get rid of your traditional acute pain service and broaden your vision!

@EMARIANOMD@EMARIANOMD

Get Rid of Your Traditional Get Rid of Your Traditional Acute Pain Service and Acute Pain Service and Broaden Your Vision!Broaden Your Vision!

Edward R. Mariano, M.D., Edward R. Mariano, M.D., M.A.S.M.A.S.

Associate Professor of AnesthesiologyAssociate Professor of AnesthesiologyStanford University School of MedicineStanford University School of Medicine

Chief, Anesthesiology and Perioperative Chief, Anesthesiology and Perioperative CareCare

Veterans Affairs Palo Alto Health Care Veterans Affairs Palo Alto Health Care SystemSystem

Acute Pain Service and PSHAcute Pain Service and PSH

Financial DisclosuresFinancial Disclosures Halyard Health, B Braun – Halyard Health, B Braun –

Unrestricted educational program Unrestricted educational program funding paid to my institutionfunding paid to my institution

The contents of the following The contents of the following presentation are solely the presentation are solely the responsibility of the speaker without responsibility of the speaker without input from any of the above input from any of the above companies.companies.


Learning ObjectivesLearning Objectives Discuss the role of acute pain Discuss the role of acute pain

management in the broader context of management in the broader context of healthcare changes;healthcare changes;

Identify specific ways to improve Identify specific ways to improve current acute pain management current acute pain management systems; systems;

Discuss potential strategies to expand Discuss potential strategies to expand the scope of acute pain services and the scope of acute pain services and affect long-term outcomes.affect long-term outcomes.


Triple AimTriple Aim

Berwick et al., Health Aff (Millwood) 2008;27:759Berwick et al., Health Aff (Millwood) 2008;27:759Vetter et al., Anesth Analg 2014;118(5):1131Vetter et al., Anesth Analg 2014;118(5):1131


Perioperative Surgical HomePerioperative Surgical Home

Anesthesiology 2015;123:A23Anesthesiology 2015;123:A23


Elements of PSHElements of PSH

PSH: Comprehensive Literature Review, www.asahq.org/pshPSH: Comprehensive Literature Review, www.asahq.org/psh


OverviewOverview Think “big picture”Think “big picture” Continuously improveContinuously improve Reach for the starsReach for the stars


Institute of Medicine 2012Institute of Medicine 2012

http://www.iom.edu/http://www.iom.edu/bestcarebestcare


Authorized by the Affordable Care Act Authorized by the Affordable Care Act but has been around longerbut has been around longer

““Pays for care that Pays for care that rewards better value, rewards better value, patient outcomes, and innovations,patient outcomes, and innovations, instead of just volume of services”instead of just volume of services”

Funded by a 1.25% Funded by a 1.25% withholdwithhold from from participating hospitals’ Diagnosis-participating hospitals’ Diagnosis-Related Group (DRG) payments Related Group (DRG) payments (2% by (2% by 2017)2017)

Value-Based Purchasing Value-Based Purchasing (VBP)(VBP)

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/downloads/Instruments/hospital-value-based-purchasing/downloads/HospVBP_ODF_072711.pdfHospVBP_ODF_072711.pdf


FY2014 Value-Based FY2014 Value-Based PurchasingPurchasing

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/NPCSlides071112.pdfhospital-value-based-purchasing/Downloads/NPCSlides071112.pdf

*NEW*

*NEW*


Assessing Patient Assessing Patient ExperienceExperience

Patients are surveyed using the Patients are surveyed using the Hospital Hospital Consumer Assessment of Healthcare Consumer Assessment of Healthcare Providers and Systems Providers and Systems (HCAHPS)(HCAHPS)11

32 questions32 questions Publicly reportedPublicly reported 4 times a year 4 times a year22

HCAHPS is administered to a random HCAHPS is administered to a random sample of adult inpatients between 48 sample of adult inpatients between 48 hours and six weeks after dischargehours and six weeks after discharge

1. http://www.hcahpsonline.org1. http://www.hcahpsonline.org2. 2. http://www.hospitalcompare.hhs.gohttp://www.hospitalcompare.hhs.govv


HCAHPS Questions on PainHCAHPS Questions on Pain

Mariano, et al. Adv Anesthesia 2013;31:119Mariano, et al. Adv Anesthesia 2013;31:119


Scoring HospitalsScoring Hospitals

“Incentive” = How Much Withholding Hospitals Get Back


Evolving Practice of Evolving Practice of AnesthesiaAnesthesia


Develop Patient Care Develop Patient Care PathwaysPathways

Hebl JR, et al. JBJS 2005;87 Suppl Hebl JR, et al. JBJS 2005;87 Suppl 2:632:63


Target AnalgesiaTarget Analgesia Injectate administered Injectate administered

distal to the femoral distal to the femoral triangle in triangle in adductor adductor canalcanal

Many variations on Many variations on technique technique

Effective vs. placebo Effective vs. placebo injectioninjection

Decreases quad strength Decreases quad strength but less than FNBbut less than FNB

Tsui & Ozelsel. RAPM 2009;34:178Tsui & Ozelsel. RAPM 2009;34:178Ishiguro S, et al. A&A Ishiguro S, et al. A&A 2012;115:14672012;115:1467Jaeger P, et al. Acta Anaes Jaeger P, et al. Acta Anaes 2012;56:10132012;56:1013Jaeger P, et al. Anesth Jaeger P, et al. Anesth 2013;118:4092013;118:409

Lund J, et al. Acta Anaes 2011;55:14Lund J, et al. Acta Anaes 2011;55:14Manickam B, et al. RAPM Manickam B, et al. RAPM 2009;34:5782009;34:578Krombach & Gray. RAPM Krombach & Gray. RAPM 2007;32:3692007;32:369

LATE

RAL

SFA

N

SARTORIUS


Update Clinical PathwaysUpdate Clinical Pathways In April 2012, clinical pathway changed In April 2012, clinical pathway changed

from CFNB to continuous adductor canal from CFNB to continuous adductor canal blocks due to concern over quad weaknessblocks due to concern over quad weakness

Hypothesis for retrospective cohort study: Hypothesis for retrospective cohort study: patients with continuous adductor canal patients with continuous adductor canal blocks blocks ambulate further ambulate further than those with than those with continuous femoral nerve blocks on continuous femoral nerve blocks on postoperative day (POD) 1 without postoperative day (POD) 1 without reduction in analgesiareduction in analgesia

Mudumbai & Mariano, et al. CORR Mudumbai & Mariano, et al. CORR 2014;472:13772014;472:1377


Patients in the adductor Patients in the adductor canal group walked canal group walked 3737 (0-90) meters vs. (0-90) meters vs. 66 (0- (0-51) meters in the 51) meters in the femoral catheter group femoral catheter group ((p=0.003p=0.003). ).

Pain scores, opioid Pain scores, opioid consumption, and consumption, and hospital length of stay hospital length of stay were similar. were similar.

Promote Early Promote Early RehabilitationRehabilitation

Mudumbai & Mariano, et al. CORR Mudumbai & Mariano, et al. CORR 2014;472:13772014;472:1377


Practice Evidence-Based Practice Evidence-Based MedicineMedicine

30-day mortality was lower30-day mortality was lower for neuraxial and for neuraxial and neuraxial/GA vs. GA alone for TKAneuraxial/GA vs. GA alone for TKA

Most in-hospital complications were lower for Most in-hospital complications were lower for neuraxial and neuraxial/GA vs. GA aloneneuraxial and neuraxial/GA vs. GA alone

Transfusion requirements lowest for neuraxialTransfusion requirements lowest for neuraxial

Memtsoudis SG, et al. Anesth Memtsoudis SG, et al. Anesth 2013;118:10462013;118:1046

Mudumbai & Mariano, et al. Mudumbai & Mariano, et al. SubmittedSubmitted


TKA Protocol (VA Palo Alto)TKA Protocol (VA Palo Alto)PreopPreop 1.1. Adductor canal catheterAdductor canal catheter

2.2. Oral gabapentin if opioid-Oral gabapentin if opioid-dependentdependent

OROR Spinal anesthesia, LIA, IV Spinal anesthesia, LIA, IV acetaminophenacetaminophen

PostoPostopp

1.1. Continuous perineural infusion Continuous perineural infusion (0.2% ropivacaine 6 ml/h basal)(0.2% ropivacaine 6 ml/h basal)

2.2. Oral NSAID and acetaminophen Oral NSAID and acetaminophen ATCATC

3.3. Oral opioid ATC and PRNOral opioid ATC and PRN4.4. IV opioid PRN but no IV PCAIV opioid PRN but no IV PCAMariano, et al. Adv Anesthesia 2013;31:119Mariano, et al. Adv Anesthesia 2013;31:119


Anesth Clinics 2014;32:853


Preoperative Preparation Preoperative Preparation TodayToday


A Vision for the FutureA Vision for the Future


Mariano, Walters, Kim, Kain. A&A Mariano, Walters, Kim, Kain. A&A 2015;120:11632015;120:1163Walters, Mariano, Clark. Pain Med Walters, Mariano, Clark. Pain Med 2015;16:1666.2015;16:1666.


Improve Long-Term Function?Improve Long-Term Function? 1 yr Western Ontario and McMaster Univ 1 yr Western Ontario and McMaster Univ

Osteoarthritis Index (WOMAC) scoresOsteoarthritis Index (WOMAC) scores

Ilfeld BM, et al. A&A Ilfeld BM, et al. A&A 2009;108:13202009;108:1320Ilfeld BM, et al. A&A Ilfeld BM, et al. A&A 2009;109:5862009;109:586


Prevent Persistent Pain?Prevent Persistent Pain?

Lavand’homme, et al. CORR Lavand’homme, et al. CORR 2014;472:14092014;472:1409

TKA Patients


SummarySummary We discussed the role of acute pain We discussed the role of acute pain

management in the broader context of management in the broader context of healthcare changes;healthcare changes;

We identified specific ways to improve We identified specific ways to improve current acute pain management current acute pain management systems; systems;

We discussed potential strategies to We discussed potential strategies to expand the scope of acute pain expand the scope of acute pain services and affect long-term services and affect long-term outcomes.outcomes.


Questions?Questions?

“The sooner patients can be removed from the depressing influence of general hospital life the more rapid their convalescence.”

- Dr. Charles Mayo, Lancet 1916