Acute Pain

Post-operative pain patients

Acute on chronic pain/complex pain patients

Cancer pain patients (often co-managed with palliative team)

Substance abuse patients (often co-managed with Addiction med service)

Patients with epidurals, nerve catheters, IT pumps

Chronic Pain

Inpatient Chronic Pain Service patients include:

Stanford Comprehensive Interdisciplinary Program (SCIPP)

Direct planned admissions for ketamine, lidocaine or occasionally dihydroergotamine (DHE) infusion

• Improve functional status of patients
• Improve pain
• Decrease length of stay
• Decrease likelihood of developing chronic pain

Goals for the Acute pain service:

• Pain management regimens
• For inpatient
• For discharge
• Management of epidurals and peripheral nerve catheters
• Therapeutic communication
• Interventions for the inpatient acute population:
• Trigger point injections, scar injections, epidural steroid or Botox injections, blood patch repair, nerve ablations, IT pump placement/management, etc.
• Interventional Pain Procedures are usually done at ASC vs. at bedside

What do we do?

Intern/

Student

PACU resident

Pain Resident

APPs

Fellows

Attending

Expectation to share equal patient load with APPs (ranges from 5-15 patients per provider each day)

See new consults as requested. Observe and perform procedures as requested by attending/team

Epidural catheters placed by surgeons should be managed by APS BUT REMOVED by surgery service that placed (i.e Alamin’s team)

Monitor INR (below 1.2* attending dependent) and platelets (above 100) for removal of BOTH: deep nerve blocks and epidurals

You will not be asked to provide anesthesia or conscious sedation

Shift start 1800-0700 (weekdays); shifts start 1700-0700 (weekend)

See new patients out of the OR (POC = post op checks for all new POD 0: epidural and nerve catheter patients)

See existing patients day-shift highlights: Consults vs Complex patients

Ensure new epidurals and nerve catheters are functioning, trouble shoot/adjust and bolus as needed

Write NEW CONSULT notes for new ALL new consults (except postop patients with regional catheters).

Not necessary to write notes on Post-op check patients. If you do, do NOT send notes (i.e., POD#0 block pts) to attendings for billing (double billing)  

Document epidural pulls, any interventions or problems overnight (progress note) and nightly update to summary line

Your main supervisor is the pain fellow. Your second supervisor is the pain attending. Please page and call with questions. 

Check in with nurses taking care of chronic pain or infusion patients and make sure patients are tucked in by the end of the shifts

Communicate with the acute pain resident regarding issues and for the acute pain resident to know how to get a hold of fellow if there are questions  

Turn on the fellow pager  

On Voalte, set self to "Busy" with the message " For acute pain patients only, contact 2-PAIN (Acute Pain) unless emergent"

In the morning, turn Voalte to available (0700) 

As part of the APS, there is cross over with regional services:

Day 1 –check in with regional attending/fellow to get orientation for regional

Look over documents provided for regional related questions/hip fracture protocol

Remember, that catheters discharged home by pain service post op will be followed up by the pain service – see document for nerve block follow up.

All notes sent to attending to cosign

Providers (residents/APPs) are responsible for own work, including notes. Poor quality notes/work will be reflected in resident evaluation by attending and APPs.

Daily communication with primary teams

Pain medication plan

When to pull epidurals or nerve catheters (though some of this is protocolized like POD 2 for ACC, approximately POD 5 for most other blocks)

Maintain Acute Pain Service (APS) handoff box and current list, update summary lines during each shift (all staff to update during AM and PM shifts)

LPCH/OB (adult) consults are part of APS workflow. OK to see consult and staff with the attending/fellow.

Blood patch consults are part of APS workflow, and should be staffed with fellow/attending see algorithm). Exception: Post partum patient who needs a blood patch the ED should contact OB Anesthesia rather than APS.

Floor Management Guide – goes over medication dosing, anticoagulation, infusions, when to pull, day to day  management 

PACU Guide – guidelines immediate post-surgery

Acute Pain Syllabus – reference guide to read and review topics

Pain CADD-Solus Pump Guide – user’s manual for the infusion pumps

Acute Pain Lecture Topics – teaching points you can ask for during the rotation, lecture ideas from fellows/attendings