Full Pain Service Guide PDF 

Introduction

Our mission is to provide timely pain consultation services to hospitalized surgical and trauma patients. By drawing upon the knowledge of a multidisciplinary team, APS strives to help surgical services better care for their patients with difficult to manage pain.

As an attending on service, your role is to lead the team while maintaining a high standard of patient care and degree of professionalism. After soliciting the input and expertise of the other team members, you will ultimately decide upon the final course of action for each patient. A highly functioning team with open lines of communication will be crucial in ensuring that patients receive excellent care.

This “survival guide” is designed to provide you with a bird’s eye view of your role/responsibilities, service logistics, and essential contact information. Detailed standard work will not be included here and will be available for various aspects of the service as needed.

MD Role and Responsibilities

The APS team consists of a physician attending, nurse practitioner, resident, and sometimes a pharmacist.

During the week your role as attending will be to:

• 7am signout from night team. If NP is working with you, the NP can hold the pain pager, otherwise it is your responsibility to hold the pain pager during the day.
• Lead daily team rounds and help create the daily plan.
• Ensure a daily note is written on patient.
• Be available for consults and questions from a variety of individuals (APS team members, floor nurses, consulting physicians)
• Supervise or perform regional/neuraxial anesthetic techniques
• Ensure the efficacy of placed catheters
• Having a global idea of how long catheters will stay in for a specific patient.
• Wean and remove catheters, when appropriate
• Actively teach the other members of the team
• Ensure updated and printed signout every day with updated daily plan, which will be ultimately given to the night team

NP and Resident Roles and Responsibilities

NP Roles

• The NP covers the APS phone (30018) and holds the pain pager from 7:00am to 3pm Monday through Friday 
• At 6:55am, you will receive signout with you from the OB night resident

Daily Service Schedule

Pain/Preop Shift Attending Schedule

Consults

All consult requests will come to the either the 30018 or the pain pager. The two most general types of consults that can be received are:

1. Catheter Patients from the OR

The anesthesia staff caring for the patient should call you to alert you of the consult. However, it is good practice to keep an eye out for catheters placed in the ORs.

When a catheter is placed, part of the order set includes a consult to the the patient should also show up in the “Anesthesia Pain Service New Consult List”, which is located in Patient list tab → Zuckerberg Hospital → ZSFG Anesthesia → ZSFG Anesthesia Pain Service New Consult

Workflow for anesthesia placed OR catheters:

1. See the patient when they arrive in PACU, evaluate the function of the placed catheter, and write initial consult note.
2. Make sure that the patient has appropriate floor pain medication orders for the catheter infusion and for systemic pain medications.
   1. This is particularly important because when patients have catheters placed, it is the job of APS to manage/order the rest of their pain medications.
   2. If the patient will be arriving to the PACU after hours, ensure that the night team is aware of the patient to both evaluate them post op and check that pain meds are ordered. If the patient arrives in PACU after hours, the day team of the following day will write the initial consult note.

3. Follow the patient daily until the catheter is discontinued with satisfactory post-operative pain control

When receiving such a consult, you should expect to hear the following information from the primary anesthesia team:

• Patient name and MRN
• Type of surgery and service
• Type of catheter and location placed (thoracic vs. lumbar epidural, upper vs. lower -extremity peripheral nerve catheter)
• Basic medical history / chronic pain history
• The drug mix and rate of infusion ordered by the anesthesia staff
• Will the catheter be started in the OR before patient arrives in PACU?
• When the patient is expected to arrive the PACU (best estimate)

*When patients have epidural/nerve catheter orders in, the order set includes an automatic consult and the patient should show up on the APS list in EPIC*

APS is responsible for ordering/managing pain meds for any patients with catheters:

Use your clinical discretion when ordering meds for patients (keep in mind age, weight, history of tolerance). Common order sets for patients without history of opioid tolerance are:

• Acetaminophen 500mg-1g q6h PO or IV
• If NSAID is permitted, ibuprofen 2-600mg TID or ketorolac 15-30mg q8h IV
• Oxycodone 5-10mg q4h PRN moderate pain
• Hydromorphone 0.2-0.6mg q2h PRN severe pain
• Consider gabapentin if there is a presence of neuropathic pain (reasonable starting dose is 300mg TID in those with normal renal function)

2. Floor Consults for Catheters

Remaining consults will be requests from surgical teams to perform regional techniques for patients admitted under their service. The most common request will be for thoracic epidurals placement for rib fracture.

Workflow for patients requesting catheters:

1. Provide recommendations for the primary team to help manage the patient’s pain (regional and systemic pain medication recommendations are expected)
2. If a catheter is placed, follow the patient daily until the catheter is discontinued
3. Identify patients who may benefit from continued consultation by the pharmacist and inform the primary service of this recommendation. This is appropriate for medically challenging pain patients who may have a history of chronic pain or opioid abuse disorder. The pharmacist represents a separate service and the request must still officially come from the patient’s primary team. Also, when dealing with patients with history of opioid use disorders, consider engaging addiction medicine service.