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Physicians in pain management programs are increasingly striking a balance between ordering proper medications and trying to ward off potential drug abuses, the American Cancer Society Action Network has found.
"Keeping the patients' perspective and needs in focus is extremely important in prescribing painkillers," says David Woodmansee, associate director for state and local campaigns for the American Cancer Society Cancer Action Network. "That is the essence of balance."
Success key No. 2: Treating children's pain
While many hospitals are launching programs primarily to help adult patients cope with pain, others are focusing on children, especially cancer patients. A major concern is that younger children may have trouble communicating the extent of their pain, making diagnosis and treatment difficult. And, too often, physicians and hospitals lack expertise in providing proper medication and integrative or nonpharmacological therapies for children in pain, says Stefan Friedrichsdorf, MD, medical director of pain medicine, palliative care, and integrative medicine at the 381-staffed-bed Children's Hospitals and Clinics of Minnesota in Minneapolis.
An independent, not-for-profit healthcare system, Children's of Minnesota provides care through more than 12,000 children inpatient visits and more than 300,000 emergency room and other outpatient clinic visits every year. By establishing a specific pain management program, the hospital
has added protocols that have resulted in improved outcomes and reduced length of stay for its patients, says Friedrichsdorf. The multidisciplinary team includes physicians, nurses, social workers, psychologists, and massage therapists. The pain management program has increased its volume of patients in each of the past several years, from a total of 1,117 children seen in 2008 to 1,440 in 2012.
Focusing on patient management has resulted in savings and reduced lengths of stay. One of the most significant efforts was establishing an advanced analgesia-sedation protocol for babies and children who had undergone open heart surgery. In pediatric circles, it is known that pediatric sedation requires a balance between risk and procedures. Studies have shown that the demand for procedural sedation for diagnostic and therapeutic procedures is increasing.
Hospitals must establish proper protocols to provide safe and high-quality sedation. The Minneapolis analgesia-sedation protocol has resulted in reduced length of stay from eight to seven days, and it intubated children four hours earlier, despite the fact that the children were considered generally "sicker" from their cardio scores, according to Friedrichsdorf.
In the cardiovascular ICU, process improvements also meant workflow changes, he adds. Adjustments were made to team roundings, such as the requirement that twice each day—from 7 a.m. to 8 a.m. and again from 4:30 p.m. to 5:30 p.m.—a team nurse, respiratory therapist, intensivist, cardiologist, cardiac surgeon, pharmacist, and pain physician round on every patient. If a rounding occurs at a cardiac ICU, a cardiac intensivist is involved.
The hospital's readmission rate within seven days, for any condition, was as low as 3.5% from January to December of 2012, which is notable when compared to 24 other children's hospitals, the lowest of which had a readmission rate of 4.1%, according to the Pediatric Health Information System, a database operated by the Alexandria, Va.–based Children's Hospital Association. Generally, Children's of Minnesota has "sent their patients home faster and that drives up satisfaction for the patients and their parents," Friedrichsdorf says.
Managing children's pain at hospitals across the country has been erratic, in part because of uncertainty among physicians in providing proper doses of medication for pain, says Friedrichsdorf. By not incorporating multidisciplinary teams to focus on children's pain needs, hospitals are coming up short for children, especially for those with acute chronic pain, he adds.
"Most children's hospitals are not even implementing the basic principles of acute or chronic pain management," he says. Among the places where these principles should be applied are in children with acute pain, postoperative pain, and cancer pain, after open-heart surgery and orthopedic procedures, and for chronic pain, such as abdominal and musculoskeletal pain.
"Children with cancer pain, they probably receive too little medication, and pediatric patients with chronic pain and headaches probably get too much," Friedrichsdorf says. "It's quite easy to prescribe strong medication and say, 'I'll see you in two weeks.' These kids need physical therapy and normalized lives. We extubate the children when they are admitted to our hospital and they receive advanced pain management. This is a business model that hospital leadership can get behind."
Success key No. 3: Comanaging pain
A pain management specialist looked around the Nevada desert and noticed it lacked more than water: There weren't many pain doctors around.
"Over the past few years, there has been only one pain management doctor for every 10,000 patients who come in for pain treatment," observes Denis Patterson, DO, now medical director of Northern Nevada Medical Center's Pain Management Center. "There's definitely a need for pain management, a huge need really, and pain management is very much underutilized in the community."
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