For years, providers viewed opioids as the go-to pain therapy for patients. However, many hospitals are now rethinking pain management protocols amid the ongoing opioid epidemic.
"Opioids are like putting a Band-Aid over a stab wound," said Stephanie Vanterpool, MD, MBA, Director of Comprehensive Pain Services at The University of Tennessee Medical Center, based in Knoxville, Tenn. "Effective pain management is more than just putting a Band Aid over the pain."
Seeking to reduce opioid use and improve patient safety at UTMC, Dr. Vanterpool and her colleagues implemented pain management pathways to standardize and streamline acute pain management at the hospital, which were innovative healthcare delivery system strategies initiated by Jerry Epps, MD, UTMC's CMO, and the medical clinical pathways development team.
Since implementing the pathways in 2016, UTMC has seen significant improvements in patient safety, staff communication and clinical accuracy. In addition, the pathways helped UTMC achieve another huge milestone: cutting morphine and hydromorphone use by more than 50 percent.
During an interview with Becker's Hospital Review, Dr. Vanterpool spoke about the acute pain pathways, how they benefited the organization and key challenges associated with their implementation.
How the acute pain management pathways work
The pathways aim to promote the accurate assessment of pain, along with safe and effective pain management practices.
The health system's EHR contains four different workflows that each have a predefined order to streamline the prescribing process. There is a non-opioid pathway, a low-opioid pathway, a high-opioid pathway and an individualized opioid pathway.
"A pathway is chosen based on a patient's baseline level of need, as well as the experience of the provider. To increase patient safety, the high-opioid pathway and individualized pathway are only available to providers and clinicians with more training," Dr. Vanterpool said.
To ensure the pain management is effective, and patients report improved pain within three hours, the organization uses a three-strike approach.
"If we tried one pathway and patient pain doesn't improve, that is strike one and the medication is administered again. If the medication was retried, and the pain was still not controlled, that is strike two. A nurse would then escalate the case to a provider who would use the information presented by the nurse to determine the next step. The third strike is if the first two attempts fail, and the escalation strategy selected by the provider doesn't work," Dr. Vanterpool explained.
The pathways also contain safeguards the ensure the accuracy of clinical pain diagnoses, according to Dr. Vanterpool. These safeguards come as three red flags that serve as critical thinking prompts. The first two red flags are pain outside of the affected area or pain out of proportion to the expected diagnosis.
"The third red flag is just a catch-all," Dr. Vanterpool said. "It is your clinician saying something is just not right. This red flag is easiest to pull when you have an inexperienced care team ... But it is important to empower your care team to pull the trigger on it if something just seems off with a patient."
She added that if any of these red flags are present, a nurse will stop administering pain medication and involve a physician to reevaluate the pain diagnosis instead of covering the pain with narcotics.
Patient safety is also a critical component of the pathways. UTMC uses an opioid sedation scale to help clinicians assess patients to prevent respiratory arrest from excessive opioid administration. The scale is consistently used to observe the degree of respiratory rate, quality of respiration and opioid-induced sedation to inform next steps.
Throughout the entire pathway, there are communication scripts that help nurses outline all pertinent information to the provider. These scripts contain information such as patient pain level, respiratory rate, the observed sedation scale, medications given, and pain red flags. The information helps physicians quickly select the appropriate escalation strategy if previous therapies were unsuccessful.
The results: Decreased opioid use, increased staff communication and more
Pain management can be complicated for even the most experienced staff. As a teaching facility, many of UTMC's providers had fewer than five years of experience and were at different stages of their residency at the time of the pathways' rollout.
To mitigate any issues that could arise from a well-trained, but inexperienced workforce, UTMC placed safeguards in the pathways, including the pain red flags, opioid sedation scale and communication scripts to prompt critical thinking, explained Dr. Vanterpool.
"We wanted to ensure nothing was missed as our providers gained experience," Dr. Vanterpool explained.
Another obstacle was getting nurses on board with the pathways and helping them understand how the process worked. To promote nurse engagement, UTMC presented the pathways to nurses during grand rounds and shared an informative webinar staff could reference prior to the rollout.
Despite these initial challenges, the acute pain pathways made staff more cautious while administering opioids and more aware of the quantity of opioids given to patients, Dr. Vanterpool said. Two years after implementing the pathways, clinicians administered 53 percent less morphine, 54 percent less hydromorphone, 29 percent less acetaminophen-oxycodone and 20 percent less acetaminophen-hydrocodone.
By cutting narcotics use and implementing the opioid sedation scale into the pathways, patient safety was also improved because staff were more aware of a patient's level of sedation. In addition, communication improved between nurses and physicians because of the standardized communication scripts, Dr. Vanterpool said.
Overall, UTMC was ahead of the curve, rolling out the pain pathways and a targeted pain treatment program two years before The Joint Commission made a similar recommendation in 2018 that the Anesthesia Patient Safety Foundation later adopted.
Read more about UTMC's pain management department here.