
      • Wheatley R.G.
      • Madej T.H.
      • Jackson I.J.
      • Hunter D.
      The first year's experience of an acute pain service.
      ), as well as to develop pain management protocols, to carry out pain management research, and to contribute to the organization of clinical audits, which evaluates the implementation of these protocols (
      • van Boekel R.L.M.
      • Steegers M.A.H.
      • Verbeek-van Noord I.
      • van der Sande R.
      • Vissers K.C.P.
      Acute pain services and postsurgical pain management in the Netherlands: A survey.
      ;
      • Webb C.A.J.
      • Kim T.E.
      Establishing an acute pain service in private practice and updates on regional anesthesia billing.
      ).
      It seems obvious that the adoption of APS is the way forward in pain management, yet our findings show that it is mainly the specialist, who carried out the operation (i.e., the doctor in charge of the patient), responsible for ordering the pain treatment in Hungary, and pain teams play only a minor role with only two hospitals using this technology at all. Of course, this raises the question, whether or not surgical specialists and ward nurses really have the necessary knowledge and skills to manage pain relief in a comprehensive manner and perform a full range of pain relief activities, in the absence of APS and anesthesiology support.

      The Deployment of Pain Relief Methods

      As far as the methods of pain therapy are concerned, it is positive that the Hungarian respondents use a mix of technologies. Nevertheless, this mix involves intramuscular and subcutaneous injections in more than half of the cases, despite that one of the fundamental quality indicators of pain relief is the deployment of modern methods of anesthesiology and the avoidance of intramuscular injections (
      • Chou R.
      • Gordon D.B.
      • de Leon-Casasola O.A.
      • Rosenberg J.M.
      • Bickler S.
      • Brennan T.
      • Carter T.
      • Cassidy C.L.
      • Chittenden E.H.
      • Degenhardt E.
      • Griffith S.
      • Manworren R.
      • McCarberg B.
      • Montgomery R.
      • Murphy J.
      • Perkal M.F.
      • Suresh S.
      • Sluka K.
      • Strassels S.
      • Thirlby R.
      • Viscusi E.
      • Walco G.A.
      • Warner L.
      • Weisman S.J.
      • Wu C.L.
      Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.
      ;
      • Gordon D.B.
      • Polomano R.C.
      • Pellino T.A.
      • Turk D.C.
      • McCracken L.M.
      • Sherwood G.
      • Paice J.A.
      • Wallace M.S.
      • Strassels S.A.
      • Farrar J.T.
      Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults: Preliminary psychometric evaluation.
      ). According to our findings neither EDA, nor patient controlled technologies are among the frequently used methods. In contrast, a German survey has found that 88% of hospitals used EDA in all types of departments, even including hospitals without APS (
      • Erlenwein J.
      • Koschwitz R.
      • Pauli-Magnus D.
      • Quintel M.
      • Meißner W.
      • Petzke F.
      • Stamer U.M.
      A follow-up on Acute Pain Services in Germany compared to international survey data.
      ). Several advantages of the deployment multimodal techniques have already been published, such as the diminishing use of opioids, reduced length of stay, fewer surgical complications, as well as the more effective and safer drug use, based on the synergies of active substances (
      • Goldberg S.F.
      • Pozek J.J.
      • Schwenk E.S.
      • Baratta J.L.
      • Beausang D.H.
      • Wong A.K.
      Practical management of a regional anesthesia-driven acute pain service.
      ;
      • Pozek J.J.
      • De Ruyter M.
      • Khan T.W.
      Comprehensive acute pain management in the perioperative surgical home.
      ;
      • Sullivan D.
      • Lyons M.
      • Montgomery R.
      • Quinlan-Colwell A.
      Exploring opioid-sparing multimodal analgesia options in trauma: A nursing perspective.
      ).
      It is not yet known what the barriers to deployment modern technologies are in Hungary. All the factors described in the literature, such as access problems, the resistance of the health care staff (
      • Coluzzi F.
      • Mattia C.
      • Savoia G.
      • Clemenzi P.
      • Melotti R.
      • Raffa R.B.
      • Pergolizzi Jr, J.V.
      Postoperative pain surveys in Italy from 2006 and 2012: (POPSI and POPSI-2).
      ), the more complicated operation (compared to the use of simple infusions), which requires more knowledge and effort on the part of health professionals, or the fact that patients have to be educated, as well (
      • Coluzzi F.
      • Mattia C.
      • Savoia G.
      • Clemenzi P.
      • Melotti R.
      • Raffa R.B.
      • Pergolizzi Jr, J.V.
      Postoperative pain surveys in Italy from 2006 and 2012: (POPSI and POPSI-2).
      ), may play a role.

      Nursing Competencies and Responsibilities

      Our findings show that the potential of nursing professionals are hardly capitalized on in pain management by Hungarian hospitals. First, those modern pain relief technologies, which can be implemented with the greater involvement and responsibility of nurses, are not widespread. Second, even in the hospitals, where these are actually applied, nurses can administer medicines only on the order of the doctor. They are not allowed to make decisions autonomously, within their own scope of authority.  In contrast, the international literature recommends the employment of at least one highly qualified pain nurse per 250 beds, as a way to increase both the quality and the efficiency of pain management (
      • Boezaart A.P.
      • Munro A.P.
      • Tighe P.J.
      Acute pain medicine in anesthesiology.
      ;
      • Meissner W.
      • Huygen F.
      • Neugebauer E.A.M.
      • Osterbrink J.
      • Benhamou D.
      • Betteridge N.
      • Coluzzi F.
      • De Andres J.
      • Fawcett W.
      • Fletcher D.
      • Kalso E.
      • Kehlet H.
      • Morlion B.
      • Montes Pérez A.
      • Pergolizzi J.
      • Schäfer M.
      Management of acute pain in the postoperative setting: the importance of quality indicators.
      ;
      • Rockett M.
      • Vanstone R.
      • Chand J.
      • Waeland D.
      A survey of acute pain services in the UK.
      ). Pain nurses have an extended discretion to implement pain management tasks on their own. They are an important relay between the patient and the doctor, they assess pain, report back to the doctor, are qualified to work and administer pain relief medicines independently on the basis of protocols (
      • Goldberg S.F.
      • Pozek J.J.
      • Schwenk E.S.
      • Baratta J.L.
      • Beausang D.H.
      • Wong A.K.
      Practical management of a regional anesthesia-driven acute pain service.
      ;
      • Samolsky Dekel B.G.
      Editorial: Acute pain service an open and challenging issue.
      ;
      • Webb C.A.J.
      • Kim T.E.
      Establishing an acute pain service in private practice and updates on regional anesthesia billing.
      ). As Rawal has pointed out, in the absence of pain nurses, the quality and efficiency of pain management suffers and its practice is inhumane, as well, because the needed pain relief interventions suffer unnecessary delays and waste the valuable work time of both the doctors and the nurses (
      • Rawal N.
      Current issues in postoperative pain management.
      ). Without proper knowledge and authority, the ward nurse has to call the doctor to seek his or her approval, each time an intervention is deemed necessary in the pain relief regimen administered to the patient. In addition to the possibility that a less experienced clinician responds to the call, the patient suffers a lot just by waiting for the therapy change to be approved. Searching for the doctor wastes the time of the nurse, while the involvement of the doctor wastes her or his time, which may result in the delay of other, more important tasks. Unfortunately, the current Hungarian practice is close to what has been described by Rawal, as pain nurses are virtually nonexistent in the health care of Hungary.
      The lack of utilizing this opportunity to improve patient care may be explained by the shortage of health professionals, mentioned before (
      • Gaál P.
      • Szigeti S.
      • Panteli D.
      • Gaskins M.
      • van Ginneken E.
      Major challenges ahead for Hungarian healthcare.
      ;
      • Girasek E.
      • Szócska M.
      • Kovács E.
      • Gaál P.
      The role of controllable lifestyle in the choice of specialisation among Hungarian medical doctors.
      ), which in turn may impede the modern pain management equipment and technologies to gain ground. Since the surgeons perform operations all day and do not have time to pay attention to these pain management tasks, while nurses do not get the necessary education, they rather not deploy these technologies. It is a paradox, that one of the solutions to ease these human resource shortages is the involvement of and task shifting to highly qualified nurses with extended discretion, yet the human resource shortages are the main reason that these unwanted practices are entrenched in the Hungarian health system, and the main obstacle of changes to happen. One of the intervention points to break out of this paradox, is the clarification of competencies and the revision of the regulation of responsibilities, which unfortunately has not happened, partly because of resistance from the medical profession (

      Oláh, A., Máté, O., Betlehem, J., & Fullér, N. (2015). Advanced Practice Nurse (APN) MSc képzés bevezetése Magyarországon. NŐVÉR, 28(02), 3-10.

      ). Because of the lack of specific regulations of the competency of nurses in Hungary, if a hospital does deploy modern pain relief technologies, most ward nurses administer medicine into the equipment on the order of the doctor, usually in possession of the necessary experience, but in the absence of the necessary special qualification and without written authorization and permission. This practice should be resolved as soon as possible with the establishment of clear, legally enabled competencies and educational requirements, not just between nurses and doctors, but also within the nursing profession, such as between the ward nurse and the highly qualified pain nurse. This is not at all an impossible task, as a Chinese example shows, where pain nurses were trained to prepare pain treatment plans, perform pain assessment, and follow-up the analgesia pumps (
      • Fang L.
      • Chen L.
      • Sun H.
      • Xu Y.
      • Jin J.
      The effectiveness of using a nurse-led pain relief model for pain management among abdominal surgical patients: A single-center, controlled before-after study in China.
      ). Such an improvement would benefit the patients with better access and quality of care, the health professionals with more job satisfaction, and the system as a whole with a more efficient use of scarce resources.

      Pain Assessment and its Documentation

      Pain assessment is a crucial part of effective pain management to relieve postoperative pain, which is an important component of patient satisfaction and hospital performance (
      • Bruckenthal P.
      • Simpson M.H.
      The role of the perioperative nurse in improving surgical patients' clinical outcomes and satisfaction: Beyond medication.
      ;
      • Hayes K.
      • Gordon D.B.
      Delivering quality pain management: The challenge for nurses.
      ;
      • Yüceer S.
      Nursing approaches in the postoperative pain management.
      ). The measurement of pain is usually carried out by nurses because they are the hospital staff that spends the most time with patients (
      • Bruckenthal P.
      • Simpson M.H.
      The role of the perioperative nurse in improving surgical patients' clinical outcomes and satisfaction: Beyond medication.
      ;
      • Hayes K.
      • Gordon D.B.
      Delivering quality pain management: The challenge for nurses.
      ;
      • Yüceer S.
      Nursing approaches in the postoperative pain management.
      ), and according to our survey results, Hungary is no exception. As far as pain measurement tools are concerned, ward nurses use scales, which are described in the literature (
      • Coll A.M.
      • Ameen J.R.
      • Mead D.
      Postoperative pain assessment tools in day surgery: literature review.
      ;
      • Gries K.
      • Berry P.
      • Harrington M.
      • Crescioni M.
      • Patel M.
      • Rudell K.
      • Safikhani S.
      • Pease S.
      • Vernon M.
      Literature review to assemble the evidence for response scales used in patient-reported outcome measures.
      ;
      • Lapkin S.
      • Fernandez R.
      • Ellwood L.
      • Diwan A.
      Reliability, validity and generalizability of multidimensional pain assessment tools used in postoperative adult patients: A systematic review protocol.
      ;
      • Montes A.
      • Aguilar J.L.
      • Benito M.C.
      • Caba F.
      • Margarit C.
      Management of postoperative pain in Spain: A nationwide survey of practice.
      ), but in one-third of the hospital departments, pain assessment is based on subjective judgement of nurses, which is a cause for concern. Of course, subjective assessment on the basis of the clinical picture plays a role in the case of non-cooperating patients with dementia, but for all the others, the use of pain scales provide more accurate results (
      • Lovasi O.
      • Gaál P.
      • Léber A.
      • Lám J.
      A műtét utáni fájdalomcsillapítás minőségének felmérési lehetőségei: Többdimenziós mérőeszközök (Options for assessing the quality of postoperative pain relief: Multidimensional measurement tools).
      ,
      • Lovasi O.
      • Lám J.
      • Léber A.
      • Gaál P.
      A műtét utáni fájdalomcsillapítás minőségének felmérési lehetőségei: egydimenziós skálák (Options for assessing the quality of postoperative pain relief: unidimensional scales).
      ). Polish and Latvian surveys reported similar practices, according to which pain therapies are carried out based on customs, and instead of using pain scales, more than half of the nurses subjectively assess the pain of patients (
      • Borys M.
      • Zyzak K.
      • Hanych A.
      • Domagała M.
      • Gałkin P.
      • Gałaszkiewicz K.
      • Kłaput A.
      • Wróblewski K.
      • Miękina J.
      • Onichimowski D.
      • Czuczwar M.
      Survey of postoperative pain control in different types of hospitals: A multicenter observational study.
      ;
      • Strode I.S.
      • Seimane S.
      Assessment of acute pain in nursing practice in Latvia.
      ). Further, despite their advantages, multidimensional scales were not mentioned by our survey respondents at all (
      • Lovasi O.
      • Gaál P.
      • Léber A.
      • Lám J.
      A műtét utáni fájdalomcsillapítás minőségének felmérési lehetőségei: Többdimenziós mérőeszközök (Options for assessing the quality of postoperative pain relief: Multidimensional measurement tools).
      ).
      The documentation of the measurement results is also a crucial part of effective pain management, without which the accurate monitoring of pain is impossible. Only the recorded scores can be easily followed up, and provide a solid basis for the selection of the appropriate intervention. Unfortunately, our findings show that this a weak point of practice in Hungary, which certainly needs to be improved. Pain is measured and documented at rest in 40.3%, and on activity only in 34.1% of the hospital departments, while only 23.7% of our respondents record the measured value in each case. According to several studies, postoperative pain should be measured and documented both at rest and during activity, because it is not possible to determine accurately when to intervene and what the outcome of the intervention has been without it (
      • Erlenwein J.
      • Koschwitz R.
      • Pauli-Magnus D.
      • Quintel M.
      • Meißner W.
      • Petzke F.
      • Stamer U.M.
      A follow-up on Acute Pain Services in Germany compared to international survey data.
      ;
      • Nasir D.
      • Howard J.E.
      • Joshi G.P.
      • Hill G.E.
      A survey of acute pain service structure and function in United States hospitals.
      ;
      • van Boekel R.L.M.
      • Steegers M.A.H.
      • Verbeek-van Noord I.
      • van der Sande R.
      • Vissers K.C.P.
      Acute pain services and postsurgical pain management in the Netherlands: A survey.
      ;
      • Wikström L.
      • Nilsson M.
      • Eriksson K.
      The association of patients' daily summarized self-rated "real-time" pain scores with physical recovery after major surgery - A repeated measurement design.
      ). According to a Croatian study, those patients, whose pain was not assessed, had more severe pain (
      • Farčić N.
      • Barać I.
      • Pačarić S.
      • Lovrić I.
      • Ilakovac V.
      Acute postoperative pain in trauma patients - The fifth vital sign.
      ).
      One of the reasons for these findings can be the lack of specialized pain nurses, which in turn is partly attributable to the lack of appropriate legal regulations on their competencies and scope of authority in practice (

      Oláh, A., Máté, O., Betlehem, J., & Fullér, N. (2015). Advanced Practice Nurse (APN) MSc képzés bevezetése Magyarországon. NŐVÉR, 28(02), 3-10.

      ).

      Regulation of Postoperative Pain Management

      Our results show that there is no written pain management protocol in over two-thirds of hospital departments, which obviously makes it difficult to provide standard, consistent care across the whole health system. This is also a weak point of Hungarian hospitals in international comparison. According to a Spanish study, pain management protocols were available in 97% of hospital with APS, while in 55% of those with no APS (
      • Montes A.
      • Aguilar J.L.
      • Benito M.C.
      • Caba F.
      • Margarit C.
      Management of postoperative pain in Spain: A nationwide survey of practice.
      ). In the USA 55% of the responding hospitals reported having a written protocol, and this proportion was higher among hospitals with APS (
      • Nasir D.
      • Howard J.E.
      • Joshi G.P.
      • Hill G.E.
      A survey of acute pain service structure and function in United States hospitals.
      ). In 2012, 86.7% of the respondents used operative protocols in Italy (
      • Coluzzi F.
      • Mattia C.
      • Savoia G.
      • Clemenzi P.
      • Melotti R.
      • Raffa R.B.
      • Pergolizzi Jr, J.V.
      Postoperative pain surveys in Italy from 2006 and 2012: (POPSI and POPSI-2).
      ). According to a Dutch report, 97% of hospitals had a written pain management protocol (
      • van Boekel R.L.M.
      • Steegers M.A.H.
      • Verbeek-van Noord I.
      • van der Sande R.
      • Vissers K.C.P.
      Acute pain services and postsurgical pain management in the Netherlands: A survey.
      ). Further advantage of postoperative pain protocols helps to reduce the demand of analgesics and increase the use of pharmacologic strategies (
      • Gonzales A.
      • Mari M.
      • Alloubani A.
      • Abusiam K.
      • Momani T.
      • Akhu-Zaheya L.
      The impact of a standard pain assessment protocol on pain levels and consumption of analgesia among postoperative orthopaedic patients.
      ).
      Where such protocols do exist in Hungarian hospitals, their content (pain assessment and reassessment, interventions to be performed in case of inappropriate pain control, order of emergency calls) by and large corresponds to what is recommended in the literature (
      • Coluzzi F.
      • Mattia C.
      • Savoia G.
      • Clemenzi P.
      • Melotti R.
      • Raffa R.B.
      • Pergolizzi Jr, J.V.
      Postoperative pain surveys in Italy from 2006 and 2012: (POPSI and POPSI-2).
      ;
      • Nasir D.
      • Howard J.E.
      • Joshi G.P.
      • Hill G.E.
      A survey of acute pain service structure and function in United States hospitals.
      ).
      As far as training in pain management is concerned, our findings show that most Hungarian hospitals do not organize in-house education. This is another problematic point, since in-house programs are more accessible to personnel already burdened with a heavy workload, especially during times of external shocks, such as the COVID-19 pandemic. Information on pain management education varies in the literature, some focus on nurses, while others on doctors (
      • Erlenwein J.
      • Koschwitz R.
      • Pauli-Magnus D.
      • Quintel M.
      • Meißner W.
      • Petzke F.
      • Stamer U.M.
      A follow-up on Acute Pain Services in Germany compared to international survey data.
      ). In Hungary, education and training is another potential intervention point to improve the practice of pain management. The volume of in-hospital training programs should be increased for all the specializations relevant in pain management. A program for the establishment of legal, structural, and professional prerequisites of a wider adoption of APS could be a seed to facilitate this process, as a well-functioning APS assumes the role of the coordination and management of education and training activities. An interesting direction for further research could be the follow up and monitoring of the spread of APS in Hungarian hospitals after the COVID-19 pandemic ends. It is certain that without an active health policy to facilitate the adoption of the technology, the necessary changes will happen much slower—even though the investment needed here would provide a return in terms of quality, access, and efficiency in the short term.

      Limitations

      While we are convinced about the validity and usefulness of the findings of our study, particularly on the basis of the high response rate and the willingness of heads of departments to participate in our survey, we have to acknowledge the limitation of the research. With the exception of one provider, we have been unable to involve the private sector because of the reluctance of hospital management to participate in the survey. While a couple of private providers, who obtained operating licenses, do not actually offer operations, hence there would have been nothing to report on in the frame of our survey, a few others do perform operations, and the lack of their participation resulted in the missed opportunity to compare the public and the private sectors in this respect. In the public sector, the high workload of hospitals and, within them hospital workers, certainly limited the willingness to respond, and despite the acceptable response rate, even better participation might have been achieved with allocating more time for the data collection period. Finally, the method of data collection made it impossible to identify the responding hospital departments in all the cases, which limited the scope of data analysis (
      • Lovasi O.
      • Lam J.
      • Schutzmann R.
      • Gaal P.
      Acute Pain Service in Hungarian hospitals.
      ).

      Conclusions

      Despite the difficulties and complexities of the task at hand, we attempted to provide a comprehensive review of postoperative pain management in Hungary for the first time, with the involvement of anesthesiologists and representatives of surgical specialties, as well. The survey of Hungarian inpatient care providers of surgical services has confirmed our earlier impression that pain teams play a negligible role, with an APS adopted only by two Hungarian public hospitals. It is not surprising then that pain therapy is ordered mainly by the operating doctors for the first 24 hours after the operation, and the application of modern pain relief technologies is not widespread. Pain assessment is usually carried out by ward nurses, specialized pain nurses are absent from the system, and the level of pain is frequently determined subjectively. Finally, two-thirds of the surveyed hospital departments do not have a written pain management protocol.
      This study has provided us with a snapshot of the present status, and identified the potential intervention points to improve the quality, access, and efficiency of pain therapy, the effect and implementation of which should be monitored with future, follow-up surveys. Among others, Hungarian health policy should focus on the establishment of the legal, professional, and financial prerequisites of the wider adoption of APS, and health professionals have to be motivated to participate in the work of pain teams. Pain management knowledge should be given more emphasis in the education and training of nurses. The training of highly qualified nurses with extended competencies and scope of authority should be developed further, together with the legal regulation of their licenses to practice in pain management.

      Clinical Implications

      From the perspective of clinical practice, the first step should be adoption of local pain management protocols and standard operation procedures (SOPs) which provide a detailed regulation of the operational framework of pain teams, the necessary qualifications of their members, the designation of the leader of the pain team, the professionals responsible for pain assessment, the frequency of pain measurement, the professionals in charge of ordering the pain therapy, the roles and responsibilities of each professional in the implementation of pain relief technologies, as well as the rules of administration and documentation of these activities in each Hungarian hospital with a surgical portfolio. The key is the clear definition and delineation of competencies on the basis of which the tasks can be divided most efficiently among the various health professionals. Practice-oriented education and training also plays an important role in the development and division of competencies, which should be made available not just in general, but within the individual hospitals, tailored to the local context and training needs, for all the surgical specialists, anesthesiologist, nurses, physiotherapists, and dieticians. Finally, on the basis of the internal regulatory framework, bilateral agreements should be concluded between the anesthesiology and the operating departments.
      Despite its limitations, we are convinced that our study has provided a valuable insight into the current practice of postoperative pain management in Hungarian hospitals, and serves a solid basis for policy making and the development of clinical practice for the sake of patients, relatives, and health workers alike.

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