The Rationale
An estimated 48 million inpatient surgical procedures are performed annually in the United States (National Center for Health Statistics, National Hospital Discharge Survey: 2009, cdcinfo@cdc.gov ). Although it is to be expected that surgical treatment results in some degree of patient discomfort, acute postsurgical pain has been widely undertreated. In one survey, 80% of patients reported experiencing moderate to extreme pain after surgery. Ineffective postoperative pain management is associated with economic and medical implications, including extended lengths of treatment, readmissions, and patient dissatisfaction with medical care.
Consequently, in 2001 the American Pain Society (APS) declared the start of a “Decade of Pain Control and Research” and urged health professionals to treat pain as “the fifth vital sign.” Thereafter, a flood of practice guidelines emerged in the literature in an attempt to emphasize and provide instructions for realization of this proposal. Nonetheless, a decade later, the parent organization of the APS, the International Association for the Study of Pain (IASP), designated 2011 the Global Year Against Acute Pain . This campaign sought to highlight “the persistent problem of acute pain…the most commonly experienced pain (e.g., surgery, childbirth, trauma)…treatable with currently available medications and techniques [but with] a large gap between evidence and practice—resulting in widespread under-treatment” ( http://www.iasp-pain.org/Content/NavigationMenu/GlobalYearAgainstPain/GlobalYearAgainstAcutePain/default.htm ).
It turns out that achieving satisfactory acute pain management is quite challenging. It is often difficult to estimate what a patient’s postoperative analgesic requirements will be.
The following factors, for example, may influence postoperative opioid requirements:
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Preoperative pain sensitivity
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Coexisting medical conditions and associated multiple drug administration
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Presurgical opioid tolerance or a history of drug abuse
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Psychological factors, including catastrophizing and anxiety
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Age
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Type of surgery
Great care must be applied to consider all the aforementioned characteristics when deriving an analgesic plan for managing an individual’s response to a surgical insult.
The sequelae associated with surgical procedures result from various components of the stress response and include cardiopulmonary, infectious, and thromboembolic complications; cerebral dysfunction; nausea and gastrointestinal paresis; fatigue; and prolonged convalescence. Throughout the process of organizing an acute pain program, it is helpful to keep the following statements in mind:
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The postoperative pain management regimen should be designed with attention to providing patient comfort and also inhibiting nociceptive impulses sufficient to allow a patient to participate fully in active rehabilitation when appropriate.
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A time-, energy-, and cost-effective acute pain program should optimally provide multimodal and multidisciplinary interventions, including systemic and regional pharmacological treatments, stress reduction, transcutaneous electrical nerve stimulation, music therapy, and acupuncture.
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Surgical stress responses are inhibited mostly by the neuraxial administration of local anesthetics; the administration of other agents—systemically, neuraxially, or perineurally—appears to contribute little additional reduction of the endocrine (metabolic and catabolic) stress response following operative procedures.
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Parenteral opioids exaggerate the perioperative immune system depression already triggered by the neuroendocrine response to surgery, although the clinical relevance of this observation is controversial. Opioids administered into the epidural space have minor suppressive effects on surgically induced proinflammatory cytokines.
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Effective analgesia can reduce postoperative morbidity. As an example, thoracic epidural analgesia has been shown to improve postoperative spirometry and reduce pulmonary infections and atelectasis. In many settings the routine and “gold standard” of care involves such facilitation of the patient’s recovery of pulmonary function.
The experience of a skilled anesthesiologist easily lends itself to providing leadership within an acute pain service. Anesthesiologists are proficient in the use of systemic and regional analgesic techniques, including peripheral and neuraxial blockade. They also often have an understanding of the surgical techniques and consequent insults that they impose. Additionally, anesthesiologists are well equipped with leadership skills for working within a multidisciplinary team; these are also vital skills within the operating theater. Nonetheless, an anesthesiologist-based team is not the only service model.
Nurse-based, anesthesiologist-supervised inpatient acute pain services have also been demonstrated to provide safe and effective postoperative pain management. Regardless of the service model, nursing involvement in an acute pain service is essential. Bedside nurses’ impression of a patient’s analgesic needs and recovery is an invaluable element in the decision-making process for any given patient, and because it is the nurse who will ultimately be delivering the care, it is vital that the nurse understand the analgesic plan and goals.
Detailed practice guidelines and protocols can help streamline the ordering and implementation of patient care. Well-established protocols have been shown to reduce errors in realms outside pain management and decrease the cost associated with prescribing choices. At the University of Washington Medical Center, for example, we have instituted multiple protocols, including order sets for patient-controlled analgesia (PCA), continuous and patient-administered epidural analgesia, ketamine infusions, and continuous perineural catheter infusions ( Figs. 3.1 to 3.4 ; we have recently switched to electronic order sets mirroring these past paper protocols). The PCA and epidural analgesia protocols must include titration and bolus instructions to treat breakthrough or incident pain. The order sets should also include routine and specific monitoring orders, as well as treatment options for common or dangerous side effects (e.g., antiemetics or antipruritics and opioid receptor antagonists to reverse respiratory depression). Ketamine and perineural anesthetics are most frequently ordered as adjuncts to other analgesic therapies (e.g., PCA). Recovery room, intensive care unit, and medical/surgical floor nurses must be trained to be familiar with the order set parameters. In most cases, nurses are able to assess the patient and implement changes that successfully achieve adequate analgesia with minimal side effects autonomously.
An emerging area of concern for any anesthesiology-based pain service is the increasing complexity of invasive pain management techniques in an era of ever-increasing numbers of anticoagulants given as treatment or prophylaxis for an ever-increasing number of medical and surgical indications (including, for example, treatment of cardiac arrhythmias or valve disease and deep vein thrombosis prophylaxis). To aid in treating such patients with the least risk, the University of Washington Medical Center has designed institutional guidelines (based on national guidelines such as those of the American Society of Regional Anesthesia, for instance) for the management of indwelling neuraxial and peripheral nerve catheters in patients treated concomitantly with anticoagulants ( Table 3.1 ). The document was designed to address placement, maintenance, and removal of the catheter in several common anticoagulation scenarios. The intention of such guidelines is to distill the existing scientific evidence and opinion into a format that is easily accessible and simple to apply to patient care.
Personal Inventory
It is important to recognize at the outset that establishing a pain service is a major endeavor. Planning, design, and implementation of a successful service will require substantial human and material resources.
If the need and desire for an acute pain service exist within a hospital facility, one must first elicit the support of the department chairperson. Although multiple design models for an acute pain management service are possible, most will require that an anesthesiologist be made available for some level of participation in the service. Unless resources allow an anesthesiologist to be easily released from operating room obligations, the staffing conflict will present a certain challenge. An agreeable arrangement of service responsibilities must allow the anesthesiologist to be available to provide safe and consistent care to whomever he or she is responsible.
Once the intradepartmental issues of resource allocation have been discussed with the chairperson, the proposal to begin an acute pain service should be brought to the medical director and team. Commitment of the medical director to the project will be necessary for provision of resources in the form of personnel and money.
Finally, appropriate leadership for the acute pain service must be selected. Operating the service will require a diverse constellation of skills. The individual must have knowledge of the mechanisms of acute postsurgical pain and the methods of treatment, including opioid and nonopioid analgesia, epidural placement and maintenance, peripheral nerve catheter placement and maintenance, and ketamine and other adjuvant drug therapies—as well as treatments of the side effects from these therapies. An anesthesiologist is often the best fit since he or she has experience with these therapies. Of course, as mentioned previously, a number of nonpharmacological therapies (e.g., physical and alternative or complementary medicine therapies) also have a role in acute pain management, and leaders of any acute pain service must likewise be aware of these therapeutic strategies.
In addition to expertise in analgesic therapies, the success and stability of any new acute pain service will require that the service director also possess certain nonclinical skills, including strong leadership, organizational, and administrative abilities. Clinical success demands the integration of multiple clinical disciplines, such as nursing, medicine, pharmacy, and others. These diverse professionals need to operate independently and in collaboration. Additionally, the leader will need to understand the place of the acute pain service within the structure of the hospital organization. The service should be structured so it is made both efficient and valuable to the hospital and its surgical services. Selection of a qualified director of an acute pain service is vital to its success.
Personal Inventory
It is important to recognize at the outset that establishing a pain service is a major endeavor. Planning, design, and implementation of a successful service will require substantial human and material resources.
If the need and desire for an acute pain service exist within a hospital facility, one must first elicit the support of the department chairperson. Although multiple design models for an acute pain management service are possible, most will require that an anesthesiologist be made available for some level of participation in the service. Unless resources allow an anesthesiologist to be easily released from operating room obligations, the staffing conflict will present a certain challenge. An agreeable arrangement of service responsibilities must allow the anesthesiologist to be available to provide safe and consistent care to whomever he or she is responsible.
Once the intradepartmental issues of resource allocation have been discussed with the chairperson, the proposal to begin an acute pain service should be brought to the medical director and team. Commitment of the medical director to the project will be necessary for provision of resources in the form of personnel and money.
Finally, appropriate leadership for the acute pain service must be selected. Operating the service will require a diverse constellation of skills. The individual must have knowledge of the mechanisms of acute postsurgical pain and the methods of treatment, including opioid and nonopioid analgesia, epidural placement and maintenance, peripheral nerve catheter placement and maintenance, and ketamine and other adjuvant drug therapies—as well as treatments of the side effects from these therapies. An anesthesiologist is often the best fit since he or she has experience with these therapies. Of course, as mentioned previously, a number of nonpharmacological therapies (e.g., physical and alternative or complementary medicine therapies) also have a role in acute pain management, and leaders of any acute pain service must likewise be aware of these therapeutic strategies.
In addition to expertise in analgesic therapies, the success and stability of any new acute pain service will require that the service director also possess certain nonclinical skills, including strong leadership, organizational, and administrative abilities. Clinical success demands the integration of multiple clinical disciplines, such as nursing, medicine, pharmacy, and others. These diverse professionals need to operate independently and in collaboration. Additionally, the leader will need to understand the place of the acute pain service within the structure of the hospital organization. The service should be structured so it is made both efficient and valuable to the hospital and its surgical services. Selection of a qualified director of an acute pain service is vital to its success.
Assessment of Need
Once the challenge of organizing an acute pain service is accepted, assessment of need is mandatory. This might be accomplished by surveying the patient population, nurses, types of specialty services, procedures commonly performed, and the people performing these procedures. Furthermore, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has set forth standards declaring the patient’s right to adequate pain assessment and treatment and has explicitly acknowledged that pain is a coexisting condition with a number of diseases and injuries that requires explicit attention. It is on this basis that the mission statement of the service should be defined.
Those constructing the service might also consider whether they wish to distinguish or separate different types of pain management challenges or manage them as a conglomerate. As an example, the University of Washington Inpatient Pain Services is divided into three factions: acute pain, chronic/cancer pain, and interventional pain. The service was separated into these groups to preserve continuity of care and more practically manage the high volume of patients. Admittedly, the boundaries between these categories are artificial and may overlap. As an example, consider a patient with acute postsurgical pain superimposed on chronic cancer pain or a patient who has recently undergone placement of an implanted epidural neuromodulating device for treating chronic pain.
Whatever the organization, an acute postoperative pain management service is likely to require 24-hour, 7-day-a-week call coverage, with appropriately available medical supervision. Immediate availability is important with regard to patient safety and patient satisfaction. Inadequacy of pain relief has been highlighted as a quality-of-care measure and a focus of patients’ concern. In a questionnaire survey, 57% of patients identified pain after surgery as their primary fear. The competitive health care environment mandates that hospitals share a focus on the issues that are most important to patients. Favorable reports of patient satisfaction may attract patients to partake of services in a given hospital facility and also encourage patient loyalty with return for future medical services. Furthermore, immediate postoperative patient satisfaction with care is a predictor of long-term, positively self-perceived health status according to one multicenter prospective cohort study. Indeed, data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) are likely to put hospital pain management, as well as patient satisfaction with that management, front and center not only with regard to comparisons between hospitals but ultimately for reimbursement of hospital services.
Definition of the Service
Once the mission statement has been formulated in response to the perceived institutional and community needs, it is necessary to define the resources that will be required. The resources and modalities that an acute pain service may use are diverse and depend on the patient population, the skills of the personnel, and the service’s therapeutic approach. Ideally, a scientific approach to the selection of treatment modalities that specifically evaluates the efficacy and cost-effectiveness of each therapy is used. Ultimately, the resources required to implement and operate an acute pain service will represent a synthesis of characteristics of the patient population, evidence-based selection of therapeutic modalities, and consistency with the service’s mission.
The feasibility of various treatment plans based on the availability of resources has been defined by the IASP task force on the management of acute pain ( Table 3.2 ). Again, individualized treatment of patients should ideally be chosen from a rational, evidence-based selection list, also outlined by the IASP task force on management of acute pain ( Table 3.3 ). Such ideal care allows maximal improvement of patients’ outcome with the most cost-effectiveness possible. To achieve this aim, resources in the form of medications, equipment, and personnel must be anticipated and negotiated with the institution’s administrative, business, and clinical departments when one is designing the structure of the service.
