Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions
Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions
Thomas Suchy . Margaret Rose . Richard D. Urman 0 1 2 3
0 R. D. Urman (&) Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA , USA
1 N. Vadivelu L. Lumermann T. Suchy M. Rose Department of Anesthesiology, Yale University School of Medicine , New Heaven, CT , USA
2 A. D. Kaye E. M. Helander Department of Anesthesiology, Louisiana State University , New Orleans, LA , USA
3 R. D. Urman Institute for Safety in Office-Based Surgery , Boston, MA , USA
The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from
the hospital, until full recovery is achieved. PSH
is discussed in this consensus article with the
emphasis on perioperative care coordination of
patients with chronic pain conditions.
Preoperative optimization can be successfully
undertaken through patient evaluation, screening,
and education. Many important positive
implications in the PSH model, in particular for
those patients with increased potential
morbidity, mortality, and high-risk populations,
including those with a history of substance
abuse or anxiety, reflect a more modern
approach to health care. Newer strategies, such
as preemptive and multimodal analgesic
techniques, have been demonstrated to reduce
opioid consumption and to improve pain relief.
Continuous catheters, ketamine, methadone,
buprenorphine, and other modalities can be
best delivered with the expertise of an
anesthesiologist and a support team, such as an
acute pain care coordinator. A physician-led
PSH is a model of care that is patient-centered
with the integration of care from multiple
disciplines and is ideally suited for leadership from
the anesthesia team. Optimum pain control will
have a significant positive impact on the
measures of the PSH, including lowering of
complication rates, lowering of readmissions,
improved patient satisfaction, reduced
morbidity and mortality, and shortening of hospital
stays. All stakeholders should work together and
consider the PSH model to ensure the best
quality of health care for patients undergoing
surgery in the future. The pain management
physician’s role in the postoperative period
should be focused on providing optimal
analgesia associated with improved patient
satisfaction and outcomes that result in reduced
health care costs.
There is widespread agreement that serious
inefficiencies in the US health care system have
led to increased costs and decreased quality of
care for patients [1, 2]. This is especially true
regarding surgical care, which accounts for
approximately 52% of total health care
spending . Critics contend that varied and
fragmented perioperative management, combined
with misplaced incentives related to
fee-for-service reimbursement, increases cost
and reduces overall quality of surgical care .
In response to these criticisms, the American
Society of Anesthesiologists (ASA) has proposed
implementation of the perioperative surgical
home (PSH), described as a patient-centered,
surgical continuity of care model, which
involves shared decision-making . The PSH
model seeks to promote high quality care and to
improve patient satisfaction throughout the
surgical experience, while reducing inefficiency
and resource utilization. These endpoints are
likely to be encouraged through changes in
reimbursement trends, which are shifting
toward rewarding physicians for quality of care
rather than quantity . Pain medicine will
undoubtedly play a major role in such an
evolving care model. Optimal pain
management has been shown to reduce costs in the
form of shorter post-anesthesia care unit
(PACU) and hospital stays, more expeditious
postoperative return to function, and improved
overall patient satisfaction [5–7]. Incorporation
of these factors into the PSH, as both individual
and team goals, will maximize the value of good
perioperative care . The purpose of this
consensus review, therefore, is to discuss pain
management strategies in the surgical
population, and to outline ways to improve quality of
care while reducing resource utilization based
on PSH models. We also emphasize a need for
developing clinical pathways to manage pain in
the perioperative setting.
This article is based on previously conducted
studies and does not involve any new studies of
human or animal subjects performed by any of
PERIOPERATIVE SURGICAL HOME
The PSH model emphasizes smooth transitions
between the preoperative, intraoperative, and
postoperative phases of care. Pivotal to this goal
is the expansion of the anesthesiologist’s scope
of practice as the ‘‘perioperativist’’.
Anesthesiologists are in the best position to bridge the
gaps between phases of care, because
perioperative management is a critical component of
their training. Anesthesiologists are trained to
evaluate and to optimize patients in
preoperative clinics, provide intraoperative care, and
manage pain and postoperative complications
in the recovery room and intensive care unit.
Furthermore, opioid and non-opioid analgesics
are being increasingly used in the management
of chronic pain, and the incidence of patients
on chronic opioid therapy undergoing surgical
procedures is steadily increasing [
perioperative management of pain in these
opioid-dependent patients is often challenging.
This patient population must be identified
preoperatively in order that the optimal
multimodal approach to their pain management
regimen can be planned prior to surgery and
effectively controlled throughout their
perioperative care [
]. Some examples include
continuous peripheral nerve catheter
placement and management for postoperative pain;
infiltration of local anesthetics prior to incision
and final skin closure at the incision site, the
use of ketamine and lidocaine infusions in
select surgical patients for pain management,
development of multimodal pain medication
templates, provision of oversight for moderate
and deep sedation by non-anesthesiologists,
and increased popularity of long-acting opioid
medications, including buprenorphine and
methadone, which require an appreciation for
pharmacokinetics, side effects, and potential
drug–drug interactions. A sample clinical
pathway algorithm for a patient with chronic pain
or opioid/substance use is shown in Fig. 1. The
patient is first seen by the primary care provider
with a condition that may require surgery, and
the patient is referred to a surgical specialist. If
the surgeon decides to operate, the patient then
undergoes a preoperative assessment to make
sure that he or she is medically stable for
surgery. During the perioperative visit, if the
patient is flagged as ‘‘high risk’’ based on history
of chronic pain, opioid or other substance use,
then a referral is made for the perioperative
acute pain care coordinator to manage the
patient’s journey before, during, and after
surgery. This may involve coordination of pain
Fig. 1 Clinical pathway algorithm for the perioperative
management of the patient with chronic pain and/or a
history of opioid/substance use
management in the inpatient unit, the pain
clinic, home, or a rehabilitation facility. The
acute pain care coordinator will play a
significant role as soon as the referral is made by the
surgeon, the preoperative clinic, or the primary
care provider. The goal is to ‘‘plug the patient
into the system’’ as early as possible, preferably
before surgery. If a patient with chronic pain
and/or history of opioid abuse has to undergo
emergent surgery, the acute pain care
coordinator can be consulted for intraoperative
analgesic recommendations. The acute pain
coordinator will also address their analgesic
needs in the PACU, during admission, and in
the clinic or rehab facility to preserve
continuity of care.
Screening for Patients at Risk for Excessive
Preoperative evaluation allows for identification
of patients with risk factors associated with
postoperative pain management issues or those
at risk for the development of chronic pain.
These risk factors include history of chronic
pain syndrome, chronic opioid therapy,
catastrophizing, substantial anxiety regarding
postoperative pain, female gender, younger age,
preoperative pain at the surgical site, pain at
multiple sites, education, lower socioeconomic
status, and possibly genetic factors [
Additional factors to consider include history of
depression, current or history of substance
abuse, and whether the patient is at risk for
developing neuropathic pain, including those
who will endure injury to nerves
intraoperatively (i.e., amputations, mastectomies,
thoracotomies, etc.) [
]. High-risk patients will
be followed throughout their entire
perioperative course, which will include daily rounding,
and outpatient clinic visits after discharge.
Certainly not all patients require preoperative
visitation solely for the purpose of
postoperative pain optimization. Thus, screening for
these risk factors can be accomplished by way of
electronic chart review, telephone, or
telemedicine. Risk stratification of patients more
likely to develop postoperative pain-related
complications enables the practitioner to
identify those patients who will benefit from more
in-depth preoperative evaluation and
counseling. This strategy also helps increase operational
efficiencies by allocating resources where they
are needed most.
The preoperative pain evaluation should
include a thorough history and physical exam
to document the patient’s baseline pain
including site, intensity, type, and duration.
The medication history should be carefully
documented, including the daily doses of both
long-acting and short-acting opioids. Such
information enables calculation of
equianalgesic dosing and quantifies baseline opioid
requirement. Attention should also be given to
non-opioid adjunctive analgesics, anxiolytics,
antidepressants, and anticonvulsants [
Assessment of psychiatric history with focus on
historical or current substance abuse,
depression, and anxiety should be performed.
Importantly, the presence of preoperative anxiety has
been linked to intensity and prolonged
duration of postoperative pain and may suggest the
need for general anesthesia versus regional
Patient education regarding pain and
management options may help set expectations and
reduce postoperative pain scores and health
care expenditures [
16, 18, 19
pain is a major concern and patients may
benefit from reassurance that their pain will be
adequately treated. This is also an opportunity
to set expectations by describing the typical
course of postoperative pain of the particular
surgery being performed. Educating patients
about pain management and analgesics may
actually result in decreased opioid consumption
in the first 48 h postoperatively [
]. If regional
anesthesia is a viable option, patients can learn
about how this technique works and why a
perineural catheter may be useful. In fact,
preoperative video-based information to
patients undergoing procedures under regional
anesthesia has been shown to reduce
perioperative anxiety [
]. Further, this provides an
opportunity to obtain consent for regional
procedures, reducing patient stress of making
decisions the day of surgery as well as the
likelihood of consent-related delays. Before the
patient leaves the preoperative visit, an
individualized postoperative pain management
strategy should be in place and discussed with
the patient with an opportunity to ask
questions. The individualized discharge plan should
include a countdown of potent opioid
Patients should be instructed to continue their
regular dose of long-acting opioid medications
up until, and including the day of surgery. If
feasible, an attempt to reduce preoperative
dosing may be a potential goal. This should be
discussed with the patient and coordinated with
the prescribing physician. Another
consideration is to initiate analgesic medications in
anticipation of surgery, using preventive
analgesia. For patients on chronic opioid therapy,
this can be accomplished by a combination of
acetaminophen and a nonsteroidal
anti-inflammatory drug (NSAID) such as a COX-2
inhibitor, typically initiated 2 weeks to 1 h prior
to surgery [
]. For those patients with a history
of neuropathic pain or at risk for intraoperative
nerve injury (i.e., amputations, thoracotomies,
mastectomy, etc.), a gabapentinoid medication
may be highly beneficial [
]. Such multimodal
analgesic approaches have been shown to
reduce perioperative opioid requirements,
decrease opioid-related side effects, and
improve pain scores [
11, 23, 24
]. Patients taking
anxiolytics, antidepressants, gabapentinoids,
and anticonvulsants should be instructed to
continue these medications up until and
including the day of surgery. Transcutaneous
opioid formulations, such as the fentanyl patch,
should be continued up until the day of surgery
and restarted postoperatively. However, the rate
of absorption of these formulations is
susceptible to changes in body temperature,
making them less reliable intraoperatively
where post-induction hypothermia and the use
of a heating blanket are commonplace. Thus,
consideration should be given to removing the
patch on the day of surgery and administering
an equivalent dose of morphine to maintain
baseline opioid levels without the risk of
intraoperative fluctuations [
Patients on Methadone Therapy
Patients on methadone therapy should have a
preoperative electrocardiogram to establish a
baseline and monitor for prolonged QT interval
]. It is also important to establish the
indication for methadone therapy, as prescribing can
be for either chronic pain or opioid-related
substance abuse. In order to elucidate the reason for a
patient’s methadone prescription the physician
may have to contact the methadone clinic.
Methadone prescribed for chronic pain
management is typically dosed on a q8hr or q12hr
]. In contrast, it is generally dosed once
daily in the treatment of opioid addiction. In
either situation, patients on methadone therapy
should receive their usual dose prior to and on
the day of surgery. There are six enzymes that are
involved in the metabolism of methadone, and
there are numerous drugs and herbal products
that can potentially alter its serum levels.
Methadone that is being administered once daily
will only have an analgesic effect for 6–8 h after
]. Preoperative personnel
should communicate with the patient’s
prescriber to verify dosing and facilitate
postoperative follow-up arrangements.
Patients on Buprenorphine Therapy
Like methadone, buprenorphine can be used for
the treatment of chronic pain or opioid
dependence. Buprenorphine is a partial opioid agonist
with high affinity for the mu receptor and a
half-life of approximately 37 h [
]. As a result
of these characteristics, if buprenorphine is not
discontinued several days prior to surgery, pure
opioid agonists will be less effective leading to
potential difficulties in treating postoperative
]. Patients undergoing low-risk pain
procedures can continue their buprenorphine
throughout the perioperative period. Those that
are undergoing surgeries deemed intermediate
or high-risk pain procedures should have their
buprenorphine discontinued 2–3 days prior to
surgery. Bridge therapy may be instituted with a
pure opioid agonist if needed, until the patient
can resume buprenorphine therapy [
Additionally patients taking buprenorphine will
likely require higher doses of opioids and
multimodal analgesia should be instituted
including regional anesthesia when appropriate [
Preoperative Anxiety and Psychological
The role of preoperative anxiety is being
increasingly recognized as a contributing factor for
postoperative pain [
10, 29, 30
]. It has been proposed
that the strong, unpleasant emotions associated
with preoperative anxiety contribute to
maladaptive psychological coping mechanisms, such as
the ‘‘fear-avoidance’’ model [
counterproductive coping mechanisms, if unchecked, can
result in catastrophization and kinesiophobia,
both contributing to increased pain, decreased
patient satisfaction, and slower recovery [
Simple interventions such as cognitive
behavioral therapy and relaxation therapy may
reduce preoperative anxiety and help patients
manage postoperative pain [
As the PSH model continues to evolve, one
constant includes optimizing patient care in
accordance with efficient use of health care
dollars. Aging populations, increased presence
of morbidities, and an abundance of elective
surgery have led to an increase in ASA physical
status 3 and 4 patients [
]. Epidemiology of
chronic pain depicts an increased prevalence
associated with aging and poorer health status
]. Intraoperative risk factors for the
development of chronic pain include open versus
minimally invasive surgery, the surgical site,
duration of procedure, and if surgery is
performed in a previously injured area [
Avoiding nerve damage through careful
dissection or modified approaches can also help to
prevent the culmination of persistent pain
One can conclude that the aforementioned
trends will lead to difficulty for the
perioperative anesthesiologists and their task of
providing adequate analgesia to patients
intraoperatively. While the ASA Committee of
Future Models of Anesthesia Practice (CFMAP)
addresses benefits of the PSH such as improved
clinical outcomes, clinical initiatives, and
reduction of complications and cost, applying
these broad principles to specific intraoperative
care will prove difficult for all patients,
especially those with significant chronic pain
]. The role of pain management must
stretch beyond the pre- and postoperative
clinical phase and into the operating room.
Through a careful preoperative evaluation, the
anesthesiologist can provide intraoperative care
catered towards a patient’s specific pain
requirements. This pain-centered information
can then be incorporated into an anesthetic
plan for specific procedures. This plan should
include insight into the strategies which can
limit overuse of intravenous opioids,
incorporate multimodal analgesia to decrease side
effects, and suggest when regional and
neuraxial anesthesia may improve outcomes and
decrease length of stay [
Traditional reliance on high dose opioids for
perioperative analgesia has been a part of the
perioperative pain management plan for
decades. While these medications can provide
efficient analgesia at a low cost, they are
associated with several side effects, which can
compromise their usefulness [
]. Of the many
adverse effects, dose-dependent respiratory and
central nervous system depression, along with
postoperative ileus (POI), which is linked to
nausea, vomiting, and delayed oral intake may
be the most significant [
]. Prolonged return of
bowel function is associated with increased
morbidity, prolonged hospitalization, and
increased hospital cost [
]. Understanding and
incorporating a best practice model for opioid
dosing would be optimal. While doses tend to
depend on surgical site pain and patient’s pain
tolerance, understanding dose correlation with
side effects may reduce adverse outcomes. One
way to accomplish this task is to understand the
dose-dependent relationship between
morphine equivalents of opioids and their side
]. Alternatives to high dose opioids,
including the use of NSAIDs, such as ketorolac,
and regional anesthesia can be effective in
reducing total IV opioid administration [
Preemptive analgesic techniques prior to
surgical incision along with multimodal
analgesia regimens are likely key to reducing side
effects and may prove pivotal as a way to move
past the standard of opioid-centered
perioperative pain control. Simultaneously targeting the
different mechanisms of analgesia has been
shown to reduce requirements of any single
]. Anesthesiologists often incorporate
this into their routine practice but a gold
standard or patient-specific plan has yet to be
concluded. Multiple studies have shown
improvement in areas including fewer adverse
events, shortened LOS, and reduced total
hospital resource utilization for certain procedures
]. As PSH gains favor, better data gathering
and numerical audits will guide these
multimodal techniques further, benefiting both the
patient and health care system.
Regional and neuraxial anesthesia have
become increasingly popular as intraoperative
anesthetic techniques in recent years, but when
compared to general anesthesia they are still
not aggressively used. Recent studies have
shown that neuraxial anesthesia, when
compared with general anesthesia, improves
perioperative outcomes and decreases total hospital
length of stay [
]. Regional anesthesia has also
been shown to decrease post anesthesia care
unit length of stay and is associated with
decreased postoperative nausea and pain
]. In the PSH, the role of pain
management in the operating room includes choosing
an optimal technique that will provide superior
anesthesia for the patient’s procedure, but also
leads to improved postoperative outcomes. As
more emphasis is placed on standards
encouraged by Centers for Medicare and Medicaid
Services (CMS), being able to choose an optimal
anesthetic plan that incorporates these
standards will be fundamental to the
anesthesiologist. The role of regional and neuraxial
anesthesia will likely continue to increase and
become more mainstream as further studies are
completed which support endpoints of
recovery, time to discharge, analgesia, and patient
In an attempt to curb costs and improve patient
outcomes, CMS is considering shifting from the
current fee-for-service system towards a single
reimbursement model, in which all health care
providers involved will share payment. The PSH
embraces this concept and attempts to optimize
perioperative services with focus given to patient
outcomes, patient experience, and reducing
health care cost [
]. One area which may
challenge the uniformity of the system is the
handling of postoperative pain. Effective analgesia
can lead to earlier rehabilitation and a decreased
length of stay, though accomplishing adequate
control of pain can prove difficult considering
the variability of patients and procedures [
Postoperative analgesia can be challenging to
manage and careful planning is required to
obtain good pain control. Adequate analgesia is
important as uncontrolled pain in the early
postoperative period has been associated with
the development of acute persistent pain [
instances of severe postoperative pain, red flag
conditions must be ruled out. Other
postoperative factors that predispose to the development
of chronic pain include anxiety, neuroticism,
depression, and radiation to the surgical area
]. The role of the anesthesia practitioner in the
postoperative period should be focused on
providing optimal analgesia associated with
improved patient satisfaction and outcomes that
result in reduced health care costs.
As surgical volume continues to rise,
postoperative pain management will become a vital
part of the perioperative experience. Central to
this statement is the association of adequate
postsurgical pain control and patient
satisfaction. In one survey, approximately 80% of
patients after surgery experienced acute pain
and most quantified it as moderate, severe, or
]. Another study following pain and
postoperative satisfaction found that poor pain
control and emetic side effects were the two
most common reasons for patient
]. In this survey, poor pain control was
strongly associated with limiting return to
normal activity after discharge and interfering with
sleep. With established cutoff points in pain
scoring, more severe pain scores have been
associated with interference in general activity
and contributing to poor sleep hygiene [
way to curb these effects may involve the
prevention of breakthrough pain (BTP). A recent
survey found that BTP was associated with poor
function, health status, and mood when
compared to patients with controlled persistent pain
]. Another method improving patient
satisfaction may be focused around administering
prophylactic antiemetic medication to
postsurgical patients. Administration of
dexamethasone and ondansetron has been shown to
reduce postoperative side effects such as
incidence of postoperative nausea and vomiting
(PONV) and the requirement of rescue
]. As the PSH model
continues to develop, pain management in the
postoperative setting must focus on reducing
patient dissatisfaction by providing adequate
analgesia and limit side effects.
As an attempt to reduce health care cost, the
CMS Hospital Readmission Reductions Program
and Physician Quality Reporting System (PQRS)
focus on a provider’s ability to reduce
postoperative length of stay (LOS), adverse events, and
readmission rates. Pain control and its side
effects have serious financial implications. A
recent study examining patients after
abdominal surgeries concluded that LOS, total
hospitalization cost, and 30-day readmission rates all
had a positive correlation to the quantity of
morphine dose patients were requiring for
adequate analgesia [
]. Thus, adequate analgesia
in the postoperative period must include a plan
to address post-discharge pain. Several studies
have found that following discharge, patients
continue to struggle with high pain scores and
poor tolerance of side effects [
study examining postsurgical readmission after
same-day surgery found that approximately
one-third of patients returning to the hospital
reported pain as the main reason for their
]. Uncontrolled acute pain has
also been found to be a predictive factor for the
development of chronic pain and effective
management may reduce the risk for pain
]. To reduce the unwanted effects of
poor postoperative analgesia, pain management
must include the use of multimodal therapies,
as well as appropriate use of site- and
surgery-specific peripheral nerve blocks and
neuraxial anesthesia. Several studies comparing
postoperative traditional morphine-derived
analgesia to multimodal regimens have shown
reduced opioid consumption, shortened LOS,
and reduced side effects with the latter [
Additionally, nerve blockade has also been
shown to reduce opioid requirement, thus
reducing side effects and improving patient
procedure-specific pain management protocols are
outlined by the PROSPECT (PROcedure-SPECific
Postoperative Pain ManagemenT) group, which
is a collaboration between anesthesiologists,
surgeons, and surgical scientists.
While high quality evidence exists for use of
some postoperative techniques, further study is
required to provide specific applications of
techniques that will improve outcomes [
Pain management in the postoperative setting
continues to be a developing field and as more
data become available, fine-tuning will not only
improve patient outcomes but also reduce the
financial strain that poor postsurgical analgesia
exerts on the health care system.
PREEXISTING CHRONIC PAIN
AND POSTOPERATIVE PAIN
Chronic pain presents a significant
socioeconomic burden with increasing numbers of
patients undergoing surgery. The management
of these patients with superimposed acute pain
as a result of surgical insult is a challenge and
needs continued investigation within the
physician-led, multidisciplinary model of the
PHS. Gerbershagen et al. showed that chronic
pain patients can have increased sensitivity to
pain with evidence of correlation of increased
preoperative chronic pain to increased
postoperative pain [
]. In a study by Chapman et al.,
patients with chronic pain who were using
opioids preoperatively experienced greater
postoperative pain as compared to patients not using
opioids preoperatively [
]. Many patients on
long-term opioids can also develop changes in
pain sensitivity. For example, hyperalgesia has
been demonstrated in patients on long-term
methadone and in patients taking slow-release
]. Optimum management of
surgical patients with preexisting chronic pain
and preexisting use of opioids for the treatment
of chronic pain requires vigilance and
meticulous monitoring to prevent withdrawal and
respiratory depression in the postoperative period.
ACUTE PAIN CARE COORDINATOR
It seems logical that central to achieving
efficiency, patient safety, and patient satisfaction
with the PSH concept is the necessity of an
acute pain care coordinator (APCC). Pain care
coordination is essential for management of
patients with pain in the PSH model. The APCC
would coordinate with primary care providers
(PCP), preoperative assessment clinics, PACU,
ICU, home care, outpatients pain clinics, and
rehabilitation facilities. A physician such as an
anesthesiologist could assume the role of an
acute pain care coordinator who is experienced,
highly skilled, and very knowledgeable in pain
care issues. The APCC does not necessarily have
to personally provide pain care but will work to
ensure that patients receive optimum
management. The APCC of the hospital in the PSH
would ensure that the pain patient navigates
through a medical system with support,
understanding, and guidance for complex pain
issues that often involve various treatment
methods and doctors of several services so that
the patient receives the best pain care possible.
The APCC would develop case management
tools, clinical pathways, order templates, and
interdisciplinary care plans facilitating smooth
pain care progression. The APCC would be
responsible for the administrative aspects of
pain care and would act as a liaison between
patients, doctors, nurses, and pain care services
and facilities. The APCC would monitor
delivery of pain care services and facilities within the
hospital and beyond.
Another role of the APCC should be to
communicate extensively and interface with
other medical care coordinators and health care
authorities, rectifying problems once they are
identified in accordance with all the pain
policies and procedures of the hospital. This
individual would be an important member of the
PSH administration representing pain care
interests of the hospital or organization. Quality
care can be measured by patient satisfaction,
reduced LOS, and decreased readmission rates
for uncontrolled pain. Finances are required to
sustain a dedicated pain care coordinator and
this has to be taken into consideration to
provide optimum pain care within the PSH model.
This funding has to be included in the budget of
the hospital and or shared with individual
departments. The savings provided by
decreasing readmission rates, hospital LOS, and adverse
events would potentially offset the cost of the
salary for the APCC.
The physician-led PSH is a model of care that is
patient-centered, with the integration of care
from multiple disciplines. Optimum pain
control will have a positive impact on the measures
of the PSH including decreasing complication
rates, preventing readmissions, and shortening
hospital stays. However, acute pain control is a
challenge by itself and is drastically complicated
in the presence of chronic pain issues and
history of substance abuse, pain medication
withdrawals, and respiratory depression. In addition,
less pain can lead to improved
cost-effectiveness, improved quality of care, better patient
outcomes, and early return to functionality. We
propose the implementation of a pain care
coordinator to work under the leadership of the
physician-led PSH director and closely with
additional surgical home leadership and
supportive personnel to facilitate communications
and be a part of the multidisciplinary team. This
will ensure that there is a focus on
patient-centered pain care, which can be
complex and will improve delivery of optimum pain
control. Serious attention to optimum
perioperative pain management under the scrutiny of
a designated perioperative pain care coordinator
closely integrated into the PSH model will only
strengthen the goals of the PSH model.
We also recommend that the PSH model
with a pain care coordinator under the
leadership of a physician-led PSH director, and
surgical home leadership should be feasible in all
health systems—community hospitals,
ambulatory care surgery centers, academic centers,
and group practices. To ensure the feasibility of
a pain care coordinator and financially sustain
such an appointment in each hospital,
innovative methods of payment models and active
pursuit of cost-effective methods would be
No funding or sponsorship was received for this
study or publication of this article. All named
authors meet the International Committee of
Medical Journal Editors (ICMJE) criteria for
authorship for this manuscript, take
responsibility for the integrity of the work as a whole,
and have given final approval for the version to
Disclosures. Alan D. Kaye, Erik M. Helander,
Nalini Vadivelu, Leandro Lumermann, Thomas
Suchy, and Margaret Rose have nothing to
disclose. Richard D. Urman has received research
funding for unrelated work from Mallinckrodt,
Merck, Cara Pharmaceuticals, and Medtronic.
Compliance with Ethics Guidelines. This
article is based on previously conducted studies
and does not involve any new studies of human
or animal subjects performed by any of the
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