| 摘要: | 背景：
病人於住院期間未受到妥善治療的疼痛是常見的，為了改善住院病人的疼痛控制，可採取定期評估疼痛、個人化病人用藥、主動介入、教育病人或是其照顧者止痛藥的知識和建立相關的監測指標等策略。在這篇研究中，我們建立了藥師-麻醉科醫師合作的多方介入之住院服務來改善住院病人疼痛控制，評估此合作介入住院疼痛病人之成效與住院病人臨床指標變化。
方法：
本研究為單一醫學中心之回溯性病歷回顧研究，分析時間自2019年1月1日至2019年12月31日。收納的族群為年滿二十歲住院病人，連續三日之每日疼痛分數大於三分，初次經藥師-麻醉科醫師訪視後即納入收案。藥師-麻醉科醫師合作介入住院疼痛病人內容包含主動訪視疼痛病人、給予病人疼痛相關知識、於病人訪視前評估病人疼痛相關資訊、與當科醫師討論及給予建議。此外，藥師建立住院疼痛電子系統警示於住院醫師醫令系統、定期對所有醫療人員疼痛教育訓練，並建構住院病人臨床指標以監測全院病人用藥合理性。
主要指標為疼痛分數的改變、發生突發性疼痛且接受止痛藥次數；次要結果為止痛藥物的改變、鴉片類藥物劑量的改變、藥師-麻醉科醫師給予治療團隊的建議。針對全部住院病人的每月臨床監測指標的改變。以one-way repeated ANOVA 與McNemar's Test等方法進行統計分析。
結果：
本研究共收納149位病人，其24小時平均疼痛分數由介入前3.05 ± 1.05(平均數 ± 標準差)顯著下降至介入當天之2.46 ± 1.26(p<0.05)，並於介入後五天維持疼痛控制，第五天疼痛分數為1.50 ± 1.35 (p<0.05)。在發生突發性疼痛且接受止痛藥次數方面在介入後也較介入前呈現顯著下降的結果(1.86 ± 1.09 vs. 1.21 ± 1.17, p<0.05)。用藥改變方面：23.5%的病人原先僅有需要時給予止痛藥物的處方，介入後顯著下降到4.11%(p<0.05)；鴉片類藥物劑量的於不同監測的時間點未有顯著性的改變，但需要時使用的鴉片類藥物劑量從23.02毫克顯著下降至14.34毫克(p<0.05)。藥師-麻醉科醫師給予治療團隊的建議主要以新增用藥為最多(占41.89%)、其次為劑量的調整(占21.62%)。臨床監測指標於2019年6月皆達100%且持續至12月。
結論：
藥師-麻醉科醫師合作介入住院疼痛病人與疼痛分數的下降、發生突發性疼痛且接受止痛藥次數的下降有相關，且同一時間並未造成鴉片類藥物的上升。未來研究可以進一步探討本院的多模組止痛在此合作模式下的成效，並結合藥物經濟學的分析。
Background:
Untreated pain is common during a patient's hospitalization. Strategies such as regular pain assessment, personalized analgesic prescriptions, proactive response, education about analgesic knowledge, and pain-related quality indicators have been suggested to be possible solutions. In this study, we built a multi-approach inpatient pain management service with pharmacists and anesthesiologists for hospitalized patient, and evaluated the effectiveness of the collaborative service and the changes of clinical indicators for hospitalized patients.
Methods:
This was a retrospective chart review study in an academic center from January 1st to December 31st, 2019. The inclusion criteria were inpatients older than 20 years of age with pain scores over three at least once per day for three consecutive days. All patients who were consulted by the collaborative service for the first time were included for analysis. The pharmacists provided education and assessed pain conditions to hospitalized patients prior to ward rounds; discussed these factors with the attending anesthesiologists, and provided suggestions. In addition, the pharmacists established a pain alert system in the inpatient physician order entry system, provided education about knowledge of analgesics periodically, and established clinical indicators to monitor the appropriateness of pharmacotherapy to all hospitalized patients.
The primary outcome was changes in pain scores and numbers of rescue analgesics for breakthrough pain per day before and after the intervention. Secondary outcomes were the changes of analgesics and morphine milligram equivalent daily dose (MEDD) per patient, types of suggestions made by pharmacists and anesthesiologists. Clinical indicators were monitored monthly to follow all hospitalized patients. Statistical analysis was done with one-way repeated ANOVA and McNemar's Test.
Results:
A total of 149 patients were included in the study. The average pain score in the past 24 hours decreased significantly from 3.05 ± 1.05 (mean ± SD) at pre-intervention to 2.46 ± 1.26 on day of intervention (p<0.05) and sustained throughout the 5-day observational period with the final pain score at 1.50 ± 1.35 (p<0.05). The number of rescue analgesics for breakthrough pain per day decreased significantly after the intervention (1.86 ± 1.09 vs. 1.21 ± 1.17, p <0.05). There were 23.49% of patients (n=35) who started with PRN only prescription for pain control, which significantly decreased to 4.11% (n=6) after the intervention (p <0.05). There were no significant changes in opioid oral morphine milligram equivalent daily dose (MEDD), but as needed opioid per patient reduced significantly from 23.02 mg to 14.34 mg (p < 0.05). Most suggestions were addition of medications (n=31; 41.89%), followed by dosage adjustments (n=16; 21.62%). All clinical indicators reached 100% in June 2019 and sustained at 100% at December 2019.
Conclusion:
The collaborative pharmacist-anesthesiologist inpatient service on pain management was associated with decreased pain scores and decreased use of as-needed analgesics without increased opioid dosage in hospitalized patients. Future studies could further explore the effectiveness of multimodal analgesics in such collaborative practice, and characterize the cost-effectiveness of the inpatient service. |
