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How to set up an acute pain service that adds value

How to set up an acute pain service that adds value

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At the conclusion of the activity participants should be able to: discuss the value-based purchasing program and its components; identify aspects of the HCAHPS survey that directly and indirectly relate to inpatient pain management; and apply strategies to provide high quality pain management and minimize risks for postsurgical patients.

At the conclusion of the activity participants should be able to: discuss the value-based purchasing program and its components; identify aspects of the HCAHPS survey that directly and indirectly relate to inpatient pain management; and apply strategies to provide high quality pain management and minimize risks for postsurgical patients.

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How to set up an acute pain service that adds value

  1. 1. How to Set Up an Acute Pain Service that Adds Value @EMARIANOMD@EMARIANOMD Edward R. Mariano, M.D., M.A.S.Edward R. Mariano, M.D., M.A.S. Professor of Anesthesiology, Perioperative & Pain MedicineProfessor of Anesthesiology, Perioperative & Pain Medicine Stanford University School of MedicineStanford University School of Medicine Chief, Anesthesiology and Perioperative CareChief, Anesthesiology and Perioperative Care Veterans Affairs Palo Alto Health Care SystemVeterans Affairs Palo Alto Health Care System
  2. 2. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service 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.
  3. 3. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service DisclaimerDisclaimer  This presentation is intended forThis presentation is intended for educational purposes only and is noteducational purposes only and is not meant to be reproduced or redistributedmeant to be reproduced or redistributed for commercial purposesfor commercial purposes
  4. 4. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Learning ObjectivesLearning Objectives  Discuss the value-based purchasingDiscuss the value-based purchasing program and its componentsprogram and its components  Identify aspects of the HCAHPS surveyIdentify aspects of the HCAHPS survey that directly and indirectly relate tothat directly and indirectly relate to inpatient pain managementinpatient pain management  Discuss strategies to provide high qualityDiscuss strategies to provide high quality pain management and minimize risks forpain management and minimize risks for postsurgical patientspostsurgical patients
  5. 5. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Let’s Go Back to 2004Let’s Go Back to 2004
  6. 6. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service The Most Important LessonThe Most Important Lesson
  7. 7. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service OverviewOverview  Think “big picture”Think “big picture”  Continuously improveContinuously improve  Reach for the starsReach for the stars
  8. 8. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service OverviewOverview  Think “big picture”Think “big picture”  Continuously improveContinuously improve  Reach for the starsReach for the stars
  9. 9. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service 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
  10. 10. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Perioperative Surgical HomePerioperative Surgical Home Anesthesiology 2015;123:A23Anesthesiology 2015;123:A23
  11. 11. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service PSH & Pain Medicine Go TogetherPSH & Pain Medicine Go Together PSH: Comprehensive Literature Review, www.asahq.org/pshPSH: Comprehensive Literature Review, www.asahq.org/psh
  12. 12. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Institute of Medicine 2012Institute of Medicine 2012 http://www.iom.edu/bestcarehttp://www.iom.edu/bestcare
  13. 13. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service  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, insteadinstead of just volume of services”of just volume of services”  Funded by a 1.75%Funded by a 1.75% 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
  14. 14. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service  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 1.75%Funded by a 1.75% 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
  15. 15. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service 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*
  16. 16. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Satisfaction Isn’t EverythingSatisfaction Isn’t Everything but we are scored on it!but we are scored on it!
  17. 17. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service 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
  18. 18. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service HCAHPS Questions on PainHCAHPS Questions on Pain Mariano, et al. Adv Anesthesia 2013;31:119Mariano, et al. Adv Anesthesia 2013;31:119
  19. 19. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service How Do CA HospitalsHow Do CA Hospitals Compare?Compare? 74% http://www.hospitalcompare.hhs.govhttp://www.hospitalcompare.hhs.gov Hosp#1 Hosp#2 Hosp#3 CA Avg US Avg
  20. 20. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service How Do CA HospitalsHow Do CA Hospitals Compare?Compare? 86% http://www.hospitalcompare.hhs.govhttp://www.hospitalcompare.hhs.gov Hosp#1 Hosp#2 Hosp#3 CA Avg US AvgStanford Kaiser SC Wash Hosp CA Avg US Avg
  21. 21. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Scoring HospitalsScoring Hospitals “Incentive” = How Much Withholding Hospitals Get Back
  22. 22. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Evolving Practice of AnesthesiaEvolving Practice of Anesthesia
  23. 23. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Avoid “Never” EventsAvoid “Never” Events Federal Register May 3, 2007Federal Register May 3, 2007 Avoid “Never” (Get Paid) EventsAvoid “Never” (Get Paid) EventsAvoid “Never” (Get Paid) EventsAvoid “Never” (Get Paid) Events
  24. 24. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Cost Savings Benefit the HospitalCost Savings Benefit the Hospital  Increasing Phase I PACU bypassIncreasing Phase I PACU bypass  Changing PACU nurse:patient ratiosChanging PACU nurse:patient ratios  Decreasing unplanned hospitalDecreasing unplanned hospital admissionsadmissions  Decreasing ER visitsDecreasing ER visits  Shortening length of stay (e.g., jointShortening length of stay (e.g., joint replacement)replacement) ……Not You!Not You!
  25. 25. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service OverviewOverview  Think “big picture”Think “big picture”  Continuously improveContinuously improve  Reach for the starsReach for the stars
  26. 26. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Improve Time ManagementImprove Time Management  Educate patients earlyEducate patients early – Surgeons’ officesSurgeons’ offices – OnlineOnline – Preanesthetic evaluation clinicsPreanesthetic evaluation clinics – Preoperative phone callsPreoperative phone calls  Centralize suppliesCentralize supplies  Teamwork with perioperative staff to getTeamwork with perioperative staff to get patients ready earlypatients ready early  Consider doing blocks outside the ORConsider doing blocks outside the OR Mariano ER. Anesth Clin 2008;28:681Mariano ER. Anesth Clin 2008;28:681
  27. 27. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Consider Making a “BlockConsider Making a “Block Room”Room”  Dedicated spaceDedicated space  Standard ASAStandard ASA monitors availablemonitors available  Oxygen sourceOxygen source  ResuscitationResuscitation equipmentequipment  Not for everyNot for every practicepractice Mariano ER. Anesth Clin 2008;28:681Mariano ER. Anesth Clin 2008;28:681
  28. 28. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service 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
  29. 29. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service  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
  30. 30. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service 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
  31. 31. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service 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
  32. 32. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Anesth Clinics 2014;32:853
  33. 33. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service OverviewOverview  Think “big picture”Think “big picture”  Continuously improveContinuously improve  Reach for the starsReach for the stars
  34. 34. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Preoperative Preparation TodayPreoperative Preparation Today
  35. 35. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service A Vision for the FutureA Vision for the Future
  36. 36. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Mariano, Walters, Kim, Kain. A&AMariano, Walters, Kim, Kain. A&A 2015;120:11632015;120:1163
  37. 37. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service Prevent Persistent Pain?Prevent Persistent Pain? Lavand’homme, et al. CORR 2014;472:1409Lavand’homme, et al. CORR 2014;472:1409 TKA Patients
  38. 38. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service SummarySummary  We discussed the value-based purchasingWe discussed the value-based purchasing program and its componentsprogram and its components  We identified aspects of the HCAHPSWe identified aspects of the HCAHPS survey that directly and indirectly relate tosurvey that directly and indirectly relate to inpatient pain managementinpatient pain management  We discussed strategies to provide highWe discussed strategies to provide high quality pain management and minimizequality pain management and minimize risks for postsurgical patientsrisks for postsurgical patients

Notas del editor

  • Goals is to achieve Triple Aim
  • Initial stages of PSH implementation
    Today’s discussion is in line with available publications. More of a case report of our experience at VA Palo Alto rather than research article.
    Not a “one-size fits all” – no single ideal PSH model
  • Components of PSH. One factor in each stage is Pain Management.
    Today, will discuss the role of APS in PSH
  • A post-hoc power calculation revealed 89% power to detect this difference.

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