At the Becker's Hospital Review 6th Annual Meeting in Chicago, May 7 to 9, William J. Long, MD, of Insall Scott Kelly Institute for Orthopaedics and Sports Medicines in New York, discussed the importance of multimodal pain management to reduce opioid use and improve patient outcomes in hip and knee reconstructions.
"There are more than 90 million hip and knee reconstructions in the United States every year," said Dr. Long. "Around 35 million are performed in an ambulatory setting. These types of procedures are among the most painful orthopedic procedures."
Patient experience is becoming a key factor affecting healthcare facilities' profitability in the brave new world of value-based care. Most patient questions are about anesthesia and perioperative pain. Patients tend to get worked up about pain long before the actual procedure, noted Dr. Long.
There are a number of reasons for postsurgical pain following orthopedic procedures, such as hip and knee reconstructions, namely the amount of tissue damage. However, inadequate pain management is also a factor, said Dr. Long. Typically, opioids have been used for pain relief, but opioids are associated with complications and pose serious public health concerns. Additionally, opioid use is associated with higher mean cost, total cost and readmission rates.
At St. Francis Hospital in Roslyn, N.Y., Dr. Long helped incorporate multimodal pain management, which includes a combination of oral medications, IV medications, blocks and injections. In the preoperative area, patients receive less narcotics and more regional anesthesia. "There is no question in my mind that patients do better with regional anesthesia techniques, such as neuro-axial anesthesia and nerve blocks. We need to use more opioid-sparing medications," he says. "I convinced the hospital to also adopt tranexamic acid, which cuts blood loss by 50 percent. If you bleed less, you hurt less."
However, despite improvement in patient's pain levels, length of stay did not change. Reducing LOS required a culture shift. According to Dr. Long, a rule was put into place that all patients had to be out of bed before they left the post-anesthesia care unit. This required more nurses and physical therapists.
"In 2013, the LOS at our facility was 3.7 [days], but by 2014 it had gone down to 2.5 days," says Dr. Long. "Ultimately, effective multimodal pain management along with rehabilitation improved the recovery of total joint replacement patients and reduced LOS."