Organizing an Inpatient Acute Pain Service

The Rationale

Over the last decade, several surgical practices and public health initiatives, in addition to drug and technology advancements, have impacted inpatient acute pain services worldwide, for example, the continued development and implementation of less invasive surgical techniques, such as arthroscopy. Laparoscopy and robot-assisted surgery have reduced post-surgical pain and allowed nearly two-thirds of surgeries to be performed on an outpatient basis. Nonetheless, moderate to severe pain is common after outpatient procedures as well, and pain is still a leading cause of why patients scheduled for outpatient surgery are unable to go home and remain as inpatients. Indeed, the last minute consults stating that “pain is the only thing keeping [patient name] here” has become an increasingly common refrain. In short, even if outpatient surgery pain is treated effectively in an institution, inpatient post-surgical patients can be expected to have high levels of pain on average, as more patients and procedures are deemed suitable for outpatient surgery. This may explain why pain after inpatient surgery has shown only a marginal reduction in patients suffering from moderate to severe pain, dropping from 80% in 1995 to 65% in 2015 —despite an increase in inpatient pain services.

Post-operative pain management in both inpatient and outpatient settings has also been complicated by the dramatic increase in opioid-related morbidity and mortality from both illicit and prescribed opioids, which have occurred since the turn of the century (the so called “opioid crisis”). Sometimes conflicting regulatory, legislative, insurance, and institutional policies, largely aimed at outpatient opioid prescribing, have proven, at best, difficult to remember and, at worst, impediments to patient-centered post-operative pain care. Both primary care services and the patients they care for are often reluctant to use opioid analgesics for fear of side effects. In this regard, it is necessary to remember that ineffective post-operative pain management is also associated with a variety of medical and economic “side effects,” including readmissions, patient dissatisfaction with medical care, possible transition to chronic pain, and extended lengths of treatment (which has been associated with opioid use disorder diagnoses). Moreover, with or without consistent evidence based policies and guidelines, achieving satisfactory acute pain management is challenging since patient post-operative analgesic requirements vary widely even following the same surgery. Several patient factors have been reported to influence post-operative opioid requirements, including:

• Preoperative pain sensitivity

• Coexisting medical conditions and associated multiple drug administration

• Pre-surgical opioid tolerance or history of drug abuse

• Psychological factors, including catastrophizing, and

• anxiety ^,

• Age

• Type of surgery

Great care must be taken to consider all the characteristics mentioned above when deriving an analgesic plan for managing an individual’s response to a surgical insult. Such careful acute pain management does not include opioids and has never been involved. The time is long past when acute or chronic pain caregivers should think of “opioid treatment” and “pain management” as synonyms. However, how can we explain how the 2001 “pain is the fifth vital sign” campaign has, in retrospect, been vilified as a plot to increase opioid prescribing? A “vital sign” implies assessment, not a particular treatment—just as a heart rate of 100 may be treated quite differently in a fetus in utero than in a cardiac cripple.

In summary, acute pain, if not pain in general, still suffers from a lack of careful assessment and functional goal-directed multimodal therapy. Despite repeated educational initiatives worldwide, including the International Association for the Study of Pain (IASP) Global Year Against Acute Pain in 2011, followed by the Global Year Against Pain After Surgery in 2017, and even the Global Year of Prevention of Pain in 2020. This chapter posits that investing in an inpatient-based acute pain service is still the best mechanism to ensure effective and safe acute pain care.

General Principles

The sequelae associated with acute pain, including surgical procedures, result from various components of the stress response, including cardiopulmonary, infectious, and thromboembolic complications, cerebral dysfunction, nausea and gastrointestinal paresis, fatigue, and prolonged convalescence. Throughout the process of organizing an acute pain program, it is helpful to remember the following statements:

• The post-operative pain management regimen should be designed with attention to providing patient comfort and inhibiting nociceptive impulses sufficient to allow appropriate rehabilitation.

• A time-, energy-, and cost-effective acute pain program should optimally provide multimodal and multi-disciplinary interventions, including systemic and regional pharmacologic, and non-pharmacologic treatments, ^, including stress reduction, transcutaneous electrical nerve stimulation, music therapy, and acupuncture.

• Surgical stress responses are inhibited most effectively by the neuraxial administration of local anesthetics, and the administration of other agents—systemically, neuraxially, or perineurally—contribute little additional reduction of the endocrine (metabolic and catabolic) stress response following operative procedures. ^,

• Parenteral opioids exaggerate the perioperative immune depression already triggered by the neuroendocrine response to surgery, although the clinical relevance of this observation is controversial. Opioids administered into the epidural space have minor suppressive effects on surgically induced proinflammatory cytokines.

• Effective analgesia can reduce post-operative morbidity and improve function. For example, thoracic epidural analgesia has been shown to improve post-operative spirometry and reduce pulmonary infections and atelectasis. ^,

The experience of a skilled anesthesiologist lends itself to providing leadership within an acute pain service. Anesthesiologists are proficient in the use of systemic and regional analgesic techniques, including peripheral and neuraxial nerve conduction blockade. They also often understand the surgical techniques and the insults that they impose and are frequently equipped with leadership skills for working within a multi-disciplinary team from their work in the operating room. Nonetheless, an anesthesiologist-based team is not the only service model. Nurse-based, anesthesiologist-supervised, inpatient acute pain services have also been demonstrated to provide safe and effective post-operative pain management. ^, Regardless of the service model, nursing involvement in an inpatient acute pain service is essential. Bedside nurses’ impressions of a patient’s analgesic needs and recovery is an invaluable element in the decision making process for any given patient, and because it is the nurse who will ultimately be delivering the care, nurses must understand the analgesic plan, goals, policies, and procedures that might pertain to their pain care.

Detailed practice guidelines and protocols can help streamline the ordering and implementation of patient care. Well-established protocols have been shown to reduce errors in realms outside pain management and decrease the cost associated with prescribing choices. At the University of Washington Medical Center, we have instituted multiple protocols, including order sets for patient-controlled analgesia (PCA), continuous and patient-administered epidural analgesia, ketamine and lidocaine infusions, and continuous perineural catheter infusions ( Figs. 3.1 - 3.5 ). PCA and epidural analgesia protocols must include titration and bolus instructions to treat breakthrough or incident pain. Order sets should also include routine and specific monitoring orders, as well as treatment options for common and/or dangerous side effects (e.g. antiemetics and/or antipruritics, and opioid receptor antagonists to reverse respiratory depression). Ketamine, intravenous lidocaine, and perineural anesthetics are most frequently used as adjuncts to other analgesic therapies (e.g. PCA opioids and scheduled acetaminophen and/or nonsteroidal anti-inflammatory drugs). The recovery room, intensive care unit, and medical/surgical floor nurses must be trained to be familiar with the order set parameters. In most cases, nurses can autonomously assess patients and implement changes that successfully achieve adequate analgesia with minimal side effects.

An emerging area of concern for any anesthesiology-based pain service is the complexity of managing invasive pain management techniques (e.g. epidurals) in an era where an ever-increasing number of anticoagulants are given as treatment or prophylaxis for many medical and surgical indications. These indications include treatment of cardiac arrhythmias, valvular disease, and deep vein thrombosis prophylaxis. To aid in treating such patients with the least risk, the University of Washington Medical Center has designed institutional guidelines (based on national guidelines such as those of the American Society of Regional Anesthesia) for the management of indwelling neuraxial and peripheral nerve catheters in patients treated concomitantly with anticoagulants (see Chapter 74). This document was designed to address the placement, maintenance, and removal of catheters in several common anticoagulation scenarios. The intention of such guidelines, which are linked to the electronic medical record, is to distill the existing scientific evidence and opinion into a format that is easy to access and apply in the patient care workflow.

Identifying Service Leadership

It is important to recognize at the outset of establishing a pain service that it is a major endeavor. Planning, design, and implementation of a successful service will require substantial human and material resources. If the need and desire for an acute pain service exist within a hospital facility, one must first elicit support from the anesthesiology department’s chairperson. Although multiple design models for acute pain management services are possible, most will require that an anesthesiologist be made available for some level of participation in the service. Unless resources allow an anesthesiologist to be easily released from operating room obligations, the staffing conflict presents a difficult challenge. An agreeable arrangement of service responsibilities must allow the anesthesiologist or his or her delegates to be available to provide safe and consistent care to whomever he or she is responsible, 24 h a day and seven days a week.

Once the intradepartmental resource allocation issues have been discussed with the chairperson, the proposal to begin an acute pain service should be brought to the medical director as a representative of the facility’s administrative team. The commitment of the medical director to the project will be necessary to provide resources in the form of personnel and money.

Appropriate leadership for acute pain services must be selected. Operating a service requires a diverse constellation of skills. The service director must have knowledge of the mechanisms of acute post-surgical pain and the methods of treatment, including opioid and non-opioid analgesics, epidural and peripheral nerve catheter placement and maintenance, and ketamine, lidocaine, and other adjuvant drug therapies, as well as treatments for the side effects of these therapies. An anesthesiologist is often the best fit because he or she has experience with these pharmacologic approaches. The recent formation of Accreditation Council for Graduate Medical Studies (ACGME) accredited fellowship programs, combining regional anesthesia and acute pain training, has been in direct response to this understanding that anesthesiology training results in clinicians well suited for providing acute pain management. Indeed, many early acute pain services, like the one started by Dr. Brian Ready at the University of Washington in the 1980s, grew out of the obstetric anesthesia team and the regional anesthetists working thereon. Nonetheless, it is important to distinguish between a regional anesthetist’s goal of keeping a patient comfortable enough to stay still for a painful procedure and an acute pain practitioner’s goal of keeping a patient comfortable enough to move during rehabilitation. Zero out of ten pain is rarely an option or goal for acute pain services. In this regard, as mentioned previously, non-pharmacologic therapies (including physical, psychological, and complementary medicine techniques) also play a role in acute pain treatment, although they are rarely used in the operating room. Acute pain service leaders must be aware of the value and indications for the full panoply of therapeutic strategies for pain.

In addition to expertise in analgesic therapies, the success and stability of any new acute pain service will require that the service director also possess certain nonclinical skills, including strong leadership, organizational, communication, and administrative abilities. The clinical success of an inpatient pain service demands the integration of multiple clinical disciplines, such as nursing, anesthesiology, medicine, physical therapy, and pharmacy. The service director must merge the strengths of these diverse professionals such that their efforts are collaborative—both outside of the normal silos inherent to patient care and without undue power struggles or inefficiencies that can arise within a multi-disciplinary team. In addition, the leader will need to understand the place of the acute pain service within the structure of the health care organization. The service should be seen as efficient and valuable to the hospital and its surgical services.

A clinical nurse specialist (CNS) or equivalent is an additional cornerstone on which to build any new inpatient pain service. The primary responsibility of the CNS is to provide ongoing education for intensive care, recovery rooms, and medical/surgical care nurses concerning pain protocols. At the University of Washington Medical Center, a CNS in pain has been a part of the acute pain service from day one (only four different individuals in 35 years). In addition to nursing education, the CNS is involved in equipment trialing and purchasing, order and policy development, committee work on pain-related (though not necessarily pain service-related) hospital committees, and helps to resolve any conflicts that might arise between nursing and prescribing care team members. Over the years, the CNS’s salary has been shared to different degrees between departmental and hospital sources.

More recently, pharmacists have begun to play a valuable role in inpatient pain services. Their understanding of drug actions, metabolism, interactions, and side effects has proven ideal for promoting safe pharmacologic pain management. Moreover, their knowledge of drug costs, prescription drug monitoring program benefits and weaknesses, and electronic health record ordering peculiarities have opened the door for practical teaching of trainees and more experienced practitioners alike. In our inpatient pain service, pharmacists seem to enjoy patient interactions (including symptom assessment and education) and have become vital parts of our multi-professional team.

Assessment of Need

Once the challenge of implementing an acute pain service is accepted, and leadership is identified, assessment of specific needs for the service is mandatory. This might be accomplished by surveying the patient population, nurses, types of specialty services, procedures commonly performed, and the people performing these procedures. Furthermore, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has set forth standards declaring the patient’s right to adequate pain assessment and treatment and has explicitly acknowledged that pain is a coexisting condition with many diseases and injuries that require explicit attention. Although JCAHO updated its pain-related requirements in 2017, the importance of pain assessment and therapy was not diminished, and the updates were mostly focused on safer opioid prescribing including teaching and practice of multimodal analgesic therapies. This encourages more hospital expertise in pain management, and on this basis, the mission statement of the service should be defined.

Those planning the structure of the service might also consider whether they wish to distinguish between different types of pain management challenges or manage them as conglomerates. For example, the University of Washington Inpatient Pain Services is divided into three factions: acute pain, chronic/cancer pain, and interventional pain. The service was separated into these groups to preserve the continuity of care (e.g. inpatient admissions of patients followed by an outpatient cancer pain clinic), and more practically manage the high volume of patients (when only a subset of practitioners on a service have the training or experience to perform certain interventional procedures). Admittedly, the boundaries between these categories are artificial and may overlap. For example, consider a patient with acute post-surgical pain superimposed on long-standing cancer pain or a patient who is now recovering from surgery to place an implanted epidural neuromodulating device for treating chronic pain.

Whatever the organizational structure, an acute post-operative pain management service is likely to require 24 h a day and seven days a week call coverage, with appropriate medical supervision. Immediate availability is important concerning patient safety and patient satisfaction. Inadequacy of pain relief has been highlighted as a quality-of-care measure and a focus on patients’ concerns. In a questionnaire survey, 57% of patients identified pain after surgery as their primary fear. Sadly, the removal of specific questions about pain management satisfaction from the Hospital Consumer Assessment of Healthcare Providers and Systems survey, because of unsubstantiated fears of opioid over-prescribing to improve survey scores, is a step back from incentivizing attention to pain hurdles patients face in recovering from painful conditions or procedures and offers another indication that the multimodal approach to pain management is still not widely appreciated. Nonetheless, the competitive healthcare environment mandates that hospitals focus on the most important issues to patients. Favorable reports of patient satisfaction may encourage patients to seek services in a given hospital facility and encourage patient loyalty in return for additional medical care. Furthermore, according to one multicenter prospective cohort study, immediate post-operative patient satisfaction with care is a predictor of long-term, positively self-perceived health status. In short, for many hospitals, following JCAHO’s requirement to have a “leadership team that is responsible for pain management” is also simply put, the right thing to do for their patients.

Definition of the Service

Once the pain service mission statement has been formulated in response to the perceived institutional and community needs, leadership must define the resources that will be required to meet the needs. The resources and modalities that an acute pain service may use are diverse and depend on the patient population, the skills of the personnel, and the service’s therapeutic approach. Ideally, an evidence based approach to the selection of treatment modalities that specifically evaluates the efficacy and cost-effectiveness of each therapy is used. The resources required to implement and operate an acute pain service will represent a synthesis of characteristics of the patient population, evidence based selection of therapeutic modalities, and consistency with the service’s mission.

The feasibility of various treatment plans based on the availability of resources was defined by the IASP task force for the management of acute pain ( Table 3.1 ). Individualized treatment of patients should ideally be evidence based ( Table 3.2 ), and several organizations have published guidelines for acute pain treatment. ^, A useful, more dynamic resource for evidence based post-operative pain management is the PROSPECT database —hosted and updated by the European Society of Regional Anesthesia and Pain Therapy. This website ( https://esraeurope.org/prospect/ ) offers procedure specific post-operative pain management (PROSPECT) recommendations based on evidence detailed on the site. Such recommended care mixes maximal improvements in patient outcomes with the most cost-effective care available. Indeed, many of the leaders of the PROSPECT project have also spearheaded the so called ERAS (Enhanced Recovery After Surgery) movement to facilitate safe and efficient post-surgical rehabilitation, minimizing hospital stays and thus reducing costs. For example, Dr. Henri Kehlet (a general surgeon) has developed ERAS principles for more than 35 years—emphasizing rapid re-feeding after bowel surgery, including, in part, the use of neuraxial local anesthetics for post-operative pain. Such techniques require special resources in the form of medications, equipment, and personnel, and these must be anticipated and negotiated with the institution’s administrative, business, and clinical departments when designing the service structure.

After the resources are defined, the range of therapeutic services to be offered can be determined. The principles of post-operative pain therapy that must be implemented in each patient interaction on the service include:

• 1

  Evaluation of the source and severity of the pain.

• 2

  Understanding the relationship between pain and other components of suffering (e.g. poor prognosis creating reactive depression or anxiety).

• 3

  Achieving and maintaining adequate pain relief and incorporating it into the acute rehabilitation scheme.

• 4

  Refining therapies based on individual needs.

These goals can be achieved through pain services built on different therapeutic emphases. For example, a single-modality service allows the provision of analgesia with intravenous opioid systems to all inpatients and the provision of regional analgesia in select instances. This model can be nurse-based with physician supervision and offers a safe, limited, and cost-effective method for the treatment of post-operative patients. On the other hand , a multi-modal service includes diverse healthcare professionals from a variety of domains. Extracting and integrating the relevant expertise from these professionals on such services is critical for individualized and optimized pain management. Professionals commonly utilized include psychologists, pharmacists, physical and occupational therapists, nutritionists, and spiritual care providers, in addition to physicians and nurses. The comprehensive approach of multi-disciplinary pain service functions is ideal for inpatients with the most complicated pain issues. Examples include patients with chronic pain suffering from acute exacerbations and post-surgical patients with severe opiate tolerance following long-term opioid treatment. This multi-professional model has been most frequently used in the context of inpatient palliative care consultation at the end of life, but this approach, or some mild modification of it, has utility in the acute care arena as well.

Ongoing quality assurance can be managed on a service, departmental, and/or institutional level but should be transparent to participants and provide an opportunity for feedback and improvement for team members (including trainees and faculty) and service policies and procedures. We have used multi-professional team meetings—no less frequently than every two months as forums to communicate new or updated policies or procedures, clinical questions or concerns, cases of morbidity or mortality, and upcoming or ongoing research updates.

Financing and the Business Plan

The next step in the process of organizing an inpatient acute pain service is to construct a business plan. This is often the most challenging phase because the financial and business skills needed may not be innate to clinical anesthesiologists and are rarely covered in their training. The value analysis of this type of service is not entirely monetary. It should be emphasized that although the cost of delivering care may be considerable, the calculation of the cost analysis is a more complicated determination. The ideal measurement of the utility for pain management is controversial. Researchers have examined outcome measures, including hospital stay, hospital readmissions, quality of life, and clinical productivity. However, regardless of the cost analysis, there is a cultural expectation and ethical imperative supporting the philosophy that appropriate treatment of pain is independently valuable. The JCAHO has emphasized this sentiment in their statement that appropriate pain management is “good medicine” and that pain assessment and pain management should be “an organizational priority.” ^, With that acknowledgment, the purpose of an acute pain service business plan is to describe the inner workings of the proposed service, including its organizational strategy, marketing plan, tentative schedule for implementation, and overall cost. This must occur before the first cent is spent on the project. The business plan has two primary components.

The first arm of the plan is a narrative that includes the mission statement, its structure, and the responsibilities of the service. Here, the job descriptions of the involved personnel are outlined, facility requirements are listed, and the marketing plan is presented. This document should clarify the role, responsibilities, duties, and expectations of various personnel that are key to a successfully operating service. Guidelines and manuals for nurses and house staff are key to this first portion of the business plan.

The second primary component of the business plan is prepared as a spreadsheet that outlines the finances of the business endeavor, and these estimates must be as accurate as possible. Estimates of fixed and variable incomes, startup capital necessary until revenue produces profit, and a month by month expenditure estimate for at least the first year must be among the data provided in this document.

The plan should also consider the acquisition costs of analgesic medications and other pharmacy costs. Macario and McCoy reviewed the records of 298 patients who underwent hip or knee replacement surgery and found that pharmacy costs accounted for only 3% of the total hospital cost. However, the costs of post-operative analgesics represented 31% of the total pharmacy cost. Intravenous acetaminophen is an example of a useful addition to our analgesic armamentarium, but its absolute indications are few. Studies have demonstrated that intravenous and oral acetaminophen are equally effective for pain, despite their hundred-fold difference in cost. In our hospital, intravenous acetaminophen is to be administered only after acute pain team discussion, and indications for use include only functionally significant pain, patients who can have nothing by mouth including medications, and a contraindication or insufficiency of nonsteroidal anti-inflammatory drugs. If intravenous acetaminophen is approved by the pain team (including the pain service pharmacist), it is only approved for 24 h, at which time indications are assessed again. Similarly, in the last few years, millions of doses of liposomal bupivacaine have been infiltrated by surgeons and anesthesiologists (at hundreds of dollars per dose). However, third-party payers have had very restricted reimbursement policies for the drug, and initial meta-analyses demonstrated limited evidence of clinical advantages over plain bupivacaine (at 1/100th its cost). ^, Liposomal local anesthetics may well be found to be efficacious and cost effective in their pain-relieving effects for certain inpatient and/or outpatient procedures or patients. However, it is unlikely that anyone is better positioned to help hospital administrators balance hospital cost and evidence based analgesic efficacy in such therapeutic decision making than acute pain service leadership.

Other cost drivers include human resources in the form of pharmacists and nurses, as well as equipment, including PCA and epidural pumps. Medication errors are another rarely considered factor that increases the cost of post-operative analgesia. Adverse drug events, for example, have been shown to result in extending hospital stay by 4.6 days at a cost of $5857 per patient.

Finally, in this section of the business plan, it is ideal to have an estimate of the anticipated monthly patient load and the minimum number of patients required to support service expenses. This is not as easy a calculation as it might seem and needs to include a discussion of anticipated challenges to reimbursement either within or outside the institution. For instance, it is necessary to examine the insurance characteristics of the patient population that the acute pain program will serve. Based on the payer mix or the percentage of the population that is served by health maintenance (HMO), preferred provider (PPO), and medical care (MCO) organizations, it may be necessary to arrange plans for the preauthorization of acute pain services with the administrators of local health plans. Additionally, there may be geographical region-specific rules for billing pain services. Post-operative pain services are bundled under Medicare surgical services fees. In our Medicare region, we must provide evidence of a request from the attending surgeon for help with pain management and why such services are requested. For this reason, we have created a pain service consult “order” with several common reasons for pain consultation listed (e.g. opioid tolerance, and regional analgesia evaluation) and have provided this electronic list both as a freestanding order and embedded in the pre-operative surgical order set. We ask our surgical colleagues to fill out this request for service but have thus far chosen not to withhold pain treatment from patients with extreme pain when awaiting electronic referral.

In the construction of the business plan, the total revenue minus the total cost will produce a predicted financial position. This calculation begins with the estimation of the approximate charge per patient for each therapeutic modality to be used. With this revenue in mind, the cost of providing the service and various therapeutic modalities can be determined. Ideally, the financial design of the acute pain service should include elements promoting flexibility as the patient loads waxes and wanes. This is best accomplished by shifting fixed costs (e.g. permanent employees) to variable costs (e.g. temporary employees) as much as possible. Note that the result of this calculation will fluctuate over time. The financial solvency of the service will be most protected by hoping for the best while planning for the worst-case scenario.

Billing and Collection

A well-organized structure for billing and collecting services is imperative to ensure the solvency of any medical organization. Knowledgeable personnel, the necessary hardware, and efficient software for data collection are necessary if the service’s business plan includes an internal billing and collection group. As medical coding and billing accelerate in complexity and specificity, many organizations have elected to employ outside billing and collection services that operate on percentage-based contracts.

It is crucial to be aware of the current Centers for Medicare and Medicaid Services (CMS) guidelines for documentation and billing and to remain informed about modifications as they occur. Accurate documentation of services will facilitate correct and timely reimbursement, as well as represent what was actually done in the medical record. Furthermore, accurate documentation will clarify what was not done for the reference of both other healthcare professionals and third-party payers, thereby avoiding time-consuming changes in documentation, fines, and even criminal charges if discrepancies between CMS guidelines and physician billing are judged to be fraudulent. Example reference guides regarding chart notation and current CMS-required documentation can be found in the Appendices F . At our particular teaching institution, we have found it useful to “bake” some of the billing criteria into the electronic medical record pain consult note and progress note templates with the use of “hard stops” for vital assessment fields. Documentation of appropriate pain assessments, including analgesic-related side effects, often ensures that suitable levels of billing are accomplished.

Over the last several years at the University of Washington Medical Center, we have transitioned from a resident home night call model to using a team of trained nurse practitioners and physician assistants working in the hospital at night with pain attending home availability for questions (as before). This arrangement has improved patient and nursing satisfaction with a member of the pain team in house and available 24/7 despite only a minimal increase in net personnel costs because we can now bill for post-operative day zero pain assessment and treatment. This additional billing is appropriate, and perhaps even overdue, as, often, the most important pain assessments and treatments occur in the first few hours after surgery, when the pain team might have previously been at home.