ORX Awards 2021 - Pain Control - ERAS Is Everything

Patient Experience Pain Management OR Excellence

By: Jared Bilski | Managing Editor

Published: 8/31/2021

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Lehigh Valley Health Network’s care pathway reduces opioid use and boosts patient satisfaction scores.


In order for an Enhanced Recovery After Surgery (ERAS) protocol to work as intended, you often need an extra something that could make some medical professionals a little uncomfortable. “Everybody involved in an ERAS initiative must be open to all ideas,” says Jill Hanisak, DNP, CRNA, anesthesia services education coordinator for Lehigh Valley Health Network (LVHN) in Allentown, Pa. “They need to try new approaches, show a willingness to change and apply the most current research.”

It’s this openness, as well as the results of such a strategy as it pertains to the facility’s ERAS program, that earned LVHN this year’s OR Excellence Award in Pain Control. Thanks to a comprehensive ERAS pathway, the facility was able to reduce patients’ opioid utilization by 61% (compared with historical controls), decrease pain scores and improve patient satisfaction scores.

The health system’s multipronged approach to managing pain was a significant departure from its previous strategy. The team at LVHN charged with overseeing the new ERAS pathway aims to preemptively attack the potential sources of pain and discomfort early on in the preoperative process by optimizing patients’ nutrition status and offering them a carbohydrate-rich drink and clear liquids up to two hours before surgery. “NPO doesn’t work,” says Dr. Hanisak. “The carb drink helps in a number of ways, including reducing insulin resistance that occurs after surgery.”

Preoperatively, patients also receive oral acetaminophen, pregabalin and tramadol, a combination that provides potent and preemptive opioid-sparing pain relief. “The goal is to mitigate the patient’s physiologic stress response to surgery,” says Dr. Hanisak.

In addition to regional anesthesia, patients are given a multimodal anesthetic regimen that includes propofol, dexmedetomidine and esmolol infusions as well as a bolus administration of both magnesium and ketamine (starting at .5 mg/kg). That course of action helps to reduce the patient’s pain after surgery and goes a long way toward preventing PONV, which many patients fear more than the discomfort of their procedures. “By using propofol infusions instead of inhalation gases, we’re able to greatly reduce rates of PONV,” says Dr. Hanisak.

Joints Replacements Don’t Have to Hurt
HONORABLE MENTION
COLLABORATIVE EFFORT The pain management team at Constitution Surgery Center work in concert to keep patients comfortable before and after surgery.  |  Rob Taylor

Multimodal pain management — a dedicated focus area practiced by a collaborative team of surgeons, anesthesiologists and nursing staff — is a critical part of the bustling total joints program at Constitution Surgery Center East in Waterford, Conn. As part of the multimodal program, each joint replacement patient is required to attend a two-hour education program designed to prepare them for every phase of their surgery.

“Part of their preparation involves introducing our pain management program and explaining how it works,” says Robert Taylor, RN, BS, the clinical director at Constitution. “We’ve replaced the joints of 300 patients so far this year, all of whom have ambulated to their cars upon discharge because of proper pain management and effective neuromuscular blockades,” he says.

The facility is always looking for ways to improve its pain control efforts and just recently added another weapon to its analgesic arsenal: cryoneurolysis. The treatment involves percutaneously guiding a closed probe next to a nerve. Carbon dioxide or nitrous oxide is sent to the probe’s tip, where it creates an ice ball that encompasses and disables the targeted nerve. Select total knee replacement patients receive the treatment before surgeries — most 30-days prior, but some 10 to 15 days pre-procedure — to reduce their pain and optimize their physical status for surgery. “We just added this technology, and we’re doing around 20 treatments per month,” says Mr. Taylor. “It’s been working really well.”

The latest addition to the surgery center’s multimodal, team-based approach to pain management has had a profound effect on lowering the heavy reliance and dependence on opioid use as the first line of post-op pain control. As surgical leaders everywhere can attest, reducing opioid usage and dependence is a must in today’s outpatient surgery climate. “Mastering multimodal pain management is the key to success for any facility with an orthopedic specialty and a total joints program,” says Mr. Taylor.                    

— Jared Bilski

LVHN’s ERAS pathway consists of administering scheduled post-op doses of non-narcotic acetaminophen and pregabalin unless the situation warrants something stronger. Patients with moderate pain (scores between 4 and 6) receive tramadol, and patients in severe pain (scores of 7 to 10) are given hydromorphone. But thanks to targeted, multimodal approaches to pain, very few patients need either one and, without these stronger medications, they’re able to recover more quickly and with fewer side effects. “Our approach to pain management promotes early mobilization, and we make it a point to get patients out of bed and moving soon after their surgery,” says Dr. Hanisak. “That’s what ERAS is all about — getting patients drinking, eating and mobilizing right away.”

The end result of LVHN’s ERAS pathway is opioid-sparing perioperative care that reduces the side effects of opioids and the risk of substance-use disorder. It also reinforces the importance of patient-centered care, says Dr. Hanisak. She urges facilities to remember that a positive patient experience is only possible when providers communicate effectively about the importance and effectiveness of a multimodal regimen. “Let patients know that multiple pain control methods will be used, and that a wide variety of medications are needed to take on different pain pathways,” says Dr. Hanisak. “But also let them know that if they wake up in pain, you’ll take care of them.” OSM

Leave it to the 'Multimodal Master'
HONORABLE MENTION
BRING IT ON Heather St. Peter, MD, administers a comprehensive multimodal regimen that essentially eliminates pain and PONV.  |  North Scottsdale Outpatient Surgery Center

Time and again, PACU nurses at North Scottsdale (Ariz.) Outpatient Surgery Center expect patients to emerge from surgery with breakthrough pain or PONV, and time and again, those complications simply don’t occur. Andrea Sinon, BSN, RN, CNOR, the nurse administrator at the facility, attributes much of this success to Heather St. Peter, MD, an anesthesiologist staff refer to as the “Multimodal Master.”

“It’s extremely rare for Dr. St. Peter’s patients to experience pain or PONV in the PACU,” says Ms. Sinon. “When she hears about a patient who is at high risk for PONV, she takes it as a personal challenge to prevent the complication and often says, ‘I’ll see you in the PACU.’ It’s her way of saying, ‘Let’s see about that PONV.’”

Her patients not only wake up pain- and nausea-free after surgery, they also generally feel “wonderful,” which leads to sky-high patient satisfaction scores.

Before surgery, Dr. St. Peter’s patients are given a small sip of water and oral acetaminophen (1,000 mg), celebrex (200 mg) and, if they are transferring to an overnight facility, gabapentin (600 mg). Transversus abdominis plane (TAP) blocks provide targeted relief, but Ms. Sinon credits an injection given intraoperatively as the key to pain-free outcomes. “Dr. St. Peter gives patients an intramuscular injection of 50 mg Demerol and 12.5 mg Phenergan,” she says. “It’s the secret sauce that keeps patients coming to recovery feeling great.”

While Ms. Sinon says the Multimodal Master rightfully deserves the lion’s share of the credit for her facility’s analgesic achievements, she’s also quick to point out that North Scottsdale’s pain control success is a total team effort — something that’s apparent by the many personalized messages of thanks written to members of the care team on patient satisfaction surveys.

— Jared Bilski

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