An innovative nonpharmacological intervention combined with intravenous patient-controlled analgesia increased patient global improvement in pain and satisfaction after major surgery

Figures & data

Table 1 Visitation schedule and assessment of questionnaires

Questionnaire contents	Screening	Daily ward visits	After termination of IV-PCA
Part 1: recorded by pain nurses
Patients’ characteristics	●	–	–
Pain severity and total daily dosage of morphine	–	●	–
Side effects of IV-PCA	–	●	–
Part 2: a 10-item questionnaire completed by patients voluntarily	–	–	●

Note: The dot indicates the action that should be conducted.

Abbreviation: IV-PCA, intravenous patient-controlled analgesia.

Table 2 Dimensions of the survey questionnaire used to evaluate the care quality of acute pain services

Dimensions	Question and assessment
Accessibility and convenience	Accessibility: Q1 – PCA information Availability: Q2 – PCA device and pain treatment
Communication	Communication skills: Q3 – initial explanation on the use of PCA; Q4 – follow-up questions during ward visits
Interpersonal manner	Ask-and-response: Q5 – for ward nurses; Q6 and Q7 – for acute pain service team members
Technical quality	Instrument proficiency: Q8 – operating the PCA device
General satisfaction	Global improvement: Q9 – patient global impression of improvement in pain Overall satisfaction: Q10 – patient overall satisfaction with acute pain services

Abbreviations: Q, question; PCA, patient-controlled analgesia.

Figure 1 Flowchart of study design.

Abbreviations: APS, acute pain service; CICARE, Connect, Introduce, Communicate, Ask, Respond and Exit program; IV-PCA, intravenous patient-controlled analgesia.

Table 3 Characteristics of postoperative patients receiving patient-controlled analgesia between the two survey groups, namely, “before” and “after” CICARE

Characteristics	Before CICARE	After CICARE	P-value
	n=95	n=92
Questionnaire response rate	55.2% (95/172)	55.4% (92/166)	0.97
Age group, years, number (%)			0.14
20–39	16 (16.8)	11 (12.0)
40–59	39 (41.1)	29 (31.5)
60–80	40 (42.1)	52 (56.5)
Mean age	58.8±12.7	54.8±13.5
Gender, number (%)			0.41
Male	48 (50.5)	52 (56.5)
Female	47 (49.5)	40 (43.5)
ASA class, number (%)			0.59
Classes I and II	25 (26.3)	23 (25.0)
Class III	67 (70.5)	68 (73.9)
Class IV	3 (3.2)	1 (1.1)
Education level, number (%)			0.59
Primary school and none	44 (46.3)	48 (52.2)
High school	34 (35.8)	32 (34.8)
College and above	17 (17.9)	12 (13.0)

Notes: Categorical variables were estimated by the chi-square test. P<0.05 indicates statistical significance.

Abbreviations: CICARE, Connect, Introduce, Communicate, Ask, Respond and Exit program; n, number; ASA, American Society of Anesthesiologists.

Table 4 Responses to questionnaires between survey groups, namely, “before” and “after” CICARE, in postoperative patients receiving PCA

Questions (Q)a		Before CICARE, mean ± SD	After CICARE, mean ± SD	P-value	Mean change differenceb
Q1	Was PCA information easily accessible for you to obtain?	3.9±0.5	4.3±0.6	<0.001	0.4
Q2	Was a PCA device readily available for your pain management?	4.0±0.6	4.4±0.6	<0.001	0.4
Q3	Was the initial explanation on the use of PCA clear?	4.0±0.6	4.4±0.6	<0.001	0.4
Q4	Was the APS team’s communication comprehensible during ward visits?	4.1±0.5	4.5±0.5	<0.001	0.4
Q5	If there were problems with PCA, did the ward nurse promptly respond?	4.2±0.6	4.4±0.6	<0.001	0.2
Q6	If there were problems with the PCA, did the APS team promptly respond?	4.1±0.6	4.5±0.5	<0.001	0.4
Q7	If you experienced side effects of PCA, were you satisfied with the APS team’s response?	3.9±0.5	4.3±0.5	<0.001	0.4
Q8	Was the APS team proficient when operating the PCA device?	4.2±0.5	4.4±0.5	<0.001	0.2
Q9	Was using PCA effective in reducing pain? (patient global impression of improvement in pain)	4.0±0.6	4.4±0.6	<0.001	0.4
Q10	Were you satisfied with the APS team services?	3.8±0.5	4.3±0.6	<0.001	0.5

Notes:

a Survey responses were assessed by a 5-point Likert scale for each question, with 1 representing extremely poor and 5 indicating excellent.

b Mean change difference: the difference between mean scores of “before CICARE” and “after CICARE” groups. Continuous variables were estimated by the Student’s t-test. P<0.05 indicates statistical significance.

Abbreviations: APS, acute pain service; CICARE, Connect, Introduce, Communicate, Ask, Respond and Exit program; PCA, patient-controlled analgesia.

Table 5 Morphine dosage, delivery/demand ratio, pain severity and rates of side effects in patients receiving patient-controlled analgesia in the “first” and “second” 24 hours after surgery between the survey groups “before” and “after” CICARE

Variables	Response	First 24 hours		P-value	Second 24 hours		P-value
		Before CICARE (n=95)	After CICARE (n=92)		Before CICARE (n=95)	After CICARE (n=92)
Morphine, mg	–	34.68±18.66	30.37±15.42	0.09	21.09±11.38	18.34±10.57	0.09
Delivery/demand ratio	–	0.66±0.22	0.65±0.20	0.80	0.68±0.22	0.68±0.18	0.95
Pain at rest, NRS score: 0–10	≥4	18	15	0.64	7	6	0.82
	<4	77	77		88	86
Itching	Yes	11	8	0.43	6	2	0.16
	No	84	84		89	90
Dizziness	Yes	22	22	0.90	10	12	0.29
	No	73	70		85	80
Nausea and/or vomiting	Yes	21	15	0.41	5	9	0.24
	No	74	77		90	83

Notes: Categorical variables were estimated by the chi-square test. P<0.05 indicates statistical significance.

Abbreviations: CICARE, Connect, Introduce, Communicate, Ask, Respond and Exit program; NRS, numeric rating scale.

Table S1 Standard operating procedures of CICARE for APS team members during postoperative visits

Component	Procedure
Connect	Eye-to-eye contact and smile while properly addressing the patient and checking his/her conscious level.
Introduce	Introduce ourselves as the APS team and our responsibilities; demonstrate the functions of the portable handheld pulse oximeter (SpO2 monitor); connect the patient’s finger to the pulse oximeter.
Communication	Explain the readings on the pulse monitor. Reinforce drug information and the operating procedures of the PCA device.
Ask	Assess pain severity using the 11-point NRS. Ask about side effects (itching, dizziness, nausea or vomiting) and whether the patient has experienced any trouble when using the PCA device.
Respond	Respond to PCA questions and treat any side effects accordingly.
Exit	Exit courteously after reminding patients how to contact the APS team if encountering PCA problems and to make a follow-up visit.

Abbreviations: APS, acute pain service; CICARE, Connect, Introduce, Communicate, Ask, Respond and Exit program; SpO₂, oxygen saturation of pulse oximetry; PCA, patient-controlled analgesia; NRS, numeric rating scale (NRS: 0–10, with 0 indicating no pain and 10 indicating the most pain imaginable).