Leading ASCs and hospitals are ushering in a new era of opioid sparing postoperative pain management

As America’s other epidemic, the opioid crisis, continues to inflict societal and economic damage on the U.S. healthcare industry, hospitals and clinicians are seeking new cost-effective and accurate ambulatory infusion pumps that can reduce and, in some cases eliminate, the need for postoperative opioids.

The decentralization of healthcare has enabled a growing number of patients to recover from surgical procedures with home infusion therapy, a global market that is expected to reach $41.6 billion by 2027, according to Research And Markets.

Home infusion when used with cGMP manufactured medicines, provides a safe, cost-effective approach to IV therapy that can contribute to improved quality of life for patients. Costs associated with outpatient surgery were shown to be consistently lower than services provided in a hospital setting, with savings ranging between $1,928 and $2,974 per course of treatment.

As healthcare providers work to reduce opioid prescriptions and succeed under value-based reimbursement models, leading organizations are leveraging a new infusion pump solution to deliver safer pain management, reduce costs and shorten length of stay, while improving outcomes and the patient experience.

Until now costs associated with outpatient ambulatory pain pumps in the ASC space have been considered a drain on supply budgets, having a negative impact on profitability and a low ROI. Finally the search has ended for a turnkey solution that is accessible, easy to use and affordable for any facility striving to deliver a more effective opioid avoidance strategy for the patients they serve.

A new era of postoperative pain management

Duke University Medical Center (DUMC) in Durham, N.C., has been using continuous catheters for home infusions for orthopedic patients, such as shoulder and knee replacement patients, for a couple of decades, said Jeff Gadsden, MD, anesthesiologist and division chief for orthopaedics, plastics and regional anesthesiology at the hospital.

Previously, the hospital utilized elastomeric pumps to deliver local anesthetic to patients postoperatively, but was limited by the technology in two key areas: “One of them is that the rate is difficult to control precisely, and the reservoir volume is also limited,” Dr. Gadsden said.

DUMC sought a solution to these drawbacks and in 2020 implemented InfuTronix Solutions’ Nimbus II PainPRO electronic ambulatory pain pump. The new technology enables clinicians to extend the duration of pain control by delaying the start of therapy for up to 24 hours, draws the local anesthetic from a medication bag with flexibility to program a larger infusion volume, and features a preprogrammed automatic bolus menu to customize pain management solutions.

“The Nimbus pain pump provided us with an increased reservoir capacity of up to one liter more volume, which gave a lot of our patients up to five days of relief with the catheter,” Dr. Gadsden said. “And because it’s an electronic pump, we can program it to run in different modes, in terms of a patient bolus or an automatic bolus, where the patient doesn’t have to push a button or wait for the next hour for relief to carry on.”

“Every day you can delay a patient from having to take their oxycodone after their operation is a victory,” he added.
The ability of the Nimbus pain pump to provide relief for patients for up to five days is one of the device’s most innovative features. It also enables patients to increase their amount of regional anesthetic if they experience discomfort, said Christian P. Christensen, MD, an orthopedic surgeon specializing in outpatient and rapid recovery hip and knee replacements at Bluegrass Specialty Surgery Center in Lexington, Ky.

Safeguards installed in the technology, that include Min-Max volume limits can be set based on patient specific information to prevent individuals from receiving more than the recommended amount of local anesthetic per hour.

“It reduces the risks of a lot of complications associated with narcotics, such as nausea, constipation, confusion and respiratory depression,” Dr. Christensen said. “But the most exciting part is that we’re able to improve the patient’s pain management by providing them with a button to elevate the dosing, so their first step when they’re not comfortable is to reach for that button, rather than a narcotic.”

“The addition of the patient bolus button is welcomed by patients and providers,” said Gregory Hickman, MD, medical director and anesthesia director at the Andrews Institute Ambulatory Surgery Center in Gulf Breeze, Fla., who has been using outpatient continuous catheters in his practice since 2007.

Dr. Hickman adopted the electronic pump to give his patients the ability to bolus themselves and allow him to run a lower infusion rate. A lot of patients in his practice receive a 2 cc/hr interscalene catheter, which is enough anesthetic for most, but patients enjoy being able to boost their treatment if they need it. However, he has noticed that most patients choose not to.

Dr. Hickman is hoping to use an even smaller amount of anesthetic with InfuTronix’s newer pump. “I can take that 2 cc/hr infusion to a 2 cc intermittent bolus every 3 to 4 hours and still give the patient the ability to give themselves a demand bolus dose if they need it,” Dr. Hickman said. “I think we’ll even use less (local anesthetic) over four days than we currently use, minimizing our opioid exposure and with even less exposure for the nerves that have been treated with local anesthetic.”

Of the patients who undergo surgery, it’s difficult to determine who could potentially become addicted to narcotics, Dr. Hickman said. “Our big thing is to get patients to use this pump for their pain management, and only take the narcotics if needed afterwards.”

Bolstering care quality with patient-reported outcomes

“When patients are discharged, following up with a phone conversation goes a long way toward reassuring them that you understand what they’re going through,” Dr. Gadsden said. “It’s important to offer support and encourage patients, so they continue physical therapy and achieve the positive outcome they desire.”

The Nimbus II PainPRO pump is complemented with new software, the AfterOp™ Mobile App that tracks patient reported outcomes (PROs) throughout their treatment at no additional cost to the facility. Patients self-enroll in the software preoperatively, then answer five simple questions, so clinicians can gauge valuable information, including the patient’s pain level, how many narcotics they are using, side effects they may be experiencing and how satisfied they are with their pain management.

Patients answer the same five questions each day creating the opportunity for practices to use that data as a benchmark to determine if patients are getting the quality care that they need. The AfterOp™ platform can even be used to track and compare patient outcomes using different analgesia techniques like single shot blocks.

“Nimbus automatically collects some of the data, in terms of how much local anesthetic is being used, how many times the patient is pushing the bolus button and correlates that with their reported pain scores,” Dr. Gadsden said. “That offers us another different way to monitor how our patients are doing.”

While using this technology to report data on their interscalene catheters, Dr. Hickman found that patients at Andrews Institute were complaining of being too numb and feeling more pain on the first day. However, the same patients were satisfied with their pain on the second day.

This new information led to the assumption that the initial block was causing patients to be very numb within the first 24 hours, and when they were transitioning to the catheter infusion using a more dilute local anesthetic concentration so not producing as intense of a block — they were noticing some pain until the infusion picked up.

“After about two weeks of data with the AfterOp™ software, we realized this and changed our process then validated that the change was effective. We started doing the initial block with a less concentrated local anesthetic,” Dr. Hickman said. “Therefore, the patients weren’t quite as numb that first day, and their transition to the catheter infusion was a lot smoother. The patients actually reported less pain this way, even though it was less numb.”

A cost-effective pain management solution

Boosting the reservoir capacity of the Nimbus II pain pump up to 1.5 liters, which can last up to five days, helps reduce the need for postoperative, oral opioid use and offers several economic benefits to healthcare organizations.

“The bottom line is it’s really helped me lower my infusion rates,” said Dr. Hickman, who uses the pump to increase the duration of his patients’ infusions after knee replacements from three days to four days. “We really want to get the patient over the hump where their need for opioids is greatly reduced, and we feel like four days greatly reduces their need for opioids after surgery. And perhaps best of all is that we can confirm that by using the AfterOP™ software to see that a patients’ pain doesn’t spike after the pain pump is finished. We finally have a method to track pain scores and opioid use all the way out to POD 5 without having to burden our nurses. It gives a lot of meaningful visibility into our patients’ recovery that we didn’t have before.”

If you can provide a pain-free experience with local anesthetic and avoid the use of opioids, it will naturally result in cost savings for the hospital, Dr. Gadsden said. Ultimately, that will prevent patients from having pain that causes readmissions and emergency room visits, which are a drain on the system — not to mention the societal and actual economic costs of the opioid crisis itself.

From a more granular financial standpoint, Duke saved “well into the six figures” over its annual projection of total catheter volume with InfuTronix’s solution, compared to its previous elastomeric pump, while also adding the improved functionality, according to Dr. Gadsden.

“That was a huge cost-savings for our hospital,” he said, “as well as getting that added patient satisfaction from the functionality.”

This article is sponsored by Nimbus.

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