Virtual Pain Unit Is Associated with Improvement of Postoperative Analgesia Quality: A Retrospective Single-Center Clinical Study

The effect of the VPU model for postoperative pain management on postoperative analgesia quality was explored in this study. This model offered improved postoperative analgesia quality and reduced adverse effects post-surgery, such as PONV and postoperative dizziness, than the traditional APS model for postoperative pain management. The current healthcare facility demonstrated a decrease in MSPP (65%), PONV (45%), and postoperative dizziness (47%) incidence when the VPU model was implemented compared with the APS model.

Postoperative pain has not been addressed appropriately for decades. The guidelines [4] issued by the American Pain Society in 2016 indicated that 80% of patients experienced acute pain post-surgery, 75% claimed to experience moderate, severe, or even extreme pain postoperation, and < 50% received good analgesia after undergoing their procedure. In 2021, Vasilopoulos et al. [15] from the University of Florida in the USA showed that 63% of patients experienced moderate to severe pain within seven days postoperatively. Likewise, a large-scale multicenter study from Denmark [16] exhibited that 20% of patients experienced moderate to severe pain immediately after awakening. After the development of APS 30 years ago, the implementation has improved postoperative analgesia quality tremendously. Nevertheless, the system is facing significant challenges and requires further upgrading.

Various APS models have been reported in the literature, including physician-led [9] and nurse-led [17] operation models. A stand-alone APS model independent of OR was widely discussed recently [11], potentially enhancing multimodal pain management and improving postoperative analgesia quality. In the present study, a novel VPU model was designed on the basis of the “virtual ward” concept to create an independent virtual nursing unit. The VPU, or stand-alone APS, was fully staffed with dedicated anesthesiologists, perianesthesia nurses, and part-time clinical pharmacists. An organizational structure was established to achieve the goals and enhance postoperative analgesic quality. The selected staff managed the VPU patients similar to those in general wards by conducting daily pain rounds and remotely monitoring operations via a PCA internet of things (IoT) (microchip, base station, and central station) [18] for timely adjustments.

The current healthcare institution upgraded the conventional APS model to the VPU model to effectively manage acute postoperative pain. The findings indicated that the VPU model reduced the incidence of MSPP (28.3% to 9.79%), PONV (17.19% to 9.38%), and the incidence of postoperative dizziness (13.41% to 7.12%). Furthermore, the VPU model supported the regional analgesia-based, opioid-sparing, multimode analgesic strategies to promote the implementation of the ERAS program, such as DREAMS (Drinking, Eating, Analgesic, Mobilising, Sleeping) [19]. In addition, the coverage rate of the nerve block was increased in the VPU model compared with APS. Optimization of analgesic regimen using the new model reduced the incidence of PONV and postoperative dizziness, suggesting that VPU is a promising and improved alternative to APS for postoperative pain management. Despite that, there were no significant differences in the incidence of PONV and dizziness in November between the two models, mainly due to more gastrointestinal surgeries in the VPU group than in the APS group (21.2% versus 9.4%). Gastrointestinal surgeries are attributed to a higher incidence of PONV and dizziness [20].

Moderate–severe pain was commonly observed among patients that underwent bariatric, thoracic, gastrointestinal, obstetric, hepatobiliary, and transforaminal endoscopic spine surgeries (TESS) compared with other sub-specialties. Gerbershagen et al. [21] also found that postoperative pain intensity differed significantly on the first day after surgery among various surgical procedures. The recognition led to developing evidence-based recommendations for PROSPECT. Thus, healthcare providers are strongly advised to adhere to the PROSPECT strategy in managing postoperative pain.

No statistical differences were identified between the two groups in terms of ALOS, but there was a tendency for ALOS to decrease. It is postulated that further upgrades of the VPU model could reduce ALOS, as this model is still new and ALOS shortening is complex. Moreover, the VPU model improved the PCIA utilization rate and the coverage rate of nerve block, which may increase per capita hospitalization cost and opioid consumption but reduce the incidence of acute postoperative pain. The slight increase in per capita hospitalization cost is deemed worthwhile to improve the patient’s medical experience. In addition, the VPU model is under continuous improvement to create an optimal pain management model that reduces the per capita hospitalization cost and enhances the patient’s future medical experience. In view of the current opioid-free concept, the developers of this study also aim to improve the coverage rate of nerve blocks.

The number of ward rounds per capita in the VPU model is double that of the APS model. This method allows the staff to listen to the patients’ concerns, provide the best comfort and care, and improve patients’ experience, enhancing the VPU model through continuous feedback. Furthermore, the extra time and interaction increase the opportunity for bedside education for patients and create a good rapport between the anesthesiologists and patients. The VPU also aligns with the concept of anesthesia and perioperative medicine, improves patients’ postoperative management, and expands anesthesiologists’ services. Another advantage of the VPU model is the complete organizational structure, multidisciplinary personnel ratio, individualized analgesia regimen, and quality control, which substantially reduces the interval between the onset of acute pain and relief, improves the treatment efficiency, and reduces the workload of OR anesthesiology team. In conclusion, the VPU is an innovative acute pain management model that improves the status quo of postoperative patient pain management.

This study has several limitations. First, there may be confounding factors and bias in the data in the present retrospective study, and the reliability of the results is not as high as that of prospective studies. Therefore, future studies are essential to validate the model performance. Secondly, this study is a single-center study, which may differ in operation type, number, and demography from other centers. Thus, large-scale multicenter research should be performed to confirm the viability of the VPU model. Finally, nearly half of the patients were excluded from the screening process as most patients included in APS and VPU mainly had MSPP. Local anesthesia surgery (minimally invasive mammotome biopsy, cataract surgery) and surgery with mild postoperative pain (vitrectomy, hysteroscopy) were not included. In the end, nearly half of the patients were finally excluded after considering other inclusion and exclusion criteria. Nonetheless, the physician can conduct APS or VPU for treatment if patients experience MSPP.

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