Adherence Level Of Medical Personnel In Implementing 2019 Postoperative Pain Management Guidelines Nasrulloh

Received: August, 29, 2021 Revised: November, 17, 2021 Available online: May 2021 Inadequate pain management may increase the risk of complications and postoperative chronic pain. Postoperative Pain Management Guidelines of The Anesthesiology and Reanimation Department, Faculty of Medicine Universitas Airlangga/ Dr. Soetomo Hospital Surabaya were arranged in 2019. This study aims to describe the medical personnel's adherence to implementing postoperative pain management guidelines. This was a descriptive observational study with a retrospective design. Total sampling was carried out on the medical records of patients who underwent elective surgery and received postoperative acute pain management during March-May 2020. A total of 349 patients had moderate pain intensity (62.8%). The medical personnel's adherence with postoperative pain management guidelines was 88.0%. The details were as follows: 99.1% adherence in patients with mild pain, 82.6% in moderate pain, and 81.2% in severe pain. The multimodal analgesia was 12.3% in patients with mild pain, 83.6% in moderate pain, and 100% in severe pain. Most medical personnel have adhered to the postoperative pain management guideline and widely used in multimodal analgesia. There should be a systematic evaluation of guidelines implementation, patient satisfaction, and outcomes.

Inadequate pain management may increase the risk of complications and postoperative chronic pain. Postoperative Pain Management Guidelines of The Anesthesiology and Reanimation Department, Faculty of Medicine Universitas Airlangga/ Dr. Soetomo Hospital Surabaya were arranged in 2019. This study aims to describe the medical personnel's adherence to implementing postoperative pain management guidelines. This was a descriptive observational study with a retrospective design. Total sampling was carried out on the medical records of patients who underwent elective surgery and received postoperative acute pain management during March-May 2020. A total of 349 patients had moderate pain intensity (62.8%). The medical personnel's adherence with postoperative pain management guidelines was 88.0%. The details were as follows: 99.1% adherence in patients with mild pain, 82.6% in moderate pain, and 81.2% in severe pain. The multimodal analgesia was 12.3% in patients with mild pain, 83.6% in moderate pain, and 100% in severe pain. Most medical personnel have adhered to the postoperative pain management guideline and widely used in multimodal analgesia. There should be a systematic evaluation of guidelines implementation, patient satisfaction, and outcomes. KEYWORDS adherence, guidelines, pain management, postoperative pain

INTRODUCTION
According to the International Association for Study of Pain (IASP), pain is a subjective and acquired unpleasant sensory and emotional experience associated with actual or potential tissue damage or represents the damage condition (Treede, 2018). Postoperative pain is still frightening for patients who undergo surgery (Schroeder et al., 2016). According to data in the United States, pain perception is a significant source of anxiety in patients undergoing surgery, and this suggests postoperative pain management is far from satisfactory (Apfelbaum et al., 2003;Glowacki, 2015). More than 80% of patients undergoing surgery had acute postoperative pain, and about 75% of these patients experience moderate, severe, or extreme pain levels. Data in Dr. Soetomo General Hospital Surabaya, most patients (59.2%) experienced moderate-severe postoperative pain in the first 24 hours postoperatively (Suwiknyo et al., 2017). Inadequate pain management can interfere with the quality of life and functional recovery and increase postoperative complications and postoperative chronic pain risk (Kehlet et al., 2006). An American survey conducted for more than 20 years showed that only 1 in 4 patients got adequate postoperative pain management. This background makes pain crucial. Pain is the fifth vital sign in the https://doi.org/10. 33086/jhs.v14i2.1744 Nasrullah -Adherence Level Of Medical Personnel In Implementing 2019 Postoperative Pain Management Guidelines patient's assessment when undergoing inpatient care at the hospital, especially as a protocol in the Recovery Room.
Adequate pain management is dependent on the commitment of medical personnel in the hospital. There are many guidelines for perioperative pain management, arranged by the American Society of Anesthesiologists (ASA), the American Pain Society (APS), and the World Health Organization (WHO).
Still, when these guidelines are not implemented, then pain therapy provision will not be adequate.
Implementing pain management guidelines depends on medical personnel's adherence, facilities, and drugs in the hospital. Good local pain management guidelines should be adjusted to local wisdom and hospital conditions (Wels, 2012).
One highlighted thing is the uniformity of understanding and adherence among medical personnel in hospital facilities. The commitment to implementing pain guidelines by non-anesthetists and other medical personnel, such as nurses, is also an essential part of pain management services (Fitzgerald et al., 2017).
Several studies also reported gaps regarding expectations of pain management implementation and medical staff adherence. Kerner et al., (2013) assessed inadequate pain management by health workers in internal medicine wards. Adherence to pain treatment guidelines was 29.3% of cases. Re-evaluation after treatment was 33.3%, and additional evaluation is only 22%. Another study was conducted by (Hakonsen et al., 2009) in patients with cancer pain in Scotland, United Kingdom. Adherence to the pain guideline criteria indicated that the overall adherence rate was 75%. However, it still showed a low level of adherence (29%) for inpatients service. There were adherence gaps between the inpatient and the outpatient palliative care, particularly to pain assessment.
A study reported that adherence level to pain management before invasive treatment in neonates increases after implementing strict protocols, socialization, and counseling (Sari, 2016 Status-American Society of Anesthesiologists (PS ASA), anesthesia technique, type of surgery, and procedure duration.

Subject Criteria
The sample selection in this study met the following inclusion criteria: (1) Medical records of inpatients aged 18 years to 60 years, did elective surgery at Dr. Soetomo General Hospital, Surabaya, with a duration of postoperative care ≥ 24 hours, with PS ASA Score 1-2.
(2) The authors can read medical records.
Meanwhile, the exclusion criteria were an incomplete medical record.

Study Procedures
The classifications of medical personnel's adherence to pain management guidelines were into adherence and non-adherence, for each category of pain intensity influenced by the type of surgery. Medical personnel's adherence level was assessed by looking at RM 30sK (Anesthesia Status) in medical records.
The adherence category, defined as therapy with one analgesic for mild pain; treatment with ≥ two analgesics for moderate to severe pain. The non-adherence category was medical personnel who are not providing analgesic therapy for mild pain; give ≤ one analgesic therapy for moderate-severe pain. The data presentation was in tables and graphs.

Subjects Characteristics
The

Analysis of Pain Management Guidelines Adherence in Each Pain Intensity Category
Almost all medical personnel (88.0%) adhered to the guidelines in providing postoperative analgesia therapy. In comparison, 12% of them did not adhere to the postoperative pain management guidelines.  The total distribution of multimodal analgesia in the study sample was 213 (61.0%). Meanwhile, multimodal analgesia usage in moderate and severe pain cases was 199 cases (84.7%).

DISCUSSION
The characteristics of the subjects certainly affect pain manifestations. In this paper, age and sex were two essential variables that influenced pain. This result is in line with Wandner et al., (2012), which reported that age was an important variable affecting pain in both children and adults. In this study, the mean ages of the subjects were 40.64 years old. A study by Nasir & Ahmed (2020) about postoperative pain management perception stated similar data. In their study, the average patient's age was 42.97 ± 13.05 years old. Research by Chae et al., (2019) found significant differences between the sex of patients and postoperative pain relief also analgesic need. Young female patients needed higher doses of analgesics than elderly patients. The long operative duration correlated with postoperative pain and analgesic consumption (Gagliese et al., 2008). Meanwhile, another study showed no correlation between the type of surgery and postoperative pain outcomes (Ip et al., 2009;Mamie et al., 2004).

The 2019 Postoperative Pain Management Guideline of Department Anesthesiology and Reanimation
Faculty of Medicine Universitas Airlangga/ Dr. Soetomo General Hospital uses the principle of multimodal analgesic therapy. This study analyzed analgesic drugs using whether suitable with the guidelines or not. The use of analgesic modalities is a multimodal approach (drug use and or action more than one). It is following the particular guidelines that every operation must get analgesia depends on pain intensity.
The first analgesia in the guideline is Nonsteroidal anti-inflammatory drugs (NSAIDs) or paracetamol. It found that in our study, the most widely used NSAIDs were metamizole and ketorolac. There were 85.9% of metamizole and ketorolac administration in patients undergoing surgery. Nonsteroidal antihttps://doi.org/10.33086/jhs.v14i2.1744 Nasrullah -Adherence Level Of Medical Personnel In Implementing 2019 Postoperative Pain Management Guidelines inflammatory drugs are the most widely used primary therapy for chronic and acute pain, mild or moderate postoperative pain. In mild intensity postoperative pain, NSAIDs are often used alone. This modality is often combined with adjuvants or opioids (multimodal analgesia) in severe postoperative pain (Cosmo & Congedo, 2015). The most used second analgesic drugs modality in postoperative pain management were paracetamol and tramadol.
Meanwhile, the least used were ketorolac and metamizole. For epidural patients, 45 patients had ropivacaine administration (88.2%), and six patients had morphine administration (11.8%). According to The American Pain Society Guidelines, the use of multimodal analgesia with more than one analgesic drug targets different mechanisms of action on the nervous system. Multimodal analgesia may combine with non-pharmacological interventions to effectively reduce pain compared to a single modality. Anesthetists can combine regional anesthetics techniques combined with systemic opioids and other analgesics as part of a multimodal approach to postoperative pain (Chou et al., 2016).
Most of the samples had multimodal analgesic therapy.  (Dürango et al., 2016). Guidelines for postoperative pain control help establish basic pain management parameters, and it is necessary to ensure that medical personnel adheres to evidence-based standards.
Further postoperative pain management will emphasize the role of communication between patients and medical personnel (Kuusniemi & Pöyhiä, 2016).
The literature points to several factors associated with the adherence of medical personnel in implementing specific practice guidelines. A study by Wulandari & Lisum (2019) showed the correlation between compliance to pain reassessment documentation with the nurse's age, years of service, and attitude. Monitoring all nurses in documenting pain reassessments according to existing standard operating procedures/guidelines is also required. The study by Houghty et al., (2019) also stated a similar thing. The factors that affected medical personnel's adherence to the guidelines were lack of facilities and training. A supportive environment such as training carried out by the education department at the hospital supports a positive attitude. Our study's limitation was the absence of an analysis of the factors that affected medical personnel's adherence to pain management guidelines. It should be a concern for further research

CONCLUSION
Medical personnel has adhered to the 2019 Postoperative Pain Management Guidelines in most patients who undergo surgery. Most of the patients with moderate to severe pain category had received multimodal analgesic therapy. After conducting this study, we recommend counselling and resocialization regarding postoperative pain management guidelines considering there is still medical personnel that provides single modal therapy in patients undergoing surgery with moderate-severe pain. Systematic follow-up/evaluation is crucial for successfully implementing postoperative pain management guidelines in the hospital wards.
Further research should analyze the correlation between medical personnel's adherence level in implementing the Postoperative Pain Management Guidelines with the level of pain and patient satisfaction and the effectiveness/outcome of implementing the postoperative pain management guideline.