Anesthesiology, Critical Care & Pain Management

The Outpatient Pain Registry is a new collaborative effort between the Pain Management Division and the Physiatry Department that enables us to more easily conduct research on patients who have been treated for pain by a physician in either department. This automated Epic analytical registry focuses on adults who have neck pain, back pain or neuropathic pain, including complex regional pain syndrome. Data collection includes longitudinal patient-reported outcome measures such as the duration of pain, pain characteristics, pain interference and overall quality of life relative to patients’ initial visits and subsequent treatments and procedures. The aims of the registry are to facilitate dialogue between providers and patients, improve quality assurance and expand research and innovation that supports non-opioid approaches to pain management.

Preoperative pain optimization, the presurgical component of the Perioperative Pain Service, continued to grow and improve throughout 2021. This service works with surgical offices to identify, screen and preoperatively optimize patients with pain-related conditions or complications that may impact their clinical outcomes, recovery and overall experience and satisfaction. Once a patient is identified, clinicians work with the patient to taper high levels of opioid use before surgery and to create a tailored perioperative pain management plan. Increased provider education and improved scheduling workflows have led to higher volumes for this service as well as more accurate patient identification and referrals. The service has continued to innovate via research on how pain management optimization affects length of stay, safety and efficacy. The nationwide increase in overdose deaths and other opioid-related issues during the COVID-19 pandemic, with 2020 having the highest volume of opioid overdose mortality in recorded history, makes this work all the more important.

The department is piloting an initiative, in collaboration with HSS surgeons, in which select patients receive a postoperative adductor canal block in the post-anesthesia care unit (PACU). After completion of the pilot program, these patients will be discharged on postoperative day zero with an indwelling peripheral nerve catheter connected to an infusion pump and reservoir of pain medicine, which they will wear for several days after surgery. Take-home nerve block catheters that infuse local anesthetic have demonstrated significant improvements after surgery, including less opioid use, faster progress in physical therapy and quicker discharge.

The department has collaborated with IT, Operational Excellence and HSS regional locations to give patients the ability to do telehealth anesthesia consults from home. In addition to making necessary space available at regional locations, telehealth anesthesia consults also improve the patient experience by providing more convenience and less wait time.

Developed by the department’s quality assurance and performance improvement team, the PACU efficiency dashboard is used to examine patients’ time to reach specific milestones in the PACU. Examining this data can help identify factors that may be delaying timely discharge, which allows us to look for opportunities to improve these areas preoperatively (such as optimizing patient selection or timing of rides), perioperatively (such as performing shorter spinal nerve blocks) and postoperatively (such as performing rescue nerve blocks). This has the potential to directly impact patient care by helping us maximize the number of patients who can go home the day of surgery.

Several of our anesthesiologists have designated days out of the operating room that they dedicate to academic activities that contribute substantially to the mission of the department and HSS. For the last several years, we have supported the academic interests of our more junior investigators with our Emerging Academician Award. In 2021, we expanded this initiative to our mid-senior level clinicians by offering a Senior Academician Award aimed at physicians who are at least five years out of training and leaders in their field. As we strive to maintain a leadership position in regional anesthesiology, the specific goals of Established Academician Awards are to afford our academicians protected time to enable them to continue to be thought leaders in a defined academic area, maintain and promote a national reputation, present at meetings, participate in relevant national societies, publish in high-impact journals and more. In August 2021, our first series of awards were presented to Stavros Memtsoudis, MD, Meghan Kirksey, MD, Ellen Soffin, MD, and Swetha Pakala, MD.

In 2021, Stephen Haskins, MD, was appointed Chief Medical Diversity Officer in the Office of Diversity, Equity and Inclusion at HSS. Our department is proud to support these initiatives to make HSS as inclusive as we can for all of our staff and patients.

In a formal collaborative effort between the Adult Reconstruction and Joint Replacement (ARJR) Service and Anesthesiology, a five-year research plan is in development to assess the feasibility of opioid-free anesthesia and analgesia for orthopedic procedures. This plan will evaluate existing data and provide a needs assessment for this research at HSS. It will include research into novel approaches and techniques to actualize minimal to opioid-free total joint arthroplasty in appropriate patient populations. A full-time research assistant will be dedicated to opioid-related collaborative studies as part of this initiative. The long-term goal of the project is to transform patient care by generating high-quality data.

Collaborators from HSS and partners around the globe have strongly recommended the use of peripheral nerve blocks during total hip and total knee arthroplasty (TKA) for improved outcomes. While more than 90% of patients undergoing TKA at HSS receive a nerve block, the average in the United States is only about 25%. This research affirms HSS’s leadership in the field and highlights our expanding geographic footprint by engaging international colleagues in consensus processes.

Our researchers are using novel techniques to investigate emerging issues in orthopaedics with the potential to use these algorithms to augment clinical decision-making. The approaches and the question posed in this study align with initiatives of the newly formed HSS Center for Analytics, Modeling & Performance (CAMP).

This study highlights that hospital-specific factors may impact the provision of regional anesthesia to patients. Not only is our department the leader of regional anesthesia for orthopedics and related research, but we are also dedicated to supporting diversity, equity and inclusion efforts at HSS. The department believes that we have a responsibility to understand and report on the state of the field and propose potential ways to decrease disparities.

The department is developing an electronic, standardized tapering tool to be incorporated into EPIC that will be the first of its kind in the United States. This tool will allow prescribers to easily generate personalized, graphical tapering plans based on the structure of the patient’s existing prescription, the intended rate at which the prescription will be tapered and the targeted ending dosage. The goal for this tool is to not only increase the use of opioid tapering strategies within the institution but also to make it easier for patients to understand and follow their tapering plans, improving their experience and making them more likely to succeed in tapering off of their opioid medications safely. If successfully implemented at HSS, this tool has the potential to be added into the foundation EPIC system throughout the country to improve patient safety on a national scale.

Research presented at the 2021 American Society of Anesthesiologists annual meeting by anesthesiologist Stephanie Cheng, MD, suggests that using acupuncture during surgery may help reduce pain while reducing the risk of opioid addiction. Researchers found that 65% of patients who received acupuncture during knee surgery took a low-dose opioid regimen of 15 pills or less or remained completely opioid-free for 30 days after surgery. By contrast, just 9% of patients who undergo knee replacement typically report such low usage. As an expansion of her existing surgical acupuncture service, Dr. Cheng has begun conducting preoperative acupuncture for patients identified as high risk for pain complications during the surgical consult. The goal is to expand this service to accommodate both pre- and postoperative patients in the future as part of an increased focus on holistic pain management.

The department is advancing its fellowship curriculum with several changes, including a new fellowship orientation program, formalized mentorship, creation of additional specialized academic tracks and an expanded curriculum. The expanded curriculum will include revised and new core curriculum lectures for the 2022-2023 fellowship schedule, as well as the production of video lectures for a flipped-classroom model. Effective for the 2021-2022 fellowship class is a monthly fellows-only journal club which will continue moving forward. Fellows will also have access to a digital handbook with numerous resources.

One of the most important elements of our future success is leadership development, notably, an investment in our growth as effective physician leaders, collaborators and communicators and the conscious development of the next generation of our department leaders. To this end, we have created a departmental Physician Leadership Assessment and Development program with NuBrick Partners. We have 22 physicians in training as current and emerging physician leaders, and we also plan to expand this program to our administrative leadership in the coming months.

To better serve the needs of our patients, we have been increasing our existing pain management services and expanding our regional services to different HSS locations. In 2020 and 2021, we hired new pain management physicians for the HSS main campus to improve patient accessibility and increase the types of care we offer. This period also included the expansion of services to HSS Hudson Yards and the new HSS Midtown location. In 2022, the pain division will continue to grow with the addition of the first pain management practice in Long Island at the Uniondale campus as well as the addition of a second practice in Stamford, Connecticut. We also have plans to expand to HSS Westchester in the near future.