Seers K, Crichton N, Carroll D, Richards S, Saunders T
Royal College of Nursing Institute, Radcliffe Infirmary, Oxford, UK.
J Nurs Manag. 2004 May;12(3):183-93. doi: 10.1111/j.1365-2834.2004.00473.x.
There is an increasing drive to make nursing care evidence-based. High quality evidence from systematic reviews relevant to postoperative pain relief exists, yet pain after surgery remains poorly controlled for many patients. This study aimed to assess whether implementing evidence-based pain management improved postoperative pain outcomes. Pain on a 0-10 scale was the primary outcome and analgesic consumption a secondary outcome. A baseline audit was undertaken on four surgical wards to establish whether there was a need for the study. A randomized-controlled trial was then designed to assess the effects of implementing an evidence-based approach to postoperative pain management. The four wards were randomized to receive the intervention or act as a control. Outcomes were assessed 3 months after the intervention on both intervention and control wards. The intervention (implementation of an oral analgesic algorithm derived from systematic reviews) was then implemented on the control wards and outcomes reassessed after 3 months on the control wards. The intervention was designed using an evidence-based approach to effective implementation. Four interactive sessions covered: (1) detailed feedback of baseline data and discussion (utilizing audit and feedback), (2) why systematic reviews, analgesic league tables and choice of drugs to develop an analgesic algorithm (see Figure 1), (3) principles of evidence based health care (EBHC), including critical appraisal and (4) facilitation and change workshop. The findings revealed no significant differences in pain level or drug use between the intervention and control wards. However, the control wards also changed during the control period. Possible explanations for this are discussed. When looking at changes compared with baseline, both intervention and control wards increased their use of algorithm drugs and reduced use of non-algorithm drugs during the study. No effects were found on pain in the intervention wards. Pain ratings at rest since surgery, on movement since surgery and worst pain on movement were significantly reduced compared with baseline in the control wards. Although there are many pressures to utilize a randomized-controlled trial study design in the culture of evidence-based health care, there will be times, especially when implementing complex changes in practice that other types of design should be considered.
将护理工作基于证据的驱动力日益增强。存在与术后疼痛缓解相关的系统评价得出的高质量证据，但对许多患者而言，术后疼痛仍控制不佳。本研究旨在评估实施基于证据的疼痛管理是否能改善术后疼痛结局。采用0至10分的疼痛评分作为主要结局，镇痛药物消耗量作为次要结局。对四个外科病房进行了基线审核，以确定是否有开展本研究的必要。随后设计了一项随机对照试验，以评估实施基于证据的术后疼痛管理方法的效果。四个病房被随机分组，分别接受干预或作为对照。在干预实施3个月后，对干预病房和对照病房的结局进行评估。然后在对照病房实施干预（实施源自系统评价的口服镇痛算法），并在3个月后对对照病房的结局重新进行评估。干预措施是采用基于证据的有效实施方法设计的。四个互动环节包括：（1）基线数据的详细反馈与讨论（利用审核与反馈），（2）为何采用系统评价、镇痛药物排行榜及药物选择来制定镇痛算法（见图1），（3）基于证据的医疗保健（EBHC）原则，包括批判性评价，以及（4）促进与变革研讨会。研究结果显示，干预病房和对照病房在疼痛程度或药物使用方面无显著差异。然而，对照病房在对照期内也发生了变化。对此的可能解释将予以讨论。与基线相比，在研究期间，干预病房和对照病房均增加了算法药物的使用，减少了非算法药物的使用。干预病房的疼痛未发现有改善。与基线相比，对照病房术后静息时的疼痛评分、术后活动时的疼痛评分以及活动时的最痛评分均显著降低。尽管在基于证据的医疗保健文化中有诸多压力促使采用随机对照试验研究设计，但有时，尤其是在实践中实施复杂变革时，应考虑其他类型的设计。
