Special thanks to contributions from Robert Trainer, DO; Allen Ha, PharmD; Mercy Orikogbo, RN; and Diane Ibanez, RN.
The Hunter Holmes McGuire VAMC cares for veterans with the most significant and life-threatening disease burden across the VHA system. Our VA in Richmond is one of only a few VA facilities across the nation that has a true dedicated Acute Pain Service (APS). It was created as part of the perioperative home as a multidisciplinary initiative in collaboration with the chronic pain clinic, palliative care, addiction medicine, and Preoperative Anesthesia Service (PAS) to improve hospital wide outcomes.
Despite the obvious benefits, the establishment of an Acute Pain Service at our institution was initially very challenging and met with skepticism. Considered one of the largest in the nation and a “Center of Excellence”, our hospital’s size alone made it difficult to establish communication across multiple services. Surgeons feared our involvement would delay their case. Nurses stated they would not have the time or resources to assist. Creation of the service required additional protected space for procedures and monitoring, and acquisition of newer equipment including ultrasounds, probes, and catheter pumps. Implementation of the Acute Pain Service also meant negotiating approval of pharmacy purchasing for large quantities of local anesthetics. We recruited two specialized Anesthesiologists with experience in regional-based anesthetic techniques and treatment of acute pain in complex patients, along with two dedicated Physician Assistants. And last, but certainly not least, we alloted hours of dedicated time to educating the nursing staff around the hospital about fundamentals of peripheral nerve blocks, managing pain catheter pumps, as well as recognizing and treating Local Anesthetic Systemic Toxicity “LAST”. (See Figure 2)
Figure 2: Diagram created by Robert Trainer, DO
Though these initial steps demanded an investment of thousands of dollars of resources and months of our time and attention, in the end, it was vital to the service’s success.
The VAMC in Richmond, Virginia provides tertiary care and surgical services up to and including oncological, general, vascular, plastics, orthopedic, neurosurgical, urological, podiatry, and cardiothoracic surgery. As such, it is imperative that we have trained staff in-house at all times to handle the acute pain needs that occur in our surgical patient populations, as well as other areas. Since inception, we have seen more than a ten-fold increase in unique consults and regional based anesthetic techniques. (See Figure 3)
Figure 3: Increase in APS Workload 2015 – 2018
The hospital has also seen an overall decrease in lengths of hospital stay as measured by the Veterans Affairs Surgical Quality Improvement Program data. (See Figure 4)
Figure 4: VASQIP data, provided by Diane Ibanez
On the post op surgical wards from 2015 to 2018, we saw a 32% decrease in use of Patient Controlled Analgesic (PCA)/month, and a 48% decrease in number of unique patients using a PCA/month. (See Figure 5)
Figure 5: Data retrieved from Surgical Ward Omnicell, provided by Allen Ha, Pharmacist
We offer comprehensive pre-emptive treatments of acute pain with the goal of improving patient satisfaction, as well as lowering the transition from acute to chronic pain. We are frequently consulted to manage post-surgical pain in patients with complex medical problems in whom we are interested in decreasing opioid utilization. In the operating room, the dedicated pain service has contributed to improved OR efficiency due to a perceived decrease in block placement times leading to an increase in on-time starts, surgeon reported improved efficacy of the blocks performed, and an increased number of cases able to be performed solely under regional anesthetic versus general anesthesia (Figure 6).
Figure 6: Increased number of Anesthetics able to be performed under Regional vs. General Anesthesia
In collaboration with the surgical and medical services, we have worked to standardize postsurgical pain regimens utilizing Enhanced Recovery After Surgery (ERAS) protocols, which are opioid sparing and include multimodal analgesics.
For example, those patients undergoing Total Knee Arthroplasty at our institution are given oral acetaminophen, meloxicam, and gabapentin (unless contraindicated) in the preoperative holding area, a spinal anesthetic, and either a peripheral nerve catheter infusing low-dose ropivacaine (0.2%) or a single shot nerve block with longer acting liposomal bupivacaine placed in the adductor canal in the post anesthesia recovery unit.
The protocol includes continuation of scheduled acetaminophen, meloxicam, and gabapentin, along with low dose oral oxycodone as needed for breakthrough pain. We have found this regimen to be very successful in ensuring our patients are discharged on time with minimal opioid requirements, and with optimal participation in physical therapy with adequate functional rehab scores.
For those patients undergoing non-traumatic trans-tibial and trans-femoral amputations, we aim to place peripheral nerve catheters upon admission to the surgical floors, sometimes days before their scheduled surgeries. Because these patients tend to have some of the most complex medical conditions, in nearly every case, we attempt to perform nerve blocks prior to the procedure that can be utilized not only to control pain, but also for the primary anesthetic technique.
Before 2015, most of these cases were performed under general anesthesia, and occasionally under spinal anesthesia, when there were no contraindications. Their pain was controlled mostly with opioids. These patients often spent days to weeks in the hospital, sometimes requiring further amputations because their pain was assumed to be related to further ischemia or disease. With a dedicated acute pain service, we are now able to better control their pain with regional-based anesthetic techniques.
Recently the Acute Pain Service teamed up with the Chronic Pain Service, and concluded a grant funded prospective randomized controlled research trial evaluating the benefits of early neuromodulator techniques in decreasing opioid utilization, controlling pain, and minimizing the transition from acute to chronic pain in amputee patients.
Our research project compared the effectiveness and safety of a temporary implanted Peripheral Nerve Stimulation (PNS) device system (see Figure 7) in conjunction with Standard Medical Therapy (SMT) to SMT alone for the treatment of acute pain following lower extremity amputations. Other acute pain research at our VA includes ongoing retrospective comparisons of liposomal bupivacaine single shot nerve blocks versus continuous infusions of local anesthetics via nerve block catheters for post-surgical pain control after shoulder and knee arthroplasty surgeries. These efforts are all a part of the APS opioid mitigation strategies.
Figure 7: PNS device with Needle Introducer and Lead
In addition to providing a twenty-four hour consultation service for acute pain related problems, we have integrated services with the chronic pain clinic, palliative care, spinal cord injury service, and addiction medicine for a more complete triage of inpatient pain consultation. Our constant presence on the wards and in the OR improves working relationships and fosters a better understanding of evidence-based pain practices for all involved services.
Lastly, we have taken on the long-term goal of eliminating opioid-related adverse events hospital wide. This includes minimizing the risk of opioid induced ventilatory impairment in post-surgical patients, especially those with OSA or at high risk of obstructed airways.
Focused efforts to achieve this goal have included collaboration between APS and the preoperative anesthesia service to identify patients with OSA, flag them as patients who require a non-opioid multimodal based perioperative anesthetic, utilization of regional anesthesia when appropriate, enhanced postoperative monitoring, and a discharge plan home with readily available intranasal or injectable narcan, as well as a functioning CPAP machine and proper fitting mask.
We have spearheaded a ketamine infusion protocol as an alternative to opioids for treating acute pain in those patients whom opioid tolerance has developed, such as those requiring escalating doses of opioids to control pain, or those in whom treatment of acute pain has become resistant to common modalities. We have had such great success with ketamine’s safety profile and efficacy that we hope to eventually expand its utilization from the ICU environment to the Wards for use as an additional opioid-sparing adjunct in the treatment of acute pain.
In conclusion, the creation of a separate and dedicated care team, the Acute Pain Service, for treating patients with acute or acute on chronic pain, has shown multiple benefits in safety and effectiveness in the VHA’s ongoing efforts to combat opioid related adverse events and has been an integral part of the successful collaboration between several multidisciplinary services.