how to set up an acute pain service that adds value
TRANSCRIPT
How to Set Up an Acute Pain Service that Adds Value
@EMARIANOMD@EMARIANOMD
Edward R. Mariano, M.D., M.A.S.Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative & Pain MedicineProfessor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of MedicineStanford University School of MedicineChief, Anesthesiology and Perioperative CareChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care SystemVeterans Affairs Palo Alto Health Care System
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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.
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
DisclaimerDisclaimer This presentation is intended for This presentation is intended for
educational purposes only and is not educational purposes only and is not meant to be reproduced or meant to be reproduced or redistributed for commercial redistributed for commercial purposespurposes
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Learning ObjectivesLearning Objectives Discuss the value-based purchasing Discuss the value-based purchasing
program and its componentsprogram and its components Identify aspects of the HCAHPS survey Identify aspects of the HCAHPS survey
that directly and indirectly relate to that directly and indirectly relate to inpatient pain managementinpatient pain management
Discuss strategies to provide high Discuss strategies to provide high quality pain management and quality pain management and minimize risks for postsurgical patientsminimize risks for postsurgical patients
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Let’s Go Back to 2004Let’s Go Back to 2004
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
The Most Important LessonThe Most Important Lesson
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
OverviewOverview Think “big picture”Think “big picture” Continuously improveContinuously improve Reach for the starsReach for the stars
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
OverviewOverview Think “big picture”Think “big picture” Continuously improveContinuously improve Reach for the starsReach for the stars
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Perioperative Surgical HomePerioperative Surgical Home
Anesthesiology 2015;123:A23Anesthesiology 2015;123:A23
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
PSH & Pain Medicine Go PSH & Pain Medicine Go TogetherTogether
PSH: Comprehensive Literature Review, www.asahq.org/pshPSH: Comprehensive Literature Review, www.asahq.org/psh
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Institute of Medicine 2012Institute of Medicine 2012
http://www.iom.edu/http://www.iom.edu/bestcarebestcare
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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 1.75% Funded by a 1.75% 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
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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 1.75% Funded by a 1.75% 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
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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*
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Satisfaction Isn’t EverythingSatisfaction Isn’t Everything
but we are scored on it!but we are scored on it!
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
HCAHPS Questions on PainHCAHPS Questions on Pain
Mariano, et al. Adv Anesthesia 2013;31:119Mariano, et al. Adv Anesthesia 2013;31:119
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
How Do CA Hospitals How Do CA Hospitals Compare?Compare?
74%
http://http://www.hospitalcompare.hhs.govwww.hospitalcompare.hhs.gov
Hosp#1 Hosp#2 Hosp#3 CA Avg US Avg
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
How Do CA Hospitals How Do CA Hospitals Compare?Compare?
86%
http://http://www.hospitalcompare.hhs.govwww.hospitalcompare.hhs.gov
Hosp#1 Hosp#2 Hosp#3 CA Avg US Avg
Stanford Kaiser SC Wash Hosp CA Avg US Avg
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Scoring HospitalsScoring Hospitals
“Incentive” = How Much Withholding Hospitals Get Back
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Evolving Practice of Evolving Practice of AnesthesiaAnesthesia
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Avoid “Never” EventsAvoid “Never” Events
Federal Register May 3, Federal Register May 3, 20072007
Avoid “Never” (Get Paid) EventsAvoid “Never” (Get Paid) Events
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Cost Savings Benefit the Cost Savings Benefit the HospitalHospital
Increasing Phase I PACU bypassIncreasing Phase I PACU bypass Changing PACU nurse:patient ratiosChanging PACU nurse:patient ratios Decreasing unplanned hospital Decreasing unplanned hospital
admissionsadmissions Decreasing ER visitsDecreasing ER visits Shortening length of stay (e.g., joint Shortening length of stay (e.g., joint
replacement)replacement)
……Not You!Not You!
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
OverviewOverview Think “big picture”Think “big picture” Continuously improveContinuously improve Reach for the starsReach for the stars
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Improve Time ManagementImprove Time Management Educate patients earlyEducate patients early
– Surgeons’ officesSurgeons’ offices– Online Online – Preanesthetic evaluation clinicsPreanesthetic evaluation clinics– Preoperative phone callsPreoperative phone calls
Centralize supplies Centralize supplies Teamwork with perioperative staff to Teamwork with perioperative staff to
get patients ready earlyget patients ready early Consider doing blocks outside the ORConsider doing blocks outside the OR
Mariano ER. Anesth Clin Mariano ER. Anesth Clin 2008;28:6812008;28:681
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Consider Making a “Block Consider Making a “Block Room” Room”
Dedicated space Dedicated space Standard ASA Standard ASA
monitors availablemonitors available Oxygen sourceOxygen source Resuscitation Resuscitation
equipmentequipment Not for every Not for every
practicepractice
Mariano ER. Anesth Clin Mariano ER. Anesth Clin 2008;28:6812008;28:681
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Anesth Clinics 2014;32:853
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
OverviewOverview Think “big picture”Think “big picture” Continuously improveContinuously improve Reach for the starsReach for the stars
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Preoperative Preparation Preoperative Preparation TodayToday
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
A Vision for the FutureA Vision for the Future
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
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.
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Prevent Persistent Pain?Prevent Persistent Pain?
Lavand’homme, et al. CORR Lavand’homme, et al. CORR 2014;472:14092014;472:1409
TKA Patients
Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
SummarySummary We discussed the value-based We discussed the value-based
purchasing program and its componentspurchasing program and its components We identified aspects of the HCAHPS We identified aspects of the HCAHPS
survey that directly and indirectly relate survey that directly and indirectly relate to inpatient pain managementto inpatient pain management
We discussed strategies to provide high We discussed strategies to provide high quality pain management and minimize quality pain management and minimize risks for postsurgical patientsrisks for postsurgical patients