Pain pumps are wonderful devices for patient care and satisfaction because they offer the best pain management available. Surgeons love them because, properly used, they mean the patient won't be calling soon after surgery complaining about pain or asking for a painkiller prescription. Yet for as good as pain pumps are, many surgical facilities fail to set up a well-managed pain pump program. Here are 5 simple steps you can take to ensure a successful pain pump program.

1. Find the best pump. We've found that patients are most satisfied with a simple-to-operate pump. A good pain pump is small, portable, easy to use and requires little or no patient interaction.

• Elastomeric pumps have a flexible bladder similar to a water balloon. As the pressure of the balloon causes the medication to flow out at the selected rate, the balloon shrinks. Some have a flexible casing around the balloon, while others have a hard external casing. Those with a flexible casing can be overfilled, letting you infuse more anesthetic over a longer period of time. A flexible casing also provides reassurance to the patient that the medication is infusing. These pumps are very simple and require little patient intervention.
• Spring-loaded pumps use the mechanical force of a spring within a fixed-size container to infuse the anesthetic.
• Electronic pumps are battery-powered devices that use a mechanical system to infuse the medication. They may have a digital interface and the advantage of having more detailed programmability, but they may also be more complicated and difficult for patients to understand.

Regardless of the mechanism, the pump should be easy to fill, program and operate. Find a company with a pump that has a proven track record of reliability and safety. Ask for references from other facilities. Just as important as ease of use and safety is the quality of customer service you get from the manufacturer.

2. Choose the right patients. Many ambulatory surgery patients are well suited for going home with a pain pump. However, here are a few situations when it is not appropriate to send patients home with the device.

• Language barrier. In order to comprehend the instructions for using the pump, patients should speak and understand grade-school English, and be able to communicate over the phone with your anesthesia providers, nursing staff or pump manufacturer representatives, who can help troubleshoot potential problems while the patient is at home.
• Home alone. Patients sent home with pain pumps should have a caregiver living or staying with them, since numbed extremities could limit mobility. This care provider can assist in communicating with your staff or surgeons or bringing the patient back in to be evaluated if a serious problem arises at home.
• Injury prone. Patients who normally have difficulty ambulating, such as the elderly or morbidly obese, may be at higher risk for falling with a lower extremity catheter. Patients who have had bilateral injuries or surgeries may also be at increased risk of sustaining a fall injury caused by numb and weak extremities.

3. Educate early and often. The more familiar patients are with the pain pump, the better they'll understand how it works and appreciate the pain relief it offers, and the better their experiences will be. Patient education should begin in the surgeon's office, where the concepts of a nerve block and the ambulatory pump are introduced. If patients come to your facility for a pre-op screening, send them home with literature that explains how the nerve block will be performed, how the pump works and what to expect post-op.

On the day of surgery, your pre-op nurses should remind patients that they'll be going home with a pump to help control post-op pain. During the pre-op anesthesia interview, the provider should discuss the pump's operation in detail and outline home management of the nerve catheter. The provider should also note the best number to contact the patient at home. Finally, once the pump is connected, give patients and family members a quick hands-on tutorial on how it works and how to remove the catheter. Also discuss when patients can take other analgesic medications and which number to call if they have any questions or problems.

4. Offer help at home. Patients with pumps at home need access to knowledgeable providers who can help them troubleshoot device-related issues or advise them when things don't go according to plan. Some pump manufacturers have very helpful 24-hour, nurse-run hotlines for patients and providers as well as informative websites.

The most common patient-asked questions are fairly simple and include: A small amount of liquid is leaking from the insertion site, is this normal? Can I take my oral pain medication while the pump is in? My extremity feels numb and tingly, is this OK? Have your staff address these questions before sending patients home.

Call patients every day that the pump is in and under their control. Ask about the amount of pain they're experiencing, how well they're sleeping, if they've taken oral pain medications (including over-the-counter products), if their extremity is still numb or weak, and if they're comfortable removing the catheter.

A nurse, CRNA, nurse practitioner or anesthesiologist can place the follow-up calls. Patients appreciate the personal attention and you'll detect problems before they become serious. A 1- to 2-minute phone call each day can prevent the surgeon from receiving phone calls from patients, which goes a long way in improving both patient and physician satisfaction.

5. Understand risks and problems. Although the overall risks of continuous nerve blocks are small, they are real. Most problems with the pump or pain control at home are minor issues that can be dealt with over the telephone. However, there are some rare situations in which a patient should be evaluated in person, including medical emergencies and severe pain that cannot be controlled with the pain pump and oral pain medication.

Anesthesia providers should be concerned about nerve injury, infection and local anesthetic toxicity, which is extremely rare but could be fatal in a patient at home. Instruct patients to recognize signs of local anesthetic toxicity: ringing in the ears, metallic taste in the mouth, numbness around the lips and tongue, or change in mental status. Theoretically, this could happen if the pump was programmed to deliver too much local anesthetic. Some of the pumps have safety features such as flow restrictors built in to absolutely prevent such a scenario.

More commonly, patients may experience minor problems with the catheter, such as leaking of local anesthetic at the site and accidental dislodgement. If this happens, the patient may try to reinforce the dressing and continue taking oral analgesics. This scenario is much less common when the anesthesia provider gains experience in placing the catheter and dressing it in a secure fashion. Almost all patients remove their own catheter at home, but sometimes a patient or caregiver may decide to come in to have it removed.

Value-added perks
Some pump manufacturers provide a great deal of support coordinating across disciplines to get your program started successfully. Look for companies that offer education for your anesthesia providers on how to place the nerve catheters using the latest technology, including ultrasound. Representatives of a good company will be involved with training your staff. They can provide opportunities for site visits to well-established programs at other facilities as well as provide sample order sets and protocols.