Access to the PPM Journal and newsletters is FREE for clinicians.
16 Articles in Volume 19, Issue #2
Analgesics of the Future: Inside the Potential of Glial Cell Modulators
APPs as Leaders in Pain Management
Cases in Urine Drug Monitoring Interpretation: How to Stay in Control (Part 1)
Complex Chronic Pain Disorders
Efficacy of Chiropractic Care for Back Pain: A Clinical Summary
Hydrodissection for the Treatment of Abdominal Pain Caused by Post-Operative Adhesions
Letters: The Word "Catastrophizing;" AIPM Ceases Operations; Patient Questions
Management of Severe Radiculopathy in a Pregnant Patient
Managing Pain in Adults with Intellectual Disabilities
Pain in the Courtroom: An Excerpt
Q&A with Howard L. Fields: How Patients’ Expectations May Control Pain
Special Report: CGRP Monoclonal Antibodies for Chronic Migraine
The Management of Chronic Overlapping Pain Conditions
Vibration for Chronic Pain
What are the dangers of loperamide abuse?
When Patient Education Fails to Improve Outcomes: A Low Back Pain Case

APPs as Leaders in Pain Management

Is there value in having an Acute Pain Service, and can APPs take the lead? Our resident APP responds.
Pages 22; 24-25

As a nurse practitioner who has focused her career on pain management and seen trends both in outpatient clinics as well as acute care hospitals, I get this question asked often. Depending on the stakeholder’s point of view, the question may take a different form, but the meaning is the same. Hospital administrators, for example, may focus on the Joint Commission’s indicators for pain assessment and management,1 or the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey concerning communication about pain during a hospital stay.2 Bedside nurses and non-pain specialist clinicians may want to focus on best practices for building interprofessional teams that can meet the pain management needs of their growingly complex patient populations (eg, the homeless, opioid tolerant, addicted, or those with mental health issues).

In the 1990s, names like Betty Ferrell, Chris Pasero, and Christine Miaskowski were touted as the trailblazers in establishing the importance of the pain resource nurse as well as the need for continued training and improved outcomes in pain management.3-5 Cindie Lou Roger, an independent consultant at CL Roger Healthcare Consulting in Georgia, shared with me that, in 1996, she created the position of a Pain Management CNS/NP/Practice Specialist at the Gwinnett Hospital System, and just a couple of years later, a formal pain service was created. “I thought the Pain Resource Nurse program created by Betty Ferrell should be implemented in all accredited institutions,” she told me.

The growing regulations and patient complexities in today’s acute care settings have gone beyond what the bedside nurse, pain resource nurse, or medical intern can handle alone. Every healthcare organization should have a dedicated pain management team—and yes, Advanced Practice Providers, or APPs, can take the lead. Acute Pain Services (APS) are becoming available in many hospitals worldwide because of the numerous advantages they hold for patients and healthcare systems. The hope is that, as formalized systems are recognized as best practice and APS are introduced, these changes will lead to a greater appreciation for pain issues and education among all healthcare providers.6 In turn, pain practice will improve.

(Source: 123RF)

APP Training: The Skill Sets Are There

Advanced Practice Registered Nurses (APRNs) have the skills and training to assess, manage, and create guidelines for pain management. They have, through their specific training, the skills to place and/or manage regional anesthesia, as well as interpersonal skills suited to interprofessional collaboration. Most APRNs have, at some point, spent time taking care of patients at the bedside, worked within complex systems, and participated in systems improvement committees.

Physician Assistants (PAs) typically enter their training with a background in healthcare and have experience with healthcare systems. Through their primary training, they develop the skills and experience to assess and recognize poorly managed pain. Although there are few PA residencies devoted to the specialty of pain management, PAs that participate in residencies that focus on intensive training in specialties such as surgery, trauma, acute care, critical care, and/or emergency medicine,7 develop the skill set to manage the complexities of acute pain in compromised patients.

APPs in Action

Below are a few examples of best practices already being put into play by APPs in the acute care setting.

Mechele Fillman, NP, Acute Pain Service

“I started an acute pain service at Saint Joseph’s Hospital, in Denver, in 2008, because I recognized that surgery patients were experiencing inadequate pain relief with opioids. In some cases, the patients’ pain management was inadequate, and they were experiencing side effects such as over-sedation and respiratory depression, causing them to have a much longer ICU stay. The pain service was started to provide pain relieving and opioid-sparing techniques, such as epidurals and ketamine infusions.

I came to Stanford HealthCare in 2012 and expanded the acute pain service from 1.5 FTEs to 5 FTEs, allowing for 24-hour pain consult coverage. Additionally, during my tenure, we saw the addition of a regional anesthesia service that allows for state-of-the-art multimodal pain management techniques. In 2018, I was recruited to Christus St. Vincent Regional Medical Center to start an Acute Pain Service. The idea was to expand on the number of non-labor epidurals already being done, add lidocaine and ketamine infusions, start a nerve catheter program, and to, overall, bring opioid-sparing knowledge and techniques to the patients of St. Vincent.

I find this work important because pain is often misunderstood and under-represented as a specialty. It often overlaps with substance abuse and addiction as well as psychiatric issues, which makes treatment difficult and time-consuming. Another important aspect is pre-emptive treatment of pain in the hopes of preventing future chronic pain.”

Yvonne D’Arcy, MS, CRNP, CNS Pain Management and Palliative Care

Yvonne D’Arcy has more than 20 years of pain management experience, having held positions at Johns Hopkins-Suburban Hospital in Maryland, and the Mayo Clinic in Florida. When asked to discuss her experiences, she shared: “Well I created my service from the bottom up. The hospital was not even using numeric rating when I started in 2002. They really needed expert resources and help for the nurses. I gave them something they did not even know they needed. They had a Joint Commission visit six months after I started, and we had no guidelines for pain management. I created all the policies, protocols, and data tracking to get us through the visit. I worked so hard I ended up with mono the day after their visit.

One of my biggest barriers was getting the MDs to accept my practice. They had no idea what an NP did. The docs all rounded in the morning and then went to their offices. I took a lot of the daily calls and consult requests, and I wrote the needed orders. It took about a year to gain full acceptance, but, in the end, they came to rely on me.

Most of my consults came from the hospitalist service. Understandably, they were young doctors new to medicine that had no comfort level with prescribing opioids or treating pain. I spent a lot of time on their rounds and giving help and feedback with their patients. My biggest joy was helping patients. With my experience, it was easy for me to get a good plan of care in place. My biggest disappointment was getting the medical staff to recognize me as an equal.

The hospital supported my practice, but financially, I was not a member of any medical service; I was an independent practitioner. Some doctors had trouble conceptualizing that my prescribing decisions were mine alone. They did not understand that my practice was my responsibility and had nothing to do with them. I prescribed heavy opioids regularly and never had any problems.”

APPs Can Lead APS & They Can Lead Now

Over the past 10 years, the representation of APPs as leaders within their respective organizations and as resources for pain management has significantly increased. At Stanford Health Care, for instance, where I practice, the Acute Pain Service manages, on average, a consult service of 30 to 40 patients a day. The Acute Pain Service at Stanford employed its first APP solely dedicated to APS in 2012, and now boasts seven full-time APPs. Memorial Sloan Kettering was the first cancer center in the country to have a service dedicated to treating pain in people with cancer.8

The value of an in-hospital APS, for all the reasons mentioned above, is disputed by few. But what if there were no acute pain services in a facility? What would be the best strategies for acute pain management? The answer lies in community engagement of all clinicians involved in that patient’s care, and was introduced by American Society of Anesthesiologists in a concept named The Perioperative Surgical Home.9 This concept was first introduced in 2013, and has been shown to increase patient satisfaction, reduce hospital costs, and decrease complications.10 The perioperative surgical home is defined by the American Society of Anesthesiologists as “a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience.”11 APPs in all specialties that care for patients where there is an anticipation of hospitalization or surgery are involved in this burden of care, which includes implementing a treatment plan for anticipatory pain management, as well as active and post-discharge pain management. The following is a hypothetical case scenario in which APPs are integral to such a process.

A Hypothetical Example

A 65-year-old male on morphine 20 mg/day for chronic osteoarthritis is at his pre-op H&P consultation visit with the surgical PA for surgery in 2 weeks. The surgical PA activates the services “perioperative surgical home, total joint replacement program,” which calls for the patient to be evaluated by the APRN at the hospital anesthesia pre-op clinic. The plan for analgesia will include a multimodal approach with non-opioid analgesics, mindful opioid management, and regional nerve block catheter.

On the day of surgery, the surgical PA communicates with the orthopedic surgical resident about the plan for pain management and discharge, while the patient is in the pre-op holding area having his peripheral nerve block catheter inserted by the CRNA. During his post-surgical hospital stay, he has a consult with the in-patient APS PA. On the day of discharge, the patient schedules a post-surgical follow up and a two-week follow-up visit with his primary care NP. He is given a two-week supply of post-surgical pain medications, including opioids with instructions for weaning safely off these medications.

This is an overly simplistic scenario. While the perioperative surgical home model further considers greater patient complexities and needs, this hypothetical case demonstrates the importance of care coordination and communication. APPs, in various instances, serve as the continuity clinicians in many aspects of patient care.

Next Steps

Pain is complex and the acuity of hospitalized patients’ pain management needs has increased, with high opioid tolerance, addiction, depression, and anxiety now on the list. Standard-of-care expectations1 have left many organizations in great need. Advance Practice Providers can fill these needs by establishing acute pain consult services within institutions (ie, acute care hospitals, sub-acute institutions, health maintenance organizations). APPs may also seek employment as pain resource clinicians within an institution, or through programmatic development with systems/policies/protocols for pain management within their current institutions. Going forward, APPs also have an active role to play in the perioperative surgical home,10 as primary care clinicians, surgical specialty clinicians, members of the anesthesia team, hospitalists, nocturnists, and pain management specialists.


Read previous For the APP columns:

Last updated on: April 12, 2019
Continue Reading:
How to Fit into a New Practice
close X