GROUP EFFORT From pre-admission to discharge, just about everybody contributes to pain control at Houston Physicians' Hospital.

The total knee patients at Houston Physicians' Hospital tend to feel surprisingly good after surgery. At times, they've felt a little too good. "Patients were flexing their knees so much on the first post-op day that we had to tell them to back off a little bit," says Patricia Ford, MSN, RN, the chief nursing officer. "We were getting feedback from surgeons that some incisions weren't healing well because patients were flexing too much."

How did it come about that this year's OR Excellence Award winner for pain control actually had to rein patients in to keep them from bolting out of the gate? Credit the hospital's multifaceted initiative to implement and standardize best practices that educate patients, minimize opioids, employ multimodal pain protocols, and help total-joint patients heal as quickly and comfortably as possible.

"We're really proud of what we've done in the last year," says Ms. Ford. The hospital, she says, had been doing joint replacements for 12 years, "but last year we decided to take a closer look at some best practices and try to standardize what we were doing. All of our surgeons were doing things a little differently, so we decided to set up some meetings and compare notes."

The result was a program in which patients set their own expectations, begin physical therapy on the day of surgery and circle back for "reunion lunches," to provide a continuous feedback loop for the care and handling of future patients.

It all hinges on careful collection of data, says Ms. Ford. "Because that's what tells the story about the effectiveness of our care." Shortly after implementing the program, the hospital was able to document that patients were getting up sooner, walking farther, decreasing their lengths of stay, and, yes, improving their flexion. "We attribute it all to better pain control," she says.

Making sure patients have realistic expectations is another key. "In the pre-operative holding area, we ask patients what they'd like their target pain score to be after surgery," says Ms. Ford. "If they say zero, we say, well, we're probably not going to get you to zero, but what will be tolerable for you? Maybe a 4?"

A nurse documents the target and hands off the info to PACU. And because the process involves the patient, he now has a target to shoot for.

Of course, by that time, the patient has graduated from the hospital's preadmission class for total joint patients. There he's learned not only how to manage his pain while hospitalized, but also how to use medications and ice packs and properly position himself to control pain and promote recovery.

HONORABLE MENTIONS
Pain, Pain, Go Away

ON TAP The all-CRNA practice at Our Lady of the Angels Hospital in Bogalusa, La., is making every effort to master regional anesthesia procedures, such as TAP blocks.

Opioid-sparing pain management. Our Lady of the Angels Hospital in tiny rural Bogalusa, La. (pop. 12,000), is doing its part to fight opioid overuse and abuse. With Raymond J. Devlin, DNP, CRNA, a faculty member at Louisiana State University, leading the way, the hospital is heavily emphasizing regional anesthesia.

"Every opportunity is made to provide instruction in ultrasound-guided nerve blocks to both the nurse anesthesia students and the staff-certified registered nurse anesthetists," says Amy Seale, RN, BSN, the hospital's surgical services manager.

Transversus abdominis plane (TAP) blocks after abdominal procedures are among the newly employed weapons against pain, along with ilioinguinal and iliohypogastric approaches, all of which typically provide 16-20 hours of somatic pain relief, says Ms. Seale. But to be sure, the anesthesia department follows up either in person or by phone to make sure the analgesia is working. Most patients, she says, don't even need oral meds, thanks to the blocks.

Small adjustment, big results. At the Teaneck (N.J.) Surgical Center, they pride themselves on sending patients home virtually pain-free. So Director of Nursing Aimee Fernandez-Cruz, RN, BSN, wanted to know why carpal tunnel patients were having pain shortly after getting home, and more importantly, what could be done about it. After extensive research, she suggested changing the lidocaine 1% injection to a combination of lidocaine 1% and Marcaine 0.5%. The result was a 95% increase in patient satisfaction of pain management.

— Jim Burger

Block time
Next up are the anesthesiologists, who administer regional blocks and provide preemptive analgesics such as gabapentin and Celebrex (celecoxib). "They do a great job of staying on the forefront of what's new in the field," says Ms. Ford.

Finally, as the procedure is completed, surgeons deliver what the hospital calls its RECK solution — a combination of ropivacaine, epinephrine, clonidine and ketorolac that's injected into the joint. The cocktail has helped eliminate the need for IV patient-controlled anesthesia, which nurses had noted tended to make patients groggy and sluggish. In fact, it's been so successful that surgeons are also now using it for other procedures, too, including ACL repairs. "It's what allows the patient to get up and start moving," says Ms. Ford.

And move they do, starting their first physical therapy sessions on the day of surgery. The hospital turned one of its semi-private rooms into a gym. "We have an excellent physical therapy aide who works with them," says Ms. Ford. "It's interesting. They actually tend to start competing with each other."

Staff, meanwhile, provide analgesics before physical therapy, which helps patients push a little harder and get maximum benefit from the sessions.

Three for all
When it's time to go home, patients have clear directions and clear expectations, having been given discharge instructions 3 times. "One of the things patients were telling us in surveys was that discharge instructions weren't always clear," says Ms. Ford. "Now we go over them before surgery, in pre-op and in PACU. And we give them to a family member."

The instructions also cover how and when to safely use opioids, incorporating input from a pain medicine specialist about how to best to limit their use and wean patients off of them.

No one's more qualified than past patients to provide advice about future patients, so the hospital holds catered reunion lunches once a month in a second-floor training room to get feedback on what patients liked and what they think could have been better.

"For example," says Ms. Ford, "we had a patient last week who had opioids left over and wasn't sure what to do with them. So we had a pharmacist come in and talk about how to get rid of those. We've had patients tell us they were getting constipated from pain medications. So now we tell patients that when they go home, to drink lots of fluids, eat a high-fiber diet and, if necessary, take some stool softeners. We've learned a lot from the patients and it's improved the education we provide." OSM

— Jim Burger