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Although pain services have been established in many hospitals, there is considerable heterogeneity among them with respect to organization of service, staff and qualifications of staff, and treatment approaches.With this recommendation, the German Society for Anesthesiology and Intensive Care Medicine defines requirements for pain services in hospitals with respect to organizational standards and staff qualifications. The therapy offered by pain services supplements the treatment provided by the other departments involved, ensuring the high quality of specialized pain management in all areas of the hospital. Pain services shall oversee treatment with specialized analgesia techniques as well as the involvement of consultants, bringing together in-hospital pain medicine expertise in one service with availability 24 h and 7 days per week via a single contact. The medical head of the pain service shall be a qualified provider of pain medicine as defined by the German Medical Association and as a minimum should also have undergone additional training in basic psychosomatic medicine. Further members of the medical staff should possess the credentials of a medical specialist: non-medical staff should have completed continuing education in the treatment of pain. Minimal guidelines for personnel resources were defined: these included a specific time frame for first contacts (20 min) and follow-up (10 min) for specific analgesic techniques and for the involvement of consultants (first contact 45 min, follow-up 20 min), with additional time for travel, set-up, training and quality management. In addition to definition of the space and equipment needed, each service should draft its own budget, and this should be adequate and plannable. Written agreements between the disciplines and transparent documentation, including patient-reported outcomes, are recommended to ensure quality. The provision of specialized pain therapy should have high priority over all disciplines or departments.Obwohl Schmerzdienste als Versorgungsmodell etabliert sind, besteht eine erhebliche Heterogenität bezüglich Organisation, personeller Besetzung und Qualifikation sowie zum Behandlungsspektrum. Mit der vorliegenden Empfehlung definiert die Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin personelle und organisatorische Voraussetzungen für Schmerzdienste, um in Ergänzung zur allgemeinen Schmerzbehandlung der primär bettenführenden Abteilungen eine qualitativ hochwertige, spezialisierte, innerklinische schmerzmedizinische Versorgung in allen Versorgungseinheiten des Krankenhauses zu gewährleisten.Schmerzdienste sollen die Betreuung spezieller anästhesiologischer Analgesieverfahren sowie die Konsil- und Liaison-Betreuung fachlich und organisatorisch in einer Dienststruktur abdecken. Sie sollen 24 h/7 Tage die Woche über einen einheitlichen Kontakt erreichbar sein. Der Ärztliche Leiter soll die Zusatzbezeichnung Spezielle Schmerztherapie innehaben, zusätzlich möglichst eine Weiterbildung in psychosomatischer Grundversorgung. Weitere ärztliche Mitarbeiter sollen den Facharztstandard erfüllen, nicht-ärztliche Mitarbeiter schmerzspezifische Weiterbildungen nachweisen. Als zeitliche Richtwerte für die Personalkalkulation wurden Mindestzeiten definiert für die Betreuung spezieller Analgesieverfahren (Erstkontakt 20 min, Folgekontakte 10 min) und für Konsil- und Liaison-Betreuung (Erstkontakt 45 min, Folgekontakt 20 min), zuzüglich Wege- und Rüstzeiten, Schulung und Qualitätssicherung. Neben der Definition der räumlichen Ressourcen und Ausstattung wird betont, dass die Sicherstellung der spezialisierten Versorgung fach- und abteilungsübergeordnet eine hohe Priorität hat und ein ausreichendes und planbares eigenes Budget zur Verfügung stehen soll. Klinikinterne schriftliche Vereinbarungen zwischen den beteiligten Fachabteilungen werden zur Sicherung der Versorgungsqualität empfohlen, ebenso eine für alle Beteiligten transparente Dokumentation und die regelmäßige Erfassung der Ergebnisqualität aus Patientensicht.

The aim of this analysis was to describe the role of anesthesiology departments in pain medicine and palliative care services in German hospitals.In the year 2012, all heads of departments of anesthesiology registered with the German Society of Anesthesiology and Intensive Care Medicine were surveyed about structures of pain medicine and palliative care services in their hospitals using a standardized postal questionnaire.Out of 408 returned questionnaires (response rate 47%) 403 could be evaluated. Of the hospitals 58% had a designated pain medicine service, in 36 (9%) of the hospitals this was organized as an independent department and in 195 (57%) as part of another department, mostly the department of anesthesiology. The "pain clinic" as an outpatient service was the most common form of structure for pain medicine services (41%). Inpatient pain medicine units were available in 77 (19%) of the hospitals and a partial inpatient unit in the form of a day hospital in 26 (7%) of the hospitals. For the care of inpatients from other departments, there was an intrahospital pain consultation service in 166 of the hospitals, which was the only structure for pain medicine in 32 of the 231 hospitals that reported having a designated pain medicine service. In 160 pain medicine services anesthesiologists were the only medical practitioners and in a further 18 both anesthesiologists and other specialists were available (orthopedist/orthopedic surgeons n = 6, internal medicine n = 4, psychiatrist n = 2, general practitioner = 1 and neurologist n = 1). Only two hospitals had no anesthesiologist in the pain medicine team and for the remaining 51 hospitals no information was provided. In 189 of the 231 hospitals with pain medicine services, there was at least 1 physician with special qualifications in pain management. In 97 (44%) of the hospitals psychologists were part of the team with 53 having at least 1 psychologist with a special qualification in chronic pain management. Of the hospitals, 16% had a specialized department for palliative care, in 32% a specialized palliative care service was part of another department, which was the department of anesthesiology in 30%. Of the hospitals 56% had a palliative care consultation service, 41% had a specialized inpatient palliative care unit, 6% an outpatient clinic, 4% a day hospital and in 16% a specialized outpatient palliative care (SOPC) serving the community was incorporated. Inpatient consultation services and the SOPC were more common when the department of anesthesiology was involved in the palliative care services.In German hospitals, the departments of anesthesiology make a significant contribution to the provision of both pain medicine and palliative care services. Nevertheless, the respective structures of care are often incomplete or even lacking. There were shortcomings in terms of organization and qualification of the team in pain medicine services (e.g. no doctor with special qualifications in pain management or no psychologist). Palliative care services are more often organized as independent departments than as pain medicine services. Engagement of the anesthesiology department in palliative care is linked to a broader scope of the services provided, which might reflect the capacity of many anesthesiologists to work in an interdisciplinary manner and across interfaces.

Due to the implementation of the diagnosis-related groups (DRG) system, the competitive pressure on German hospitals increased. In this context it has been shown that acute pain management offers economic benefits for hospitals. The aim of this study was to analyze the impact of the competitive situation, the ownership and the economic resources required on structures and processes for acute pain management.A standardized questionnaire on structures and processes of acute pain management was mailed to the 885 directors of German departments of anesthesiology listed as members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin).For most hospitals a strong regional competition existed; however, this parameter affected neither the implementation of structures nor the recommended treatment processes for pain therapy. In contrast, a clear preference for hospitals in private ownership to use the benchmarking tool QUIPS (quality improvement in postoperative pain therapy) was found. These hospitals also presented information on coping with the management of pain in the corporate clinic mission statement more often and published information about the quality of acute pain management in the quality reports more frequently. No differences were found between hospitals with different forms of ownership in the implementation of acute pain services, quality circles, expert standard pain management and the implementation of recommended processes. Hospitals with a higher case mix index (CMI) had a certified acute pain management more often. The corporate mission statement of these hospitals also contained information on how to cope with pain, presentation of the quality of pain management in the quality report, implementation of quality circles and the implementation of the expert standard pain management more frequently. There were no differences in the frequency of using the benchmarking tool QUIPS or the implementation of recommended treatment processes with respect to the CMI.In this survey no effect of the competitive situation of hospitals on acute pain management could be demonstrated. Private ownership and a higher CMI were more often associated with structures of acute pain management which were publicly accessible in terms of hospital marketing.

In 2007, the German national guidelines on "Treatment of acute perioperative and post-traumatic pain" were published. The aim of this study was to describe current structure and process data for acute pain management in German hospitals and to compare how the guidelines and other initiatives such as benchmarking or certification changed the healthcare landscape in the last decade.All directors of German departments of anesthesiology according to the DGAI ("Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin", German Society for Anesthesiology and Intensive Care) were mailed a standardized questionnaire on structures and processes of acute pain management in their hospitals.A total of 403 completed questionnaires (46 %) could be evaluated. Of hospitals, 81 % had an acute pain service (ASD), whereby only 45 % met defined quality criteria. Written standards for acute pain management were available in 97 % of the hospitals on surgical wards and 51 % on nonsurgical wards. In 96 %, perioperative pain was regularly recorded (generally pain at rest and/or movement, pain-related functional impairment in 16 % only). Beside these routine measurements, only 38 % of hospitals monitored pain for effectiveness after acute medications. Often interdisciplinary working groups and/or pain managers are established for hospital-wide control. As specific therapy, the patient-controlled analgesia and epidural analgesia are largely prevalent ( 90 % of all hospitals). In the last decade, intravenous and oral opioid administration of opioids (including slow release preparations) has become established in acute pain management.The survey was representative by evaluating 20 % of all German hospitals. The organizational requirements for appropriate pain management recommended by the German guidelines for acute pain recommended have been established in the hospital sector in recent years. However, the organizational enforcement for acute pain management in nonsurgical areas is not adequate yet, compared to the perioperative care. In all hospitals modern medication and invasive techniques are widely available.

Data on practice and quality of postoperative pain treatment by anaesthesiologists after ambulatory surgery are sparse. The current survey enrolled anaesthesiologists in private practice who were responsible for pain therapy after ambulatory surgery. The aim of this investigation was to evaluate the implementation of the German S3 guidelines for acute and postoperative pain therapy in the outpatient setting.A total of 2,156 anaesthesiologists in private practice received a postal questionnaire which was limited to those anaesthesiologists who were responsible for postoperative pain therapy. The questionnaire included items such as types of surgery, techniques of anaesthesia and analgesic drugs used for pain management during the immediate postoperative phase and for the treatment at home as well as details of pain measurement.Out of 116 responses 108 could be analyzed covering a total of 86,616 patients receiving postoperative pain therapy, 80% of the operations were performed using general anaesthesia and local anaesthesia was additionally used in 9% of the institutions. In the perioperative period 66% of the respondents administered non-steroidal-antiinflammatory drugs (NSAIDs), 62% metamizol (dipyrone), 41% paracetamol (acetaminophen) and 73% opioids. After discharge 81% of the responding anaesthesiologists prescribed NSAIDs, 55% metamizol and 47% opioids for pain relief at home. Only 40% of the respondents measured and documented pain intensity. Nearly all respondents (93%) were satisfied with their pain management after outpatient surgery.Pain therapy after ambulatory surgery significantly varied with respect to the methods, drugs and measures of quality assurance used by anaesthesiologists in private praxis. This survey demonstrated that the national guidelines of acute pain therapy have only been partially implemented.

A survey was performed to obtain information on the organization and practice of postoperative pain management.A questionnaire was mailed to 773 directors of German departments of anesthesiology.A total of 446 replies (57.7%) could be analyzed. Of the departments, 161 (36.1%) had established an acute pain service (APS), more often in hospitalsor = 1000 beds (63%) than in hospitals with 400-999 beds (40%) and hospitals with400 beds (27%). Epidural analgesia was practiced in 97% of the departments, however, it was the analgesic technique of choice for larger abdominal surgery or amputation of the lower limb only in 60.8% and 45.5% of the departments, respectively. Departments with APS provided epidural analgesia more often on general wards than departments without APS (88.2% vs. 68.4%, p0.01). Technically more challenging methods (e.g. catheters for regional anesthesia, PCA, PCEA) were more often provided in hospitals running an APS (p0.001).The number of departments with APS has increased over the last 10 years. Future decisions on reimbursement should consider this extensive service.

Obviously there is a world-wide trend towards regional analgesia for pain relief during delivery. Data on the current practice in Germany are lacking.In 1996 questionnaires on obstetric anaesthesia and analgesia were mailed to all university departments of anaesthesia.All 38 university hospitals with obstetric units replied (100%). Mean annual delivery rate was 1156. Epidural analgesia (EA) (n = 22), intramuscular injection of opioids (n = 18), and non-opioids as a suppository (n = 17) were often used for pain relief during labour. Intravenous injections (n = 12) or pudendus anaesthesia (n = 7) were practised as well. Entonox (N2O/O2), paracervical blocks or transcutaneous electrical stimulation (TENS) was rarely used. EA for relief of labour pain was offered in all university hospitals. Twelve of them had an epidural rate of less than 10%, in nine the rate was 10-19%, in eight hospitals 20-29% and 30% or more in nine. Indication for EA was a demand by the parturient (n = 34), by the obstetrician (n = 26) or the midwife (n = 18), predominantly because of prolonged labour (n = 32) or significant pain (n = 21). Half of the university departments used an epidural combination of local anaesthetics (bupivacaine) and opioids (sufentanil (n = 12) and/or fentanyl (n = 9)). In all but one department the application of an epidural catheter was performed by anaesthesiologists exclusively. In some hospitals obstetricians (n = 10) or midwives (n = 4) were allowed to give epidural top-up injections. Of the 38 university departments 11 had an anaesthesiologists on duty 24 h a day responsible for the obstetric unit exclusively.In 1977, 14 of 18 university departments of anaesthesiology offered epidural analgesia for parturients. This option was available in all university departments in 1996. A mean rate of 10-20% epidurals for vaginal delivery is well within the limits reported from other countries, whereas the rate of regional anaesthesia for scheduled caesarean section (40%) still is rather low in Germany, as reported in part 1 of this survey (Anaesthesist 1998;47:59-63).

Obviously there is a world-wide trend towards regional anaesthesia for caesarean section (CS). Data on the current practice in Germany are lacking.In 1996 questionnaires on obstetric anaesthesia were mailed to all University departments of anaesthesia.All 38 University Hospitals with obstetric units replied (100%). Mean annual delivery rate was 1156 with a mean CS-rate of 24%. For scheduled CS the University departments used general anaesthesia in most cases (60%), followed by epidural (31%) and spinal anaesthesia (9%). General anaesthesia was predominantly used for more urgent (87%) or emergency deliveries (99%). Spinal anaesthesia was offered to patients as an option of anaesthesia for CS in 16 of 38 departments, epidural anaesthesia in 36 of 38. The majority of university hospitals (22 of 38) performed more than 25% of their CS in epidural anaesthesia; 14 departments had a ratio of at least 50% of regional anaesthesia. 28 of 32 centres administered some kind of acid aspiration chemoprophylaxis as a routine management. Special devices for the management of a difficult airway were provided in 61% of the hospitals within the delivery unit. In 70% the anaesthesiologist was responsible for the postoperative pain management following CS.A significant trend towards regional anaesthesia for CS has taken place in German university hospitals: According to a former survey regional anaesthesia was used in less than 10% of CS in 1977, whereas in the current evaluation from 1996 this figure was significantly higher (40%). Nevertheless, compared to other countries the rate of general anaesthesia still is rather high.