Shifting to Non-Narcotic Pain Management

Orthopedic surgery patients at Sibley Memorial Hospital in Washington D.C., learn about and plan their postop pain management strategy long before surgery. This is by design, explains Cynthia Wade, BSN, RN, CNOR, perioperative nurse and leader of a team initiative to implement non-narcotic pain management plans that also include a mechanism to respond to individual patient needs.

Power to Patients

“Research tells us that when patients are partners in their medical decisions, pain management compliance is higher, the use of narcotics is lowered, and there is no corresponding increase in reported pain,” Wade shares. Her team is seeing this in practice through coordinated, multidisciplinary perioperative work that is proving successful based on orthopedic surgery patients’ consistent top percentile ranking for pain management on the CMS HCAHPS questionnaire.

Through established patient-centric management practices, every orthopedic patient’s pain plan begins with education through a pre-surgical Joint Class led by orthopedic nurse navigators to explain infection control protocols, post op expectations and pain management modalities available to the patient, with a focus on non-narcotic options and addressing other factors that can impact pain management, including age and comorbidities.

Sibley Memorial Hospital’s pain management protocols include a combination of:

• neuromodulators,
• NSAIDS,
• Intravenous (IV) acetaminophen,
• ice,
• positioning,
• nerve blocks (including blocks through a continuous pain pump), and
• narcotics.

This preoperative education through the Joint Class also sets the stage for the patient’s perioperative journey from pre-admission paperwork through discharge and follow-up care.

With this knowledge, the patient works with their anesthesiologist and surgeon prior to surgery to develop a tailored pain management plan that takes into account the patient’s preferences and individual history. “Adjustments to this pain management strategy are made during frequent check-ins throughout a patient’s stay to ensure patient needs are being met,” Wade says.

Successful Change Management

In 2011 a core team including representatives from pharmacy, nursing, physical therapy, case coordination, and physicians applied an orchestrated change management approach for each step in creating and launching a patient-centric pain management protocol. To ensure this work was focused on patient need, Wade followed up with patients after surgery to understand their pain management experience.

“I followed all of the patients over a three month period with each medication/procedure implementation, talking to them about what they felt worked and what information they wished they had received preoperatively,” Wade shares. This patient input was shared with anesthesiologists, surgeons, and pharmacists who worked out different combinations of pain management that were then established as part of formal pain management protocols that could be tailored to individual patient needs.

“Using change management was critical through each step of the way—from developing the initial protocols to holding in-services and other educational offerings—to gain buy-in from stakeholders and keep our mission for a patient-centric focus top-of-mind,” Wade acknowledges.

One important aspect of these protocols included establishing policy, procedures and educational competencies for continuous pain pump administration of regional anesthesia as a nerve block for postop pain management. This involves a small disposable pump filled with local anesthesia medication to continuously relieve pain at the incision site for 2–5 days via a catheter. This method is used in both inpatient and outpatient settings, and nurses play a key role in educating the patients in the use and care of the pump as part of their pain management options.

“This pain pump approach is most effective when applied to appropriate patient populations and this has required dedicated multidisciplinary collaboration between surgeons, anesthesiologists, pharmacists and nurses specializing in preop, block, OR, PACU and unit care,” Wade says.

As new best practices emerge, Wade and the team adapt pain management protocols to fall in line with current information. “With every change, I follow patients for a three-month period to obtain information from their perspective about the effectiveness of the program,” she says.

Consistency and ongoing communication have been two important keys to sustaining and constantly improving our approaches to help patients recover reducing narcotics use when possible, Wade stresses. “We all want what is best for our patients and our shared understanding of the adverse side effects that come with narcotics for pain management inspires us to continue working with each other and our patients to achieve the best recovery possible for our patients.”

Learn more about the work of Wade and her team to implement continuous pain pump regional anesthesia as a patient-centric non-narcotic pain management option.

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