Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision!

@EMARIANOMD@EMARIANOMD
Get Rid of Your TraditionalGet Rid of Your Traditional
Acute Pain Service andAcute Pain Service and
Broaden Your Vision!Broaden Your Vision!
Edward R. Mariano, M.D., M.A.S.Edward R. Mariano, M.D., M.A.S.
Associate Professor of AnesthesiologyAssociate Professor of Anesthesiology
Stanford University School of MedicineStanford University School of Medicine
Chief, Anesthesiology and Perioperative CareChief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health CareVeterans Affairs Palo Alto Health Care
SystemSystem

Acute Pain Service and PSHAcute Pain Service and PSH
Financial DisclosuresFinancial Disclosures
 Halyard Health, B Braun – UnrestrictedHalyard Health, B Braun – Unrestricted
educational program funding paid to myeducational program funding paid to my
institutioninstitution
The contents of the following presentationThe contents of the following presentation
are solely the responsibility of the speakerare solely the responsibility of the speaker
without input from any of the abovewithout input from any of the above
companies.companies.

Learning ObjectivesLearning Objectives
 Discuss the role of acute painDiscuss the role of acute pain
management in the broader context ofmanagement in the broader context of
healthcare changes;healthcare changes;
 Identify specific ways to improve currentIdentify specific ways to improve current
acute pain management systems;acute pain management systems;
 Discuss potential strategies to expand theDiscuss potential strategies to expand the
scope of acute pain services and affectscope of acute pain services and affect
long-term outcomes.long-term outcomes.

Triple AimTriple Aim
Berwick et al., Health Aff (Millwood) 2008;27:759Berwick et al., Health Aff (Millwood) 2008;27:759
Vetter et al., Anesth Analg 2014;118(5):1131Vetter et al., Anesth Analg 2014;118(5):1131

Perioperative Surgical HomePerioperative Surgical Home
Anesthesiology 2015;123:A23Anesthesiology 2015;123:A23

Elements of PSHElements of PSH
PSH: Comprehensive Literature Review, www.asahq.org/pshPSH: Comprehensive Literature Review, www.asahq.org/psh

OverviewOverview
 Think “big picture”Think “big picture”
 Continuously improveContinuously improve
 Reach for the starsReach for the stars

Institute of Medicine 2012Institute of Medicine 2012
http://www.iom.edu/bestcarehttp://www.iom.edu/bestcare

 Authorized by the Affordable Care Act butAuthorized by the Affordable Care Act but
has been around longerhas been around longer
 ““Pays for care thatPays 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 1.25%Funded by a 1.25% withholdwithhold fromfrom
participating hospitals’ Diagnosis-Relatedparticipating hospitals’ Diagnosis-Related
Group (DRG) paymentsGroup (DRG) payments (2% by 2017)(2% by 2017)
Value-Based Purchasing (VBP)Value-Based Purchasing (VBP)
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-
value-based-purchasing/downloads/HospVBP_ODF_072711.pdfvalue-based-purchasing/downloads/HospVBP_ODF_072711.pdf

FY2014 Value-BasedFY2014 Value-Based
PurchasingPurchasing
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-
based-purchasing/Downloads/NPCSlides071112.pdfbased-purchasing/Downloads/NPCSlides071112.pdf
*NEW*
*NEW*

Assessing Patient ExperienceAssessing Patient Experience
 Patients are surveyed using thePatients are surveyed using the HospitalHospital
Consumer Assessment of HealthcareConsumer Assessment of Healthcare
Providers and SystemsProviders and Systems (HCAHPS)(HCAHPS)11
 32 questions32 questions
 Publicly reportedPublicly reported 4 times a year4 times a year22
 HCAHPS is administered to a randomHCAHPS is administered to a random
sample of adult inpatients between 48sample of adult inpatients between 48
hours and six weeks after dischargehours and six weeks after discharge
1. http://www.hcahpsonline.org1. http://www.hcahpsonline.org
2. http://www.hospitalcompare.hhs.gov2. http://www.hospitalcompare.hhs.gov

HCAHPS Questions on PainHCAHPS Questions on Pain
Mariano, et al. Adv Anesthesia 2013;31:119Mariano, et al. Adv Anesthesia 2013;31:119

Scoring HospitalsScoring Hospitals
“Incentive” = How
Much Withholding
Hospitals Get Back

Evolving Practice of AnesthesiaEvolving Practice of Anesthesia

Develop Patient Care PathwaysDevelop Patient Care Pathways
Hebl JR, et al. JBJS 2005;87 Suppl 2:63Hebl JR, et al. JBJS 2005;87 Suppl 2:63

Target AnalgesiaTarget Analgesia
 Injectate administeredInjectate administered
distal to the femoraldistal to the femoral
triangle intriangle in adductor canaladductor canal
 Many variations onMany variations on
techniquetechnique
 Effective vs. placeboEffective vs. placebo
injectioninjection
 Decreases quad strengthDecreases quad strength
but less than FNBbut less than FNBTsui & Ozelsel. RAPM 2009;34:178Tsui & Ozelsel. RAPM 2009;34:178
Ishiguro S, et al. A&A 2012;115:1467Ishiguro S, et al. A&A 2012;115:1467
Jaeger P, et al. Acta AnaesJaeger P, et al. Acta Anaes
2012;56:10132012;56:1013
Lund J, et al. Acta Anaes 2011;55:14Lund J, et al. Acta Anaes 2011;55:14
Manickam B, et al. RAPM 2009;34:578Manickam B, et al. RAPM 2009;34:578
Krombach & Gray. RAPM 2007;32:369Krombach & Gray. RAPM 2007;32:369
LATERAL
SF
A
N
SARTORIUS

Update Clinical PathwaysUpdate Clinical Pathways
 In April 2012, clinical pathway changedIn April 2012, clinical pathway changed
from CFNB to continuous adductor canalfrom CFNB to continuous adductor canal
blocks due to concern over quad weaknessblocks due to concern over quad weakness
 Hypothesis for retrospective cohort study:Hypothesis for retrospective cohort study:
patients with continuous adductor canalpatients with continuous adductor canal
blocksblocks ambulate furtherambulate further than those withthan those with
continuous femoral nerve blocks oncontinuous femoral nerve blocks on
postoperative day (POD) 1 withoutpostoperative day (POD) 1 without
reduction in analgesiareduction in analgesia
Mudumbai & Mariano, et al. CORR 2014;472:1377Mudumbai & Mariano, et al. CORR 2014;472:1377

 Patients in thePatients in the
adductor canal groupadductor canal group
walkedwalked 3737 (0-90)(0-90)
meters vs.meters vs. 66 (0-51)(0-51)
meters in the femoralmeters in the femoral
catheter groupcatheter group
((p=0.003p=0.003).).
 Pain scores, opioidPain scores, opioid
consumption, andconsumption, and
hospital length of stayhospital length of stay
were similar.were similar.
Promote Early RehabilitationPromote Early Rehabilitation
Mudumbai & Mariano, et al. CORR 2014;472:1377Mudumbai & Mariano, et al. CORR 2014;472:1377

Practice Evidence-Based MedicinePractice Evidence-Based Medicine
 30-day mortality was lower30-day mortality was lower for neuraxial andfor neuraxial and
neuraxial/GA vs. GA alone for TKAneuraxial/GA vs. GA alone for TKA
 Most in-hospital complications were lowerMost in-hospital complications were lower
for neuraxial and neuraxial/GA vs. GA alonefor neuraxial and neuraxial/GA vs. GA alone
 Transfusion requirements lowest forTransfusion requirements lowest for
neuraxialneuraxial
Memtsoudis SG, et al. Anesth 2013;118:1046Memtsoudis SG, et al. Anesth 2013;118:1046
Mudumbai & Mariano, et al. SubmittedMudumbai & Mariano, et al. Submitted

TKA Protocol (VA Palo Alto)TKA Protocol (VA Palo Alto)
PreopPreop 1.1. Adductor canal catheterAdductor canal catheter
2.2. Oral gabapentin if opioid-dependentOral gabapentin if opioid-dependent
OROR Spinal anesthesia, LIA, IV acetaminophenSpinal anesthesia, LIA, IV acetaminophen
PostoPosto
pp
1.1. Continuous perineural infusion (0.2%Continuous perineural infusion (0.2%
ropivacaine 6 ml/h basal)ropivacaine 6 ml/h basal)
2.2. Oral NSAID and acetaminophen ATCOral NSAID and acetaminophen ATC
3.3. Oral opioid ATC and PRNOral opioid ATC and PRN
4.4. IV opioid PRN but no IV PCAIV opioid PRN but no IV PCA
Mariano, et al. Adv Anesthesia 2013;31:119Mariano, et al. Adv Anesthesia 2013;31:119

Anesth Clinics 2014;32:853

Preoperative Preparation TodayPreoperative Preparation Today

A Vision for the FutureA Vision for the Future

Mariano, Walters, Kim, Kain. A&AMariano, Walters, Kim, Kain. A&A
2015;120:11632015;120:1163

Improve Long-Term Function?Improve Long-Term Function?
 1 yr Western Ontario and McMaster Univ1 yr Western Ontario and McMaster Univ
Osteoarthritis Index (WOMAC) scoresOsteoarthritis Index (WOMAC) scores
Ilfeld BM, et al. A&A 2009;108:1320Ilfeld BM, et al. A&A 2009;108:1320
Ilfeld BM, et al. A&A 2009;109:586Ilfeld BM, et al. A&A 2009;109:586

Prevent Persistent Pain?Prevent Persistent Pain?
Lavand’homme, et al. CORR 2014;472:1409Lavand’homme, et al. CORR 2014;472:1409
TKA
Patients

SummarySummary
 We discussed the role of acute painWe discussed the role of acute pain
management in the broader context ofmanagement in the broader context of
healthcare changes;healthcare changes;
 We identified specific ways to improveWe identified specific ways to improve
current acute pain management systems;current acute pain management systems;
 We discussed potential strategies toWe discussed potential strategies to
expand the scope of acute pain servicesexpand the scope of acute pain services
and affect long-term outcomes.and affect long-term outcomes.

Questions?Questions?
“The sooner patients can be removed from
the depressing influence of general
hospital life the more rapid their
convalescence.”
- Dr. Charles Mayo, Lancet 1916

Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision!

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (19)

Ähnlich wie Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision!

Ähnlich wie Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision! (20)

Mehr von Edward R. Mariano, MD

Mehr von Edward R. Mariano, MD (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision!

Hinweis der Redaktion