Improving Patient and Nurse Outcomes: A Comparison of Nurse Tasks and Time Associated With Two Patient-Controlled Analgesia Modalities Using Delphi Panels

The Importance of Optimizing Acute Pain in the Orthopedic Trauma Patient

Postoperative pain control is a highly studied topic because of its significant effect on costs, hospital course, and, most importantly, patient satisfaction. Opioid use has been the "status quo" of postoperative pain management but prolongs hospital stays and increases complications. Optimizing acute pain management in patients with orthopedic trauma is important and can translate into significant positive physiologic and financial outcomes. Although multiple viable examples of optimizing acute pain management in the literature demonstrate outcome improvements, implementation has not been widespread. Significant outcome success will depend more on systemwide implementation than a specific regimen for postoperative pain control.

The Efficacy and Safety of the Fentanyl Iontophoretic Transdermal System (IONSYS®) in the Geriatric Population: Results of a Meta-Analysis of Phase III and IIIb Trials

Background and Objectives

Acute postoperative pain management in the geriatric patient can be challenging, including their response to medications. The purpose of this analysis was to evaluate whether the efficacy and safety profile of fentanyl iontophoretic transdermal system (ITS) (IONSYS^®) was similar in geriatric (≥65 years) and non-geriatric (<65 years) patients.

Methods

Efficacy and safety data from three randomized, double-blind, placebo-controlled trials and four randomized, open-label, active-comparator trials were utilized for this analysis. Efficacy was assessed via the patient global assessment (PGA) and the investigator global assessment (IGA) scales. The PGA and IGA are categorical 4-point scales (excellent, good, fair, or poor) with treatment success defined as excellent or good. Safety was evaluated via adverse events.

Results

A total of 1763 patients were assigned to the fentanyl ITS treatment group. Of the 1763 patients in the fentanyl ITS group, 499 patients were ≥65 years of age; 65.1% were 65–74 years of age, 31.7% were 75–84 years of age, and 3.2% were ≥85 years of age. In the fentanyl ITS treatment groups, there were no statistically significant differences between the non-geriatric and geriatric patients in terms of patients reporting success on the PGA at 24 h (80.0 vs. 83.0%, respectively; p = 0.3415). There were no statistically significant differences between the groups in success rates on the IGA at study discharge (82.8 vs. 87.5%, respectively; p = 0.1195). The safety profile was similar between the age groups.

Conclusions

Overall, efficacy and safety of the fentanyl ITS were similar between the geriatric and non-geriatric patients.

Meta-Analysis of the Ease of Care From the Nurses' Perspective Comparing Fentanyl Iontophoretic Transdermal System (ITS) Vs Morphine Intravenous Patient-Controlled Analgesia (IV PCA) in Postoperative Pain Management

PURPOSE

The aim of this meta-analysis was to compare the ease of care (EOC) of fentanyl iontophoretic transdermal system (ITS) vs the morphine intravenous patient-controlled analgesia (IV PCA) as assessed by the nurse.

DESIGN

Meta-analysis of three phase 3B randomized active-comparator trials.

METHODS

This meta-analysis according to Cochrane's approach assessed EOC using a validated nurse questionnaire (22 items grouped into three subscales, which include time efficiency, convenience, and satisfaction) in adult patients treated with fentanyl ITS or morphine IV PCA for postoperative pain management. The weighted mean difference (WMD) between treatments was calculated.

FINDING

EOC analyses were based on responses to questionnaires from 848 (fentanyl ITS) and 761 (morphine IV PCA) nurses. Fentanyl ITS was reported to provide significant advantages compared with morphine IV PCA in terms of nurses' overall EOC (WMD = -0.57, P < .0001) and each of the subscales: time efficiency (WMD = -0.58, P < .0001), convenience (WMD = -0.57, P < .0001), and satisfaction (WMD = -0.47, P < .0001).

CONCLUSIONS

In this meta-analysis, fentanyl ITS is associated with a superior EOC profile from the nurses' perspective than morphine IV PCA.

Meta-Analysis of the Ease of Care From a Patients' Perspective Comparing Fentanyl Iontophoretic Transdermal System Versus Morphine Intravenous Patient-Controlled Analgesia in Postoperative Pain Management

PURPOSE

The purpose of this meta-analysis was to evaluate patients' assessment of fentanyl iontophoretic transdermal system (ITS) and morphine intravenous patient-controlled analgesia (IV PCA) ease of care (EOC) using a validated patient EOC questionnaire. Fentanyl ITS is a preprogrammed, needle-free PCA system used for the management of acute pain in postoperative patients.

METHODS

This meta-analysis assessed the patient EOC of fentanyl ITS and morphine IV PCA using data from three randomized, active-comparator trials in adult postoperative patients with moderate-to-severe pain. All three studies utilized a validated patient EOC questionnaire which consists of 23 items grouped into seven subscales (confidence with device, comfort with device, movement, dosing confidence, pain control, knowledge/understanding, and satisfaction). Each item is scored on a six-point Likert scale. The weighted mean difference between treatments was calculated for the overall EOC and for each of the seven subscales.

RESULTS

The EOC analyses were based on responses to questionnaires from 1,943 patients treated with either fentanyl ITS (n = 961) or morphine IV PCA (n = 982). There was a statistically significant advantage in favor of fentanyl ITS over morphine IV PCA in terms of overall EOC (weighted mean difference = 0.28; 95% confidence interval (0.22 to 0.34); P < 0.0001). Five of the seven subscales (confidence with device, comfort with device, movement, dosing confidence, and knowledge/understanding) on the patient EOC questionnaire showed a statistically significant advantage for fentanyl ITS versus morphine IV PCA. The two subscales that did not show any difference were pain control (P = 0.7303) and satisfaction (0.0561).

CONCLUSION

In this meta-analysis, fentanyl ITS is associated with some advantages in terms of an EOC profile from a patients' perspective when compared with morphine IV PCA.

Comparison of fentanyl iontophoretic transdermal system and routine care with morphine intravenous patient-controlled analgesia in the management of early postoperative mobilisation: results from a randomised study

INTRODUCTION

Fentanyl iontophoretic transdermal system (ITS) (IONSYS^®, The Medicines Company, Parsippany, NJ, USA) and morphine intravenous (IV) patient-controlled analgesia (PCA) have demonstrated equivalent pain control in several published studies. The primary objective of the current study was to compare fentanyl ITS with morphine IV PCA with regard to the patient's ability to mobilise with acute postoperative pain.

METHODS

In this multicentre, open-label, randomised, active-controlled, prospective phase IV study, postoperative patients initially received IV morphine and were titrated to pain score ⩽ 4out of 10 on a Numeric Rating Scale (NRS) and then received fentanyl ITS (up to 240 µg (6 doses)/hour; up to a maximum of 3.2 mg (80 doses)/24 hours) or morphine IV PCA (doses up to 20 mg morphine/2 hours, up to 240 mg/24 hours). The primary efficacy measure was ability to mobilise, assessed using patient responses to three validated questions regarding mobility on a 6-point Likert scale (0 = no difficulty to mobilise to 5 = a very great deal of difficulty to mobilise). The study was originally planned to include ~200 patients. However, following the early suspension and termination of the study, a total of 108 patients were randomised to study treatment.

RESULTS

One hundred and eight patients were recruited prior to undergoing surgical procedures (orthopaedic surgical procedures (72%) or underwent major abdominal procedures (28%)). Postoperatively, 58 were randomised to receive fentanyl ITS, and 50 to morphine IV PCA. Fentanyl ITS patients had a greater ability to mobilise at the time of stopping study drug, with an adjusted mean ability to mobilise score (95% confidence interval (CI)) of 0.14 (-0.19, 0.47) for fentanyl ITS patients and 2.37 (1.98, 2.76) for morphine IV PCA patients (p < 0.001).

CONCLUSION

Patients treated with fentanyl ITS reported that they were better able to mobilise than patients treated with morphine IV PCA, at all time-points following surgery out to 24 hours.

Meta-analysis of the efficacy of the fentanyl iontophoretic transdermal system versus intravenous patient-controlled analgesia in postoperative pain management

OBJECTIVE

This meta-analysis was conducted to analyze and compare the efficacy outcomes associated with the fentanyl iontophoretic transdermal system (ITS) and morphine intravenous (IV) patient-controlled analgesia (PCA) in the management of postoperative pain.

RESEARCH DESIGN AND METHODS

This meta-analysis assessed the efficacy of the fentanyl ITS versus morphine IV PCA using data from four randomized, active-controlled trials (n = 1271 fentanyl ITS and 1298 morphine IV PCA patients). Main outcome measures were patient global assessment (PGA) of the method of pain control at 24 h.

RESULTS

Fentanyl ITS and morphine IV PCA did not significantly differ regarding 'good' and 'excellent' ratings on the PGA of the method of pain control at 24 h (odds ratio = 0.95, p = 0.66), however, fentanyl ITS was superior in terms of 'excellent' PGA ratings at that time point (odds ratio = 1.53, p < 0.0001). No significant differences were found in weighted mean pain intensity scores at 24, 48 and 72 h.

CONCLUSIONS

In this meta-analysis, fentanyl ITS was as efficacious as morphine IV PCA and may offer additional benefits as demonstrated by its 'excellent' PGA ratings.

Development of the fentanyl iontophoretic transdermal system (ITS) for patient-controlled analgesia of postoperative pain management

The fentanyl iontophoretic transdermal system (ITS) is a needle-free, patient-activated drug delivery system used for patient-controlled analgesia in adult hospitalized patients with postoperative pain. The system design has been updated to a separated system consisting of a Controller and a Drug Unit, and has had regulatory submissions in USA and Europe in 2014. Fentanyl ITS has been shown to be therapeutically equivalent to morphine intravenous (iv.) patient-controlled analgesia. One of the advantages of fentanyl ITS is that patients have better mobility as there is no need for an iv. pump, iv. lines and pole. The introduction of the updated fentanyl ITS will add a versatile tool to the postoperative pain management armamentarium.

Current and developing methods of patient-controlled analgesia

Moderate-to-severe acute postoperative pain is commonly controlled with opioids administered via programmable intravenous (IV) patient-controlled analgesia (PCA) infusion pumps. Intravenously administered opioids provide effective relief of postoperative pain, and IV PCA enables patients to control their level of analgesia, which has advantages over nurse-administered approaches, including more satisfied patients and improved pain relief. Unfortunately, commonly used opioid analgesics can cause significant adverse effects. Furthermore, IV PCA has drawbacks, such as device programming errors, system errors, medication errors, limitations in patient mobility, and potential for IV tubing kinks, clogging, and transmission of infection. The IV route of administration is also characterized by a rapid, high peak in analgesic drug concentration followed by rapidly decreasing concentrations. Consequently, respiratory depression, excessive sedation, and inadequate pain control can occur. Furthermore, the technical assembly of an infusion pump is often complex and time-consuming. PCA modalities that incorporate superior opioid analgesics, such as sufentanil, and novel noninvasive routes of administration offer great promise for enhancing the patient and caregiver experience with the use of postoperative PCA.

Fentanyl HCl iontophoretic transdermal system versus morphine IV-PCA for postoperative pain management: survey of healthcare provider opinion

OBJECTIVE

This survey estimated differences in staff time requirements between fentanyl HCl iontophoretic transdermal system (fentanyl ITS) and intravenous patient-controlled analgesia (IV-PCA) in post-operative pain management.

RESEARCH DESIGN AND METHODS

European Delphi panels of nurses and anaesthesiologists, who had practical experience with both fentanyl ITS and IV-PCA, were provided a task list, developed from a previous clinical trial, associated with each modality. The panellists were asked to estimate time spent on each task. Estimates were calculated by multiplying the estimated patient proportion for whom the task was performed by the expected frequency of task performance, by the estimated task time.

RESULTS

Data is presented as mean minutes (standard deviation). Fentanyl ITS use was estimated to save an average of 68.7 min total staff time per patient per treatment period compared to IV-PCA (86.5 (20.3)) vs. 156.4 (55.2); respectively; p < 0.001), the largest amount of savings being in the 'Setup' category (19.4 (6.7) vs. 47.8 (17.5), respectively; p < 0.001), and mostly due to IV-PCA task elimination. Significant time savings were estimated using fentanyl ITS over IV-PCA in the 'Discontinuation' category (4.8 (2.4) vs. 20.6 (3.3), respectively; p < 0.001). Panellists agreed that fentanyl ITS use would decrease staff assistance time required for helping patients during self-care routines and it may also decrease the patient's time to ambulation. Survey limitations included: possible recall bias due to the observational nature of the data; task list descriptions resulting in possible double-counting of data; no sensitivity analyses; and the declarative nature of the responses possibly leading to a dilution of survey findings.

CONCLUSIONS

Fentanyl ITS use was estimated, by expert opinion, to require 44% less staff time than IV-PCA use.