The document discusses setting up an acute pain service that adds value. It covers value-based purchasing programs that reward better outcomes and patient experiences. Hospitals are evaluated based on HCAHPS surveys, which include questions on pain management. The document provides strategies for an acute pain service to improve patient satisfaction, outcomes, and reduce costs, such as standardized care pathways, regional anesthesia, and multimodal analgesia.

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. 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. 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. 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. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Let’s Go Back to 2004Let’s Go Back to 2004

6. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
The Most Important LessonThe Most Important Lesson

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. 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. 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. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Perioperative Surgical HomePerioperative Surgical Home
Anesthesiology 2015;123:A23Anesthesiology 2015;123:A23

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Scoring HospitalsScoring Hospitals
“Incentive” = How
Much Withholding
Hospitals Get Back

22. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Evolving Practice of AnesthesiaEvolving Practice of Anesthesia

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. 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. 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. 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. 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. 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. 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. 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. 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. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Anesth Clinics 2014;32:853

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. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
Preoperative Preparation TodayPreoperative Preparation Today

35. Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service
A Vision for the FutureA Vision for the Future

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. 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. 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