Educating Surgical Team is Biggest Challenge in Implementation

To learn how other surgeons in the United States have implemented ERAS pain management practices, Surgical Products connected with Anita Gupta, D.O., Pharm.D., member ASA Committee on Pain Medicine; Dr. David B. Auyong, attending anesthesiologist, medical director at Lindeman Ambulatory Surgical Center, Virginia Mason Medical Center; Dr. Deborah Keller, a colon & rectal surgery doctor in Houston, Texas; and Dr. Lawrence Volz, director of ERAS programs for Dunes Surgical Hospital and Mercy Medical Center-Sioux City, Iowa.

What were some early challenges to multimodal pain management systems?

Auyong: Studies show that multimodal approaches to pain management – using a combination of post-operative pain pumps, nerve blocks, periarticular injections, neuraxial anesthesia and anti-inflammatory drugs – provide better results for patients, but an early challenge was determining how to put systems in place to make multimodal pain management the core standard of care. Demonstrating multimodal pain management’s ability to decrease narcotic usage, improve pain scores, increase satisfaction and enhance early recovery for patients post-surgery was instrumental in addressing this challenge.

There are many elements that comprise a multimodal pain management program, so a therapeutic approach that works for one patient, practice area or center may need to be adjusted for another. It’s important for healthcare professionals to consistently audit their strategy, fine tuning where necessary to continue to improve patient outcomes. Consistently striving to take an evidence and outcomes-based approach, rather than viewing pain management as “one size fits all,” is crucial to a successful multimodal program. Developing multimodal pain management pathways means involving many departments – including surgery, anesthesia, nursing, pharmacy, physical therapy, occupational therapy and social work. Keeping open lines of communication between these departments and working jointly to make the patient’s healthcare experience as smooth as possible should be the common goal.

Keller: Early challenges are defining the ideal standardized pain management arm of an Enhanced Recovery Pathway, then getting buy-in from all other physicians in your practice, nurses that take care of your patients, pharmacists that administer the medications, and support from the administration for the implementation process. Educating patients about the new ideology in pain management can also be challenging, but understanding the negative impact of opioids,

Volz: I was very surprised at how comfortable these patients were after surgery.  When I could perform a laparoscopic sigmoid colectomy and the patient go home the next day on Tylenol and motrin.  I was shocked.   Outpatient surgical patients I find take narcotics because they think they will need them, not because they actually do need them.  Education about how to take their medications helps avoid the postop narcotics.

This is one in a five-part series. These experts also answered:

• How has ERAS program impacted your pain management practices?
• How have you seen patient outcomes affected by multimodal pain management approaches?
• What role do you think opioids play in pain management?
• Why are surgeons still hesitant to transition to this new approach?