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Remifentanil patient-controlled analgesia for labour: a complete audit cycle.

I read with interest the report "Remifentanil patient-controlled analgesia for labour: a complete audit cycle" by Drs Buehner, Broadbent and Chesterfield (1). This is an important account describing the process of introducing a high quality service and gaining its acceptance from the healthcare team when there is a departure from the traditional model of care. The authors had faced a common dilemma in modern medical practice: how to best provide high quality care with limited resources. In this case it was labour analgesia that was safe, effective and acceptable for a small obstetric service, in which maintenance of technical proficiency for medical and midwifery staff was a real issue. What is commendable is that they provide a detailed report of the process whereby a number of principles of quality in healthcare, which I would like to highlight, are observed.

Quality in healthcare has been defined as "the extent to which a healthcare service or product produces a desired outcome or outcomes" (2). A number of dimensions are considered individually in determining whether overall quality care has been delivered. These include safety, access, efficiency, appropriateness and acceptability to the patient, all of which the authors addressed. Remifentanil patient-controlled analgesia for labour analgesia performed well as a high quality health care intervention in a resource-limited clinical environment. The authors commented that the positive feedback from parturients regarding this method encouraged midwifery staff to engage in this program. Further, the authors reported a course of remedial action, when poor performance occurred (low recording of patient-controlled analgesia observations once the period of observation ended) was corrected by a targeted education program and production of a new chart to capture information in a more user-friendly way.

The procedure of quality improvement can also be assessed in terms of the structure, process and outcome (3). In this report, the impetus for change was structural deficiency (limited anaesthetic resources and case load for skill maintenance), the process of providing labour analgesia was modified in keeping with recent evidence-based practice (4,5) and the outcome was systematically assessed.

Anaesthetists have been at the forefront of innovation in quality in health care in the region since the Quality in Australian Health Care Study was published almost two decades ago (6). This report should provide a blueprint for how other organisations can approach the introduction of changes to clinical practice. The authors are to be commended for providing a comprehensive account of this process to the wider anaesthesia community.


(1.) Buehner U, Broadbent JR, Chesterfield B. Remifentanil patient-controlled analgesia for labour: a complete audit cycle. Anaesth Intensive Care 2011; 39:666-670.

(2.) Runciman W. Shared meanings: preferred terms and definitions for safety and quality concepts. Med J Aust 2006; 184:S41-S43.

(3.) Donabedian A. The quality of care: how can it be assessed? JAMA 1988; 260:1743-1748.

(4.) Evron S, Glezerman M, Sadan O. Remifentanil: a novel systemic analgesic for labor pain. Anesth Analg 2005; 100:233-238.

(5.) Douma MR, Verwey RA, Kam-Endtz CE. Obstetric analgesia: a comparison of patient-controlled meperidine, remifentanil, and fentanyl in labour. Br J Anaesth 2010; 104:209-215.

(6.) Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995; 163:458-471.

M. L. Allen

Melbourne, Victoria

Remifentanil patient-controlled analgesia for labour: a complete audit cycle--Reply

We thank Dr Allen for her encouraging letter of support to our recent publication, in which we reported on the implementation process of remifentanil patient-controlled analgesia (PCA) for labour to our maternity unit and a completed audit cycle on its use (1). We acknowledge that this Quality Improvement Program is still a 'work in progress'.

As a result of our audit and parturient satisfaction findings, we recently adjusted the remifentanil PCA prescription further, reducing the incremental bolus doses (starting from 0.35 [micro]-g/kg, increasing to a maximum of 0.75 [micro]g/kg). We found women experience more side-effects with higher doses, without gaining a proportional increase in analgesic benefit or satisfaction.

We also developed a remifentanil PCA consent form/check list with prompts (tick boxes) of benefits and risks, for junior doctors rotating through the obstetric department. This serves as a memory aid and ensures that quality informed consent is sought.

Since the introduction of remifentanil PCA to our maternity unit, the use of pethidine has fallen to almost zero and our epidural rate remains unchanged at 2 to 4%. A major hurdle for smaller maternity units in New Zealand is still the unfounded fear of the College of Midwives about the safety and efficacy of remifentanil analgesia. This understandably results in apprehension among their members about engaging in the implementation process. Regrettably, our midwifery colleagues find themselves misrepresented by their own professional body.


(1.) Buehner U, Broadbent JR, Chesterfield B. Remifentanil patient-controlled analgesia for labour: a complete audit cycle. Anaesth Intensive Care 2011; 39:666-670.

U. Buehner

Rotorua, New Zealand
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Title Annotation:Correspondence
Author:Allen, M.L.
Publication:Anaesthesia and Intensive Care
Article Type:Letter to the editor
Date:Nov 1, 2011
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