Pain Management Protocol in Adolescent Idiopathic Spinal Fusion Reduces Length of Stay and Complications

Transcription

1 Pain Management Protocol in Adolescent Idiopathic Spinal Fusion Reduces Length of Stay and Complications Abstract Authors: Karen Martin, RHIT, CPHQ - Surgical Clinical Reviewer - Quality Management Analyst, East Tennessee Children's Hospital; Tammy VanDyk, RN, MSN, CPEN Director of Quality & Patient Safety, East Tennessee Children's Hospital

2 No Disclosures

3 The ETCH Spine Team A Multidisciplinary Task Force Pain & Palliative Care Director, Lorna Keeton, CPNP-AC Pediatric orthopedic surgeon, Cameron Sears, MD Chief Quality Officer, Dr. Jeananne Pardue, M.D. QI Specialists, Tammy VanDyk, Karen Martin Surgical Floor, Nurse Manager, Debra Dobbs, RN Clinical Nurses Pharmacist Anesthesiologist Physical Therapist Nutritionist Social Work Patient/Family Input Mission: A Comprehensive Care Map for AIS Spine Fusion

4 Goal Postoperative Multimodal Analgesia with Less Opioid use and Fewer Side Effects Methods: Record Review (190 AIS Cases ) Internal Process Evaluation Best Practice References Gap Analysis Outcome Measurement Benchmarking (SPS, CHA-PHIS, THA, NSQIP-Pediatric) Opportunities: Length of Stay Medication Standards Pre-op Education Nausea Control Early Mobility ICU Stay

5 NSQIP-Pediatric Information Reports Spine Fusion Targeted Measures Report 2014 Risk, Utilization and Outcomes Specific to Spine Fusion What We Learned Good Outcomes for Spine Fusion Semi-Annual Reports (SAR) Risk adjusted Outcomes for All Surgery and Orthopedics All Surgery Postop Pneumonia High Odds Ratio: 2014 (10 cases with occurrence - 3 were Spine Fusion cases) All Surgery Pneumonia Occurrence Jan-Dec 2014 Without Complication With Complication Workstation Reports Comparative Rates for hospital and NSQIP-P Group Low Spine Fusion Operation Duration in Minutes Hospital 100 NSQIP-P AVG

6 Multimodal Analgesia for AIS Spine Fusion PCA Morphine with added low-dose Naloxone drip IV Acetaminophen IV Opioids 30 hrs postop Transition to Oral Opioids with ITMs, adjuvant meds, and non-opioid analgesics Oral Opioids More Non-opioid Analgesics, Continue Adjuvants & Integrative Treatments Non-opioid analgesics: Acetaminophen, NSAIDS Adjuvants: Diazepam, Antiemetics, Bowel Regimen Integrative Treatment Modalities (ITMs) physical therapy, massage, aroma, & music therapy Monito CL, et al (2011) Multimodal Analgesia (MMA) Reduces Opioid Use and Side-effects

7 Integrative Treatment Modalities (ITMs) Pain Management Specialists provide therapies to help get kids moving in a way that medication alone cannot Cameron Sears, MD Massage Therapy: minute individualized sessions provided with take-aways for patients and family. Aroma Therapy: Inhaled Peppermint and Lavender oil to alleviate nausea and promote rest Music Therapy: Breathing exercises, relaxation and distraction Last Year (2017) 86% AIS Spine Fusion Patients received ITMs

8 Comprehensive AIS Spinal Fusion Care Map Preoperative Preadmission counseling Meet with Pain Specialist and Physical Therapy Social Needs Assessment Training for Discharge Home Intraoperative Dual Surgeons/Low Operative Times Maintenance of Normothermia IV Antibiotic Prophylaxis Intraop wound irrigation IV Acetaminophen NMDA Antagonist: Ketamine Cell Saver if needed Synthetic bone graft Postoperative No routine ICU Standard Pain Order Set Integrative Therapy: Massage, Aroma, and Music Early Mobilization with Physical Therapy Early Diet Advance Papanastassiou I, et al (2011)

9 Results: AIS Spine Fusion Avg Length of Stay 1.6 Spine Fusion Morbidity Risk Adjusted Odds Ratio Standard Bypass of ICU May Jan-Dec NSQIP-P ETCH Linear (ETCH) 2015 Jan-Dec 2016 Jan-Dec 2017 Jul16-Jun17

10 References: All Photos: Property of East Tennessee Children s Hospital Marketing Department, 2018 Clinch Ave. Knoxville, TN Visit: for more information about this scoliosis care project. Shan LQ, et al (2013) Intensive Care Unit Versus Hospital Floor: A Comparative Study of Postoperative Management of Patients with Adolescent Idiopathic Scoliosis J Bone Joint Surg Am Apr Monito CL, et al (2011) The Optimal Dose of Prophylactic Intravenous Naloxone in Ameliorating Opioid-Induced Side Effects in Children Receiving Intravenous Patient- Controlled Analgesia Morphine for Moderate to Severe Pain: A Dose Finding Study. Anesth Analg October ; 113(4): Papanastassiou I, et al (2011) Effects of preoperative education on spinal surgery patients SAS J. 2011: 5(4)