An Acute Pain Management Service with Regional
Anesthesia: How to Make it Work
Eugene R. Viscusi, MD, Rehana Jan, MD, Deborah Warshawsky, RN, BSN
Acute pain management has made the transition from treat-
ment primarily with opioids to an array of regional anesthesia
techniques. Epidural analgesia, with a combination of local
anesthetics and opioids, has become a standard of care for
many painful surgical procedures. Peripheral nerve blocks are
being applied more broadly for postoperative pain control
(either as primary anesthetics or in combination with general
anesthesia) and employing catheter techniques will prolong
their action for as long as the analgesia is required. Regional
analgesia techniques work best in combination with other
analgesics to maximize pain relief while minimizing side ef-
fects. Outcome may thus be improved. As such, acute pain
management with aggressive regional anesthesia techniques
requires an organized service beyond the operating room, with
dedicated trained personnel and extensive protocols. A nurse-
based approach fulfills these requirements.
Copyright 2002, Elsevier Science (USA). All rights reserved.
A
cute pain management has changed dramatically in the last
decade. From a field dominated by opioid analgesics, we
now see the utilization of regional anesthetic techniques (epi-
duralanalgesia and a variety of continuous catheter tech-
niques). Ideally, these techniques are launched on a platform of
multimodal analgesia using nonsteroidal anti-inflammatory
agents (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, and
opioids.
1
For the successfulimplementation of these techniques, ded-
icated acute pain specialists—anesthesiologists—play a pivotal
role. They perform regional blocks in the preoperative period
and then follow these patients postoperatively, making appro-
priate therapeutic adjustments. Floor nurses carry out the or-
ders and contact the acute pain management team for inade-
quately managed pain or side effects.
The primary goals of an acute pain management service are
to offer a variety of services, provide a high level of patient
surveillance, and seamlessly integrate these services within the
hospitalsetting.
Optimalanalgesia requires carefultherapeutic fine-tuning to
maximize the benefits and minimize the side effects of therapy.
This can only be accomplished with close surveillance. We
propose that a nurse-based acute pain management service is
the most effective way to provide this service. Whereas the
physician component is in no way diminished, the addition of
trained pain nurses provides a mechanism for continuous mon-
itoring and adjustment of therapy. Nurses can be empowered to
assess pain, side effects, and treat at the “point of care” by
designing and implementing protocols.
In the United States, the Joint Commission on Accredita-
tion of Healthcare Organizations (JCAHO) has established
standards for pain management.
2
These standards have pro-
vided an impetus for institutions to provide effective pain
management. Acute pain management services (APMS) are a
criticalpart of this initiative. Establishment of a successful
pain management service requires strong institutionalsup-
port and collaboration among anesthesiologists, surgeons,
nurses, and pharmacists.
In 1988 L. Brian Ready et aldescribed the purpose and orga-
nization of an anesthesiology-based acute pain service.
3
By the
mid 1990s some 40% of US hospitals had acute pain services.
4
Practice guidelines for acute pain management in the perioper-
ative setting were established by the American Society of Anes-
thesiologists Task Force in 1995.
5
Narinder Rawalhas pro-
moted the concept of a nurse based pain service in the
European experience.
6,7
We have organized our service to be nurse based. Whereas
physicians maintain the role of deciding and performing the
appropriate regionalanesthesia technique, nurses manage
these patients on the floor using treatment protocols. For this
service to perform optimally, there must be defined personnel
roles, protocols, and standardized orders.
The following discussion describes the organization of the
APMS at Thomas Jefferson University Hospital.
Description of Roles
The various physician and nursing roles are defined (Fig 1).
The APMS director or attending staff member determines the
patient’s pain management and performs appropriate regional
anesthesia techniques. During morning rounds, each patient is
assessed by the team (attending, resident, and clinical nurse
specialist) and a daily management plan is determined. The
clinical nurse specialist coordinates this care plan with the
patient’s nursing team.
The nursing team consists of pain nurses, pain resource
nurses, and the floor nurses. Pain nurses are specially trained
nurses, usually with critical care or postanesthesia care
unit (PACU) experience, who see patients on frequent
rounds, optimizing analgesia and treating side effects by
using decision trees and standing orders. Pain resource
nurses are floor nurses with specialtraining in assessment of
pain and trouble-shooting of infusion pumps. Their role,
From the Acute Pain Management Service, Jefferson Medical College,
Thomas Jefferson University, Philadelphia, PA
Address reprint requests to Eugene R. Viscusi, MD, Director, Acute
Pain Management Service, Department of Anesthesiology, Thomas Jef-
ferson University, 111 S 11th St, Suite G8490, Philadelphia, PA 19107-
5092. E-mail: eugene.viscusi@mail.tju.edu
Copyright 2002, Elsevier Science (USA). All rights reserved.
1084-208X/02/0602-0001$35.00/0
doi:10.1053/trap.2002.122927
Techniques in Regional Anesthesia and Pain Management, Vol 6, No 2 (April), 2002: pp 40-49
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