Tag Archives: patient education

Anesthesiology, Healthcare, Pain Medicine

7 Guiding Principles for Acute Perioperative Pain Management

March 3, 2021 ermariano

I had the privilege of co-chairing the 2021 Pain Summit hosted by American Society of Anesthesiologists (ASA). In the months preceding the summit, ASA physician volunteers and staff as well as representatives from 14 other surgical specialty and healthcare organizations worked towards achieving consensus on a common set of principles to guide physicians and other clinicians who manage acute perioperative pain.

These 7 proposed principles are:

Conduct a preoperative evaluation including assessment of medical and psychological conditions, concomitant medications, history of chronic pain, substance abuse disorder, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan.
Use a validated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly.
Offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in adults.
Provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for managing postoperative pain, and document the plan and goals for postoperative pain management.
Provide education to all patients (adult) and primary caregivers on the pain treatment plan, including proper storage and disposal of opioids and tapering of analgesics after hospital discharge.
Adjust the pain management plan based on adequacy of pain relief and presence of adverse events.
Have access to consultation with a pain specialist for patients who have inadequately controlled postoperative pain or at high risk of inadequately controlled postoperative pain at their facilities (e.g., long-term opioid therapy, history of substance use disorder).

This is the first project from this new collaborative, which focused on the adult surgical patient, and there are already plans for future projects. The participating organizations are:

American Academy of Orthopaedic Surgeons
American Academy of Otolaryngology-Head and Neck Surgery
American Association of Neurological Surgeons
American Association of Oral and Maxillofacial Surgeons
American College of Obstetricians and Gynecologists
American College of Surgeons
American Hospital Association
American Medical Association
American Society of Breast Surgeons
American Society of Plastic Surgeons
American Society of Regional Anesthesia and Pain Medicine
American Urological Association
Society of Thoracic Surgeons

Healthcare, Leadership, Outcomes Research, Patient Safety, Social Media

More Reasons for Doctors to Tweet

August 30, 2019 ermariano

This press release came out during the annual scientific meeting of the New Zealand Society of Anaesthetists based on my talk, “The Role of Social Media in Modern Medicine.” While in New Zealand, I was interviewed on Newstalk ZB by host Andrew Dickens and Afternoons with Jesse Mulligan.

Doctors need to be active on social media and other communication platforms to offset the noise of the anti-science movement according to a visiting professor of anaesthesiology, Dr. Ed Mariano from Stanford University in the US.

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Dr. Mariano is speaking at the New Zealand Anaesthesia Annual Scientific Meeting in Queenstown this week on the role of social media and medicine. He says, there has been a growing anti-science movement and physicians have a moral imperative to stand up for science and evidence-based treatments.

“Surveys show that physicians are one of the most trusted professions in the eyes of the public. Yet most people in the world today get their information, including health information, from the internet. We have to be there to offset the noise,” he says. “We can’t ignore where our patients get their information, and we can join the conversation.”

Dr. Mariano, who is one of the top 10 anaesthetists on Twitter, says social media also offers a way for doctors to keep up-to-date with the latest research and new treatments. For example he cites the exponential growth of regional anaesthesia. Regional anaesthesia allows procedures to be done without the patient being unconscious and can provide targeted pain relief.

“We have more tools at our disposal. New blocks are being performed and described every month and it’s hard to keep up with the literature. Social media allows you to be part of a learning community made up of people who have similar interests and it can curate information for you,” he says.

Dr. Mariano says it works the other way too. He says he’s created great collaborations through social media. “As well as learning things, I’ve had interesting conversations on Twitter that have developed into projects. As an academic physician, I’ve found the use of social media has been invaluable. Engaging in social media gives physicians a worldwide community of colleagues who can help curate the vast and ever-growing amount of information available today.”

Anesthesiology, Healthcare, Medical Education, Patient Safety

Partnering with Patients for Patients

December 5, 2017 ermariano

As an anesthesiologist, I am a physician who cares for patients when they are most vulnerable. Under anesthesia, no one is able to call for help. Every day patients have surgery in operating rooms all over the world, and it is the job of the physician anesthesiologist to watch over them, monitor their bodies’ responses to stress, breathe for them, provide them with pain relief, and fight for them when unexpected crises occur. It is my job to calm the fears of my patients and families, listen to their requests, manage their expectations, and develop a plan that will provide them with the best outcome after surgery.

“It is my job to calm the fears of my patients and families, listen to their requests, manage their expectations, and develop a plan that will provide them with the best outcome after surgery.”

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My belief in this connection between physicians, patients, and families as an anesthesiologist stretches into my administrative roles as well. As Chief of the Anesthesiology and Perioperative Care Service and Associate Chief of Staff for Inpatient Surgical Services at the VA Palo Alto Health Care System (VAPAHCS), I am grateful for the opportunity to work with an incredible team of physicians, respiratory therapists, surgeons, advanced practice providers, technicians, and administrative staff members who are focused on our mission to provide the highest quality Veteran-centered care by leading, educating, and innovating in anesthesiology and perioperative medicine.

In order to accomplish this mission, we need the best information available to guide our decisions and a diversity of perspectives to enhance our ability to train new clinicians and explore relevant research questions. We have been fortunate to partner with our friends and colleagues in the Veteran and Family Advisory Council (VFAC) on a number of exciting projects. First, our Service manages the simulation center at VAPAHCS and is responsible for coordinating simulation-based training for all clinicians. Members of VFAC have been directly involved in simulation activities, even taking on active roles as the patient or family member in standardized training scenarios, to help us educate clinicians from various disciplines and all training levels. Debriefing after these simulation exercises gives our clinical trainees and practicing clinicians the unique perspective of real patients and family members which is essential to their professional development as modern medicine continues to progress towards a model of patient-centered care.

Once a year, our Service organizes a faculty development retreat during which we reassess our mission, vision, strategic priorities, and tactics and work on one or two big ideas. Two years ago in 2015, we invited our VFAC partners to join us at our annual retreat to brainstorm improvement ideas related to patient-centered care in the perioperative environment, intensive care unit, and pain management. The general theme of the retreat addressed public perception and professional reputation of anesthesiologists and the specialty of anesthesiology. Having members of VFAC present at the retreat to share their knowledge, opinions, and questions has inspired a few subsequent improvement activities and other projects to enhance the range of services that we provide to our patients and their families.

Finally, working together with VFAC, and knowing members personally, has allowed our clinical Service to solicit feedback on a regular basis. Not all hospitals enjoy the level of access to a community of engaged patients and families like we do at VAPAHCS. When we revised our preoperative education materials for patients, we went to VFAC for input. When we were critically reviewing our website to update our online patient educational materials on anesthesia and perioperative care, we presented at the VFAC meeting to get the members’ feedback and suggestions. With their help, we have been able to improve the accessibility and readability of our online content and provide our patients and their families with useful information that can help prepare them for surgery.

We are very grateful to VFAC for its priceless contributions to our healthcare system, our patients, and our Service. We look forward to continued collaboration on future projects!

This blog has also appeared as a featured story on the VA Palo Alto Health Care System website.

Anesthesiology, Healthcare, Knee Replacement, Leadership, Medical Education, Regional Anesthesiology, Research

Changing Clinical Practice Doesn’t Have to Take So Long

January 10, 2017 ermariano

Guest post by Seshadri Mudumbai, MD, MS. Dr. Mudumbai is an Assistant Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine. He is also a health services researcher and physician anesthesiologist at the Veterans Affairs Palo Alto Health Care System.

Changing physician behavior is rarely easy, and studies show that it can take an average of 17 years before research evidence becomes widely adopted in clinical practice. One study published in JAMA has identified 7 categories of change barriers:

Lack of awareness (don’t know guidelines exist)
Lack of familiarity (know guidelines exist but don’t know the details)
Lack of agreement (don’t agree with recommendations)
Lack of self-efficacy (don’t think they can do it)
Lack of outcome expectancy (don’t think it will work)
Inertia (don’t want to change)
External barriers (want to change but blocked by system factors)

Why Change?

According to the Institute of Medicine’s Crossing the Quality Chasm: a New Health System for the 21st Century: “Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.” Our group has focused our efforts on implementing updated evidence-based medicine initiatives for surgical patients with a special emphasis on the total knee replacement population. Knee replacement is already one of the most common types of surgery in the United States (over 700,000 procedures per year). Given an aging population, the volume of knee replacement surgeries is expected to increase to over 3 million by the year 2030.

We now have sufficient evidence to support “neuraxial anesthesia” (such as a spinal or epidural) as the preferred intraoperative anesthetic technique for knee replacement patients. With neuraxial anesthesia, an injection in the back temporarily numbs the legs and allows for painless surgery of the knee. Several studies have now shown better outcomes and fewer complications after knee replacement surgery with neuraxial anesthesia when compared with general anesthesia. Despite these known benefits, a large study evaluating data from approximately 200,000 knee replacement patients across the United States reveals that use of neuraxial anesthesia occurs in less than 30% of cases. At our facility prior to changing our practice, we noted a 13% rate of neuraxial anesthesia utilization. In the face of growing evidence, we chose to change our practice, and the results of these efforts are reported in our recently published article.

How Did We Start?

An important tool used to coordinate the perioperative care of knee replacement patients has long been the clinical pathway. A clinical pathway is a detailed care plan for the period before, during, and after surgery that covers multiple disciplines: surgery, anesthesiology and pain management, nursing, physical and occupational therapy, and sometimes more. The concept of the clinical pathway should be dynamic and not static. This requires a process to ensure clinical pathways are periodically updated and someone to take a leadership role in managing the process.

At our institution, we established a coordinated care model known as the Perioperative Surgical Home (PSH). The PSH provides the overall structure and coordination for perioperative care, and multiple clinical pathways exist within this structure. With a PSH, physician anesthesiologists are charged with providing leadership and oversight of specific clinical pathways, collecting and reviewing data, engaging frontline healthcare staff and managers across disciplines, and suggesting changes or updates to clinical pathways as new evidence emerges.

Within our PSH model, we invested in a 5 month process to change our preferred anesthetic technique from general anesthesia to neuraxial anesthesia within the clinical pathway for knee replacement patients. This process involved many steps and followed the Consolidated Framework for Implementation Research:

Literature review and interdepartmental presentation
Development of a work document
Training of staff
Prospective collection of data with feedback to staff.

After one year, the overall percentage of knee replacement patients receiving neuraxial anesthesia increased to 63% from 13%, and a statistically-significant increase in neuraxial anesthesia use took place within one month of the updated clinical pathway rollout.

How Do We Keep It Going?

Neuraxial anesthesia continues to be the predominant anesthetic technique that our knee replacement patients receive today. We attribute the ongoing success of this change to multidisciplinary collaboration, physician leadership in the form of a departmental champion, peer support and feedback, frequent open communication, and engagement and support from facility leadership. The results of our study and experience show that a PSH may help facilitate changes in clinical practice quicker than other less-coordinated models of care. As PSH models continue to be developed, further evidence to support the impact of clinical practice changes on patient-oriented outcomes related to quality and safety and healthcare economics is needed.

For patient education materials regarding anesthetic options for knee replacement surgery, please visit My Knee Guide.