Acute Pain Management Service?

[Stillwater45]

So there is a lot of talk about Anesthesiologist needing to step outside of the OR, be more involved in perioperative care, ect. Any groups out there have an Acute Pain Management service? A service that extends beyond typical ortho catheter management. We are kicking around the idea of one at my Academic institution. The idea is that you could consult on patients with acute pain (mostly post-op) but some medicine pts. It would involved medication management (opiates, ketamine, ect.) and possibly blocks. Epidurals, paravertebrals, TAP blocks, and the usual ortho catheters.

Anybody doing this? Is there a need for this? Does is seem viable? Any thoughts?

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[ssmallz]

This sounds like more trouble than its worth

 

[Planktonmd]

So there is a lot of talk about Anesthesiologist needing to step outside of the OR, be more involved in perioperative care, ect. Any groups out there have an Acute Pain Management service? A service that extends beyond typical ortho catheter management. We are kicking around the idea of one at my Academic institution. The idea is that you could consult on patients with acute pain (mostly post-op) but some medicine pts. It would involved medication management (opiates, ketamine, ect.) and possibly blocks. Epidurals, paravertebrals, TAP blocks, and the usual ortho catheters.

Anybody doing this? Is there a need for this? Does is seem viable? Any thoughts?

It won't work in private practice since it costs money and effort.
In academia it is already a common thing to have an acute pain service since manpower (residents and fellows) is available and cheap.

 

[PinchandBurn]

It won't work in private practice since it costs money and effort.
In academia it is already a common thing to have an acute pain service since manpower (residents and fellows) is available and cheap.

why wouldnt this work in PP?

A RN/PA/NP (whoever is most cost effective) could 'round' on the patients. The physician would administer all the blocks that the OP described.

 

[Mac4]

This sounds like more trouble than its worth

I second that. Our residency program tried this when I was on the acute pain/RA service. We were paged 24/7 by the floor nurses for any post-op or acute pain issues. Trust me, when some nurse, at 2 am, pages you and asks you to give verbal order of 6 mg dilaudid stat for a sickle cell crisis patient who you have never seen, it can cause some significant stress and pretty much ruin your whole night. Or the drug seeker complans of 10/10 pain at 4 am. You can not refuse it either, because you are the "acute pain" service.

If you do offer the service, please make it 7am-4 pm and be prepared to run up and down stairs all day.

 

[Planktonmd]

why wouldnt this work in PP?

A RN/PA/NP (whoever is most cost effective) could 'round' on the patients. The physician would administer all the blocks that the OP described.

Who is going to pay the salary of the nurse or PA doing the rounding?
Who is going to respond to after hours consults and cover weekends?
We all follow patients with post-op pain and help other physicians manage difficult pain management issues on inpatients, but once you have a dedicated acute pain service you will suddenly inherit all the IV PCA's and all simple pain issues currently handled by others in the hospital and this will be a free service because no one will pay you to do this.

 

[bullard]

Agree with Plank. Our compensation for regional is poor. Hiring a nurse and starting a true APS would be a money-loser. If surgeons wanted it, hospital would have to subsidize us for it. If they wanted us to hire CCM-trained guys to cover the unit, hospital would have to subsidize the loss of income from the OR. But the hospital is either too short-sighted, too cheap, or they're just happy with status quo.

 

[Ventil8]

I wonder if the move to bundled care happens if showing our overall value to the hospital (albeit a bunch of scut work with a few blocks) is a strategic move we SHOULD be making. Short term loss for future benefit. If we covered all the "pain" in the hospital, that could be a huge negociating chip...

 

[ssmallz]

I wonder if the move to bundled care happens if showing our overall value to the hospital (albeit a bunch of scut work with a few blocks) is a strategic move we SHOULD be making. Short term loss for future benefit. If we covered all the "pain" in the hospital, that could be a huge negociating chip...

No way. I would rather quit than get dumped on like this. Remember what it was like to be an intern? It's going to turn into non stop pages by nurses for pain meds. Other docs are gonna say "call anesthesia" for every pain malady under the sun whether or not you've actually seen the pt. Sickler in crisis at 2am? Call the APS, post op pt can't sleep? Call APS PCA malfunction? Call APS. You will get a ton of narc mgt, few blocks, and less sleep.

 

[MommyMD]

We have an acute pain service (academic with residents, fellows and a rotation of pain attendings who round in the morning with whoever is "on call") ...mainly epidural and catheter management. Epidurals for post-csection, abdominal surgeries and thoracic cases. Also acute pain management for patients we were called in as a consult. We dont do basic pca orders and we are consultants and make reccomendations (ie converting IV to PO, cancer pain, our chronic pain patients who are in the hospital for another reason). We have created a culture that we are called for the more difficult to manage patients, not for basic things. Not sure if we are making money but we the attendings do bill for every patient we see everyday.

 

[WholeLottaGame7]

We have an acute pain service (academic with residents, fellows and a rotation of pain attendings who round in the morning with whoever is "on call") ...mainly epidural and catheter management. Epidurals for post-csection, abdominal surgeries and thoracic cases. Also acute pain management for patients we were called in as a consult. We dont do basic pca orders and we are consultants and make reccomendations (ie converting IV to PO, cancer pain, our chronic pain patients who are in the hospital for another reason). We have created a culture that we are called for the more difficult to manage patients, not for basic things. Not sure if we are making money but we the attendings do bill for every patient we see everyday.

Same at my institution. We round on post-op catheters, place some others, and if a team has an issue with pain control or PCA management, it goes in as a consult. After 5pm it's usually deferred to the next day.

 

[TrustMe]

When I was a resident our ortho guys tried to get the acute pain service to start managing their PCA's post-op. Thankfully our division chief said "no thanks". The acute pain service only saw patients that we put in catheters or epidurals for post-op pain control. The calls from nurses for thoracic epidural questions were bad enough. I can't imagine managing all the PCA's for the hospital or getting called for every non-surgical patient with pain. I would find a different job if I was asked to do that.

Stick with managing catheters and epidurals only.

 

[psychbender]

We have an APS (and Regional/APS fellowship) that deals with catheters and complex pain consults. For a time, it got ridiculous (like a 50 patient list, with only a half-dozen catheters), as we were almost literally rounding on everyone with a PCA. After a shift in departmental politics, and the arrival at the new hospital of our colleagues in PM&R, we were able to shift a lot of our less acute patients back to the primary teams. Managing the APS is still a major responsibility of the junior overnight, and on weekends, though.

 

[G0S2]

That is the rotation I am on now. Painful. We follow and place epidurals for post-op pain and make med recs for those teams that write PCA orders of 0.2MG Dilaudid q 20mins for people at home on a 100mcg/hr fentanyl patch. Got rib fractures? Page APS for the thoracic epidural that will save lives.

Every time there is a nursing shift change, the pager starts going off the hook.

We do have a NP that rounds with us and runs around pulling all the <24hr ortho epidurals prior to anticoagulation.

 

[Noyac]

I thought every legitimate academic center had an acute pain service these days. We had one when I trained and that was a long time ago. Like someone said, residents and fellows are cheap. The training is worthwhile

But in PP it isn't worth it. No residents to answer the pages.

 

[DOctorJay]

We have an inpatient pain service that is broken up into acutes and chronics. Acutes are catheters, chronics anyone we get consulted on to manage pain without a catheter, most are on high dose opioids as outpatients who have had surgery and require upward titration. Acutes are followed by NP and staffed with consultant, CA1 and visiting residents (PMR like me) see the chronic consults. CA2s cover the pain service pager (along with code pager) for their overnight call. Lots of pca mgmt, transition to orals, and some procedures.

 

[BLADEMDA]

When I was a resident our ortho guys tried to get the acute pain service to start managing their PCA's post-op. Thankfully our division chief said "no thanks". The acute pain service only saw patients that we put in catheters or epidurals for post-op pain control. The calls from nurses for thoracic epidural questions were bad enough. I can't imagine managing all the PCA's for the hospital or getting called for every non-surgical patient with pain. I would find a different job if I was asked to do that.

Stick with managing catheters and epidurals only.

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