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Total Joints with Few Opioids A company shares its successful pain management program BY ROBERT KURTZ
W
hen HealthCrest Surgical Part- ners, an Edmond, Oklahoma-
based ASC management company, set out in 2017 to build comprehensive total joint replacement programs at its two Maryland ASCs the team decided it also wanted to develop a supporting opiate- sparing pain management program that delivered excellent pain relief. HealthCrest manages Frederick Surgi- cal Center in Frederick, Maryland, and Cumberland Valley Surgery Center in Hagerstown, Maryland. “The standard outpatient model for total joints tends not to be very coordi- nated,” says Eric Shepard, MD, Fred- erick Surgical Center’s director of anesthesia. “The relationship with the ASC usually begins the day of surgery and ends with discharge. The surgeons usually handle postoperative pain, and narcotics are the mainstay of therapy.” The ASCs chose to base their pro- grams on the perioperative surgical home model of care, says Amy Sachs, RN, administrator of both centers. That model, she adds, focuses on physician and patient satisfaction, improving population health and reducing costs. “We had the support of our board of directors, surgeons and HealthCrest,” Sachs says. “We set up meetings with the various stakeholders and, over the course of five months, designed a program.” Initial work at the ASCs focused on researching patient selection, anesthetic techniques and postoperative pain man- agement. “We developed a tool to help surgeon offices screen out patients inap- propriate for outpatient joint replace- ment,” says Shepard, who also is the director of regional anesthesia for Ais- thesis Partners, an anesthesia man- agement company based in Bethesda, Maryland. “We interviewed rehab providers to see who could provide a home-based program that included an assessment of the patient’s home envi-
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Our time-release local anesthetics and continuous local infusion provide almost complete pain relief for the first three postoperative days. Most patients reported no pain at rest and minimal and tolerable pain with therapy.”
— Eric Shepard, MD Frederick Surgical Center
ronment, diet and nutrition support, and physical and occupational therapy.” Participating surgeons are screened to ensure they can complete proce- dures in fewer than two hours, with short tourniquet times and low pres- sures. “We also made sure team mem- bers worked together to maximize strengths,” says Shepard. “Our anes- thesiologists are experts in regional anesthesia and acute pain manage- ment. Surgeons defer the anesthetic technique and perioperative pain man- agement to the anesthesiologists.” About 30 days before surgery, the ASCs’ rehab provider partner vis- its patients to perform assessments of patients and their home environment, Sachs says. “The patient is given a pre-habilitation program that includes exercises and nutrition optimization.”
26 ASC FOCUS SEPTEMBER 2018 |
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Three weeks prior to the surgery, patients come to the ASC to meet the total joint nurse coordinator and anes- thesiologist. During that meeting, a complete assessment of the patient is performed and the anesthesia plan is dis- cussed. The patient is then given a carbo- hydrate-rich hydration solution to drink the night before and morning of surgery. For the surgery and postoperative pain management, patients receive a combination of multi-modal analgesia, regional anesthesia, extended-release liposomal bupivacaine and continuous perineural postoperative analgesia using an ambulatory infusion of local anes- thetic. “No opiates are used during the surgical procedure or recovery,” Shepard says. “Patients are given a prescription for tramadol for moderate postopera- tive pain that may present. They are also given a prescription for a small number of oxycodone for breakthrough pain.” Once home, patients are seen twice daily by a rehab provider and receive therapy, dressing and wound checks, pain checks and a vital sign assess- ment. “These visits continue until the patient is discharged to standard ambu- latory therapy,” Sachs says.
The program, Shepard says, has
been extremely successful, with most patients requiring zero or one oxy- codone and an occasional tramadol. “There has been no significant opiate use. Our time-release local anesthetics and continuous local infusion provide almost complete pain relief for the first three postoperative days. Most patients reported no pain at rest and minimal and tolerable pain with therapy. “When the local anesthetics wear
off or are discontinued, all patients have been comfortable on only acetamino- phen and nonsteroidal anti-inflammatory drugs,” he adds. “The program has been very rewarding for all of us at the ASCs and, most importantly, our patients.”
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