PALM SPRINGS, CALIF. – The University of Louisville has had an acute pain service for nearly a decade, but for many hospitals in the United States this still is a new idea.

"What we’re seeing is the birth of a new modality in treatment" and possibly a new specialty, Dr. Laura Clark said.

An acute pain service (APS) primarily manages pain after traumatic injury or surgery. The basic aspects of an APS include standardization of analgesic techniques, increased pain monitoring and assessment, and the ability to respond to inadequate or excessive doses of analgesics.

Establishing an APS, however, takes a lot of persuasion and education, said Dr. Clark, professor of anesthesiology and director of acute pain and regional anesthesia at the University of Louisville (Ky.).

Hospital administrators must be convinced that an APS can benefit the hospital by increasing patient satisfaction (which is strongly associated with adequate pain relief) and by cutting costs through reducing nausea and vomiting, respiratory depression, the incidence of ileus (and thus the length of hospitalization), and the incidence of chronic pain.

Physicians and pharmacists need to be willing to accept an APS as part of the care team. Many anesthesiologists mistakenly think that a single nerve block that dissipates in 10 hours is sufficient acute pain management, she said. But more than anyone, surgeons need convincing, Dr. Clark said at the annual meeting of the American Academy of Pain Medicine.

Currently, a surgeon must request involvement of the APS and that request must be documented in order for the service to be covered by insurers. "That needs to change," she said.

To get surgeons on board, include them in developing protocols for all analgesic techniques, she suggested.

There are two groups that don’t need convincing about the benefits of an APS – patients and nurses, she said. Still, education of nurses and all staff about the APS is essential. Simply asking nurses to follow written orders is not sufficient, especially for the more advanced pain therapies. Good acute pain care requires a change in culture and attitudes; for example, nurses need to change empty bags of analgesics just as they change other bags of fluids.

Nurses can be certified in pain management, and "I recommend that you have your nurses do that," Dr. Clark said.

The need for better acute pain management has been established by major reports in the United States, England, Australia, Germany, Sweden, and elsewhere. At least eight published studies report that an APS improves pain relief, five studies report a lower incidence of side effects, and three studies suggest that an APS may reduce the incidence of persistent pain after surgery, she said.

One study reported reduced postoperative morbidity and mortality with an APS but noted that "the workload is considerable" (Anesthesia 2006;61:24-8).

A recent study concluded that an APS is "likely" to be cost effective, but the investigators "didn’t even study what we do," Dr. Clark said. Key treatment techniques such as peripheral nerve blocks and epidural patient-controlled analgesia were not included in the study (Anesth. Analg. 2010;111:1042-50). Had it included those, she believes the study would have shown that an APS is very cost effective, she said.

Better studies with hard data are needed, she added.

The service ideally is physician directed but multidisciplinary, including physicians, nurses, pharmacists, and physical therapists. The most common but least desirable model of an APS in the United States includes a private physician or regionalist who may not do rounds unless called by a surgeon to manage a problem, Dr. Clark said. A second model that may be the most flexible and cost effective for around-the-clock care involves a nurse-led physician consult, in which the nurse makes daily rounds, reports to the physician, and implements therapy based on standard orders and protocols developed by the pain physician and surgeon.

The most common model in academic centers, and Dr. Clark’s favorite, is a physician-led team with a pain management nurse. The team makes rounds and decides on care. The pain physician may or may not be the regionalist. Medical residents are on call for the pain service. The pain nurse is involved in cases before, during, and after surgery and implements advanced pain management techniques, provides consultations, and coordinates with trauma, surgery, and critical care services.

Once you’ve convinced your institution and colleagues to establish an APS, make sure that someone on the APS can be reached by telephone at any hour of every day. Establish "acute pain champions" on every floor and in every area of the hospital, and make sure that at least one champion is available on every shift.

Running an APS can be challenging, but it’s a therapeutic tool that’s worth the effort, she said: "With our twice-a-day rounds, we often hear from the patients that we talk to them more than any other physician. It can be quite rewarding."

Dr. Clark has been a speaker for Covidien and Cadence and an adviser and researcher for Covidien.

Establishing Acute Pain Service Deemed Worthwhile