ASRA Pain Medicine Update

Cite as: Hamsher C. Running an inpatient pain service. ASRA Pain Medicine News 2022;47. https://doi.org/10.52211/asra050122.019  

The tasks of an inpatient pain service can be broad and far-reaching within a hospital. Poorly controlled inpatient pain can result in increased costs as well as decreased patient satisfaction and quality of life.¹ The prevalence of pain is undoubtedly high with 80% of patients who undergo surgery reporting postoperative pain.² In a study of more than 1,600 admitted cancer patients, 88% reported pain the previous 7 days.³ While many inpatient services may focus on postoperative pain and cancer pain, general medical units also experience a high prevalence of pain, with it being reported in more than 50% of patients during hospitalization.⁴

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Practitioners and hospitals should create a patient-centered collaborative environment regardless of the delineation of inpatient pain services.

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When setting up and running an inpatient pain service, the structure and staffing model is of utmost importance. Financial constraints always play a role, as it is difficult to “break even” with direct costs and billing of an inpatient pain service. Depending on the size and needs of a hospital, an initial team for a service may be small, sometimes consisting of only one practitioner that rounds on patients part-time. A more robust service for a larger hospital may consist of a team of physicians, advanced practitioners, nurses, fellows, residents, and pharmacists that cover the service around the clock. An efficient service can both directly and indirectly result in a significantly positive financial impact to a hospital system.

Within anesthesiology departments, a pain service is often delineated to be either acute or chronic. Typically an acute service will manage postoperative pain with a focus on peripheral and neuraxial catheters, patients with complex comorbidities that may affect postoperative pain, and patients that have existing chronic pain prior to a surgery. A chronic pain service is more likely to manage ongoing difficult-to-treat non-cancer pain in patients who have not undergone surgery. In many hospitals, oncologists or a palliative care service treat cancer-related pain in admitted patients. Although there are many possible subsets of inpatient pain services, it is important to realize that not all hospitals are large enough or have the resources to have or make use of all of them. One practitioner from any department with training or a comprehensive background in pain management could potentially cover all aspects of inpatient pain care for a hospital (cancer pain, acute postoperative pain, complex chronic pain, and more). One of the simplest iterations of this is a pharmacist doing medication reviews and recommendations on patients with more complex medication regimens for chronic pain.

The division of pain services at our university hospital setting generally conforms to the above-mentioned scopes of practice. We have medical oncologists and a palliative care team that perform most of the care for cancer pain, an acute pain division that covers mostly postoperative pain and catheter-based infusions, and a chronic pain division that covers chronic pain in complex medical patients. Within our department of anesthesiology, we attempt to foster communication between our “chronic” and “acute” pain services and often share patients between each service. We believe this can result in a higher quality of care given that each service may be able to offer something unique to a patient. For example, patients may be followed by our chronic service with an acute exacerbation of non-operable joint pain because of a trauma or accident where they could benefit from blocks or catheters that our acute pain service may be more comfortable performing. Conversely, a postoperative cancer patient on our acute service may have a prolonged hospital stay because of uncontrolled cancer pain and could benefit from targeting an autonomic plexus, which would be more suitable for our chronic team to do. Practitioners and hospitals should create a patient-centered collaborative environment regardless of the delineation of inpatient pain services.

A hospital system must consider the indirect financial impact of an inpatient pain service as it may decrease hospital length of stay and readmission rates in certain patient populations.^5-7 An inpatient pain service also can increase patient satisfaction with a dedicated team managing a patient’s pain, usually by using evidence-based methods to improve pain control while minimizing opioid use. One study demonstrated that initiating an integrative medicine program to inpatients with pain resulted in a decrease of pain by an average of 2.05 points on an 11-point numeric scale and a decreased cost of $898 per hospital admission.⁶

When organizing and running an inpatient pain service, it is important to keep in mind the overall needs of the patient population you are serving as well as the needs of the hospital. Each hospital is unique in what may be offered by medical and surgical units, and there may be a gap that can be filled. In our hospital system, our chronic pain service will often take care of chronic pain patients with comorbid substance addiction. We have used this opportunity to attempt early and aggressive buprenorphine initiation while patients are admitted. This allows the patient to have a higher level of monitoring while making that medication transition and to have more comfort knowing that a dedicated team is there to serve them around the clock. For many of these patients, this can be the first step toward a successful path to recovery with a potential added benefit of improved pain control.

Another population our chronic pain service noted to be in need were patients admitted with sickle cell pain. Along with our hematologists, we implemented individualized pain care plans for high hospital-utilizing adults with sickle cell disease.⁷ We were able to decrease hospital length of stay, seven-day readmission rate, and use of IV hydromorphone. The potential cost saving of this initiative in our hospital system was more than $1.3 million.⁷ This resulted in significant benefits to these patients while simultaneously achieving substantial cost reductions to the health care system and hospital directly.

In summary, dedicated inpatient pain services can provide substantial benefits to patients. The direct and indirect cost benefits to a hospital or health care system can be significant as well. When setting up and running an inpatient pain service, it is important to target the most at-risk and high hospital-utilizing populations at first to obtain the most value. If resources and financial constraints are tight, an inpatient pain service can be simple to begin and then grow as more resources become available and the economic impact is realized. Using a patient-centered approach and fostering good communication among all team members taking care of your patients will ensure continued success and a multitude of benefits to your hospital system.

Carlyle Hamsher, MD, is an assistant professor at the Atrium Health Wake Forest Baptist in Winston-Salem, NC.

References

1. Fortner BV, Demarco G, Irving G, et al. Description and predictors of direct and indirect costs of pain reported by cancer patients. J Pain Symptom Manage 2003;25(1):9-18.
2. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington: National Academies Press; 2011.
3. Doyle KE, El Nakib SK, Rajagopal MR, et al. Predictors and prevalence of pain and its management in four regional cancer hospitals in India. J Glob Oncol 2018;4:1-9. https://doi.org/10.1200/JGO.2016.006783
4. Morris AC, Howie N. Pain in medical inpatients: an under-recognized problem? J R Coll Physicians Edinb 2009;39(4):292-5.
5. Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv. 2020;4(12):2656-701. https://doi.org/10.1182/bloodadvances.2020001851
6. Dusek JA, Griffin KH, Finch MD, et al. Cost savings from reducing pain through the delivery of integrative medicine program to hospitalized patients. J Altern Complement Med 2018;24(6):557-63. https://doi.org/10.1089/acm.2017.0203
7. Welch-Coltrane JL, Wachnik AA, Adams MCB, et al. Implementation of individualized pain care plans decreases length of stay and hospital admission rates for high utilizing adults with sickle cell disease. Pain Med 2021;22(8):1743-52. https://doi.org/0.1093/pm/pnab092