Sometimes, you need a pair of fresh eyes to put a situation in perspective.
Such was the case when Lisa McDonald, RN, CNOR, CNFRA, participated in post-operative group rounding as part of a committee at Canton-Potsdam Hospital in Canton, N.Y., to decrease post-op infection rates in total hip and total knee replacement.
“It was the first time I saw patients outside of the OR where I usually work,” McDonald recalled. “It was clear right away that we could be managing their pain better. Elderly patients were just lying in bed. They were apathetic and prone to hallucinations, respiratory depression and postop pneumonia.”
The literature backed up McDonald’s observations. Along with a team including the surgeon, physical therapist, social worker and fellow nurses, McDonald spent a year review evidence-based research and other literature on the relationship between post-operative narcotic use and negative outcomes.
“High pain rates after surgery, like high glucose and not being normal thermic, impact post-op infection rates,” she said.
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Comprehensive Pain Management
Though many facilities are fine tuning their pain protocols, Canton-Potsdam Hospital and Sharon Hospital in neighboring Connecticut received nationwide attention for adopting a new pain management multimodal approach, including a cocktail of medications given before, during and after surgery.
Patients undergoing knee replacement surgery at Canton-Potsdam Hospital in Potsdam, New York, receive medication before surgery including the anti-inflammatory Celebrex, and Lyrica, which treats nerve pain and blocks pain impulses to the central nervous system.
During surgery, patients receive anesthesia in the lower spine, as well as a sedative, intravenous Tylenol and an anti-nausea medication. The anesthesia lasts up to 24 hours after surgery.
The surgeon also injects medications into the tissues around the knee, including a numbing agent, a drug to control bleeding and another anti-inflammatory agent. If it’s not contra-indicated, durmorph is included in the spinal to make it last longer.
The drug cocktail, injected during surgery, is also being used as an alternative to femoral nerve blocks, which are often given with general anesthesia to numb the knee and can last several hours after the surgery. In McDonald’s research, studies continued to demonstrate the blocks can also lead patients to fall after surgery.
Once patients are in recovery, they receive a continuous cooling pad to decrease swelling and stimulate nerve endings, which reduces pain. They receive 24 hours of intravenous Tylenol and more Celebrex and Lyrica. Scheduled doses of Zofran help prevent nausea. Patients are discharged with oral pain pills and that transition begins after the first 24 hours.
The hospital started this new approach in September 2012 on 130 total joint surgeries. The intra-operative injection was used by one doctor on all total hips and total knees and another doctor on just total knees. The protocol – minus the injection – remains the same for total hip and total knee surgeries.
Should patients be in chronic pain, an IV is available. If the IV is given in the first 24 hours, expanded monitoring protocol for ventilation is put into play.
Earlier Physical Therapy Initiation
As predicted, the less groggy patients are participating in physical therapy as soon as the spinal wears off.
“This never happened before with femoral blocks and epidurals, but most patients are up doing physical therapy the day of surgery,” said McDonald. “Early mobility is the key to getting the range of motion back in the knee.”
Some of the most vocal proponents of the new protocols are the patients who’ve had one knee replaced under the old pain management equation and the second under the new.
“This is a small town and we hear from our patients not just during their stay, but also in church and at the grocery store,” McDonald explained. “They say the difference is like night and day.”
More formal outcomes assessments are equally positive. Post-operative pneumonia has decreased and McDonald believes the new pain management approach is impacting Canton-Potsdam’s fall rate. The average length of stay has dropped to two days from three.
Changing Surgeons’ Mentality
While the patient reaction has been strong, prompting surgeons to universally adopt the new protocols was one of the challenges of this project.
“It all depends on which surgeon is working at the time,” she said. “If the surgeon has the attitude that he wants to give patients the best care and increase the knowledge, skills and drive of the people working beside him, it goes a long way. We learned make the surgeon with the good attitude the champion of this initiative so he could convince his peers.”
Standardizing the order sets made a big difference as well. “Everyone had different postop order sets,” McDonald recalled. “If you can lessen the degree of variation, you lessen the chance for error.”
Today, all surgeons speak highly of the new pain management protocols for orthopedic surgery. Some recent publicity prompted a surgeon in Michigan to contact McDonald about options for his wife’s upcoming operation, as she has historically not fared well with narcotics.
Despite the enthusiasm for the new pain management regimen, McDonald is doubtful their approach will ever become a standard of care.
“Hospitals are all taking different approaches. Many are using IV narcotics and others are establishing their own cocktails. It’s so surgeon-specific. If femoral blocks are working for their patients, I don’t know that they’ll ever standardize.”
Robin Hocevar is on staff at ADVANCE. Contact [email protected].
