AT OUR FACILITY, we have 450 obstetric deliveries each month. We believed, based on evidence in the literature and our experiences, that our laboring patients would benefit from using patient-controlled epidural analgesia (PCEA) instead of continuous epidural analgesia. We decided to introduce PCEA as a pain control option and then evaluate the impact of this change by conducting patient-satisfaction surveys.
In this article, we'll briefly review PCEA, explain how we introduced it into our obstetric practice, and share our survey results.
PCEA, in a nutshell
A drawback of traditional continuous epidural infusion is that patients don't receive additional analgesia until they complain of pain, creating a gap between pain perception and treatment. This is especially detrimental during labor, when a patient's analgesia requirements may increase progressively. In contrast, PCEA provides continuous epidural infusion and lets the patient self-administer bolus doses to manage her own pain.
Research by Stienstra showed that PCEA reduced patients' hourly dose requirements compared with patients receiving traditional continuous epidural infusions. Laboring patients with PCEA also benefited from feeling in control of their own pain management.
Similarly, a meta-analysis by van der Vyver, et al., showed that laboring patients who received PCEA were less likely to require anesthetic interventions, required fewer doses of local anesthetic, and had less motor block.
A literature search revealed that little research has been done comparing patient satisfaction with the two methods. After trying PCEA with our patients, we hoped to contribute to this area of research with our patient-satisfaction survey.
Planning for change
To incorporate PCEA into our practice, we revised our policy on caring for the laboring patient with an epidural infusion. We reviewed the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based clinical practice guidelines, then used this data to support our clinical practices. We updated our policies to include teaching patients how to use PCEA, including potential adverse reactions they needed to report to the nurse.
The anesthesiologist and the nursing staff collaborated to identify candidates for PCEA. The anesthesiologist obtained informed consent. The nurse reinforced how to use the PCEA pump, told the patient that she needed to notify the nurse if she had any unexpected sensations during the epidural, and informed her that a nurse would continue to measure her pain level.
Nursing staff education
Nurses who worked in labor and delivery were required to attend a 1-hour staff-development training session. Our goal was to answer questions about the nurse's role in PCEA and to find out how this change might affect patient outcomes.
The clinical nurse specialist developed content for the staff-development training session and the nursing leadership team (the labor and delivery director and four assistant directors) provided support and feedback.
This training, based on lecture and discussion, was incorporated into the labor and delivery nurses' mandatory education schedule. It covered anatomy and physiology, a review of AWHONN guidelines for epidural infusions during labor, reasons for the practice change, and our plan to collect data about patient satisfaction. The nurses supported instituting PCEA because they believed it would let patients participate in their pain management more actively.
An anesthesiologist who was the chair of the obstetrics anesthesia committee introduced the proposed change in obstetric anesthesia practice to physicians and to labor and delivery nursing staff.
First data collection
We began to use PCEA in our obstetrics department in May 2002. At that time, about half of the anesthesiologists were administering PCEA epidurals. We planned to measure patient outcomes by asking patients to rate their satisfaction in three areas: the timeliness of the epidural, its effectiveness, and whether they felt in control of their pain management. Patients rated each component on a Likert scale: 1 (very poor), 2 (poor), 3 (fair), 4 (good), 5 (very good).
We reviewed the daily medical records to identify patients who'd received either a continuous epidural infusion or PCEA for labor pain. On their first postpartum day, we asked these patients to rate their epidural analgesia experience. For a valid sample, we needed 30 surveys from each of the two groups. By June we'd collected enough for a valid sample.
To analyze the collected data, we decided that we'd interpret a rating of 1, 2, or 3 (very poor, poor, or fair) as negative customer service and a rating of 4 or 5 (good or very good) as positive customer service.
The results of this survey supported our hypothesis that implementing PCEA would improve customer satisfaction (see And the winner is [horizontal ellipsis] PCEA). We shared the results of our survey with the obstetric anesthesiologists and with the labor and delivery nursing staff.
Second data roundup
In February 2003, we repeated the customer satisfaction survey to see if results would still support our hypothesis. By March, we'd collected 30 surveys from patients who'd used PCEA. As before, 90% or more of PCEA patients rated all three survey items as good or very good. But we couldn't compare these ratings with those for continuous infusions because we couldn't find enough patients receiving continuous infusions to obtain a valid sample size. We believe this reflects a shift away from continuous epidural infusions, which we interpret as a successful implementation of PCEA.
Improved patient satisfaction is only one potential benefit of PCEA. In the future, we'd like to study whether PCEA is associated with a lower total anesthetic dosage during labor. We'd also like to investigate how PCEA affects nursing staff's workload. If the patient can manage her own pain, her nurse's pain management workload may be lessened.
We think that PCEA may offer these other benefits in addition to improved patient satisfaction, but we'll continue to study it and then to base our policies on the evidence.
Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). Evidence-Based Clinical Practice Guideline: Nursing Care of the Woman Receiving Regional Analgesia/Anesthesia in Labor. Washington, D.C., AWHONN, January 2001.
D'Angelo R. New techniques for labor analgesia: PCEA and CSE. Clinical Obstetrics and Gynecology. 46(3):623-632, September 2002.
Stienstra R. Patient-controlled epidural analgesia or continuous infusion: Advantages and disadvantages of different modes of delivering epidural analgesia for labour. Current Opinion in Anaesthesiology. 13(3):253-256, June 2000.
van der Vyver M, et al. Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: A meta-analysis. British Journal of Anaesthesia. 89(3):459-465, September 2002.