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The Therapeutic Activity Goal for Acute Postoperative Pain Management

Dieterichs, Chad, MD*; Davis, James, D., RN, MSN, MAHCM; Uhler, Lauren, MPH*; Vetter, Thomas, R., MD, MPH*

doi: 10.1213/XAA.0000000000000729
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Acute pain intensity has conventionally been assessed with a patient self-reported, unidimensional pain scale. This approach can inadvertently underestimate analgesia and result in large cumulative opioid doses and greater dose-dependent side effects and complications. We have thus created the Therapeutic Activity Goal (TAG) as an alternate, more comprehensive way to assess acute postoperative pain, and even more so, to define and determine adequate postoperative analgesia. The TAG comprises the level of acceptable pain intensity, the level and types of desired activities, and accomplishing other patient-centered functional goals. The TAG evolves throughout the patient’s hospitalization to promote timely discharge.

From the *Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas; and Seton Healthcare Family, Austin, Texas.

Accepted for publication December 19, 2017.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Thomas R. Vetter, MD, MPH, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Health Discovery Bldg, Room 6.812, 1701 Trinity St, Austin, TX 78712. Address e-mail to thomas.vetter@austin.utexas.edu.

Acute pain intensity has conventionally been assessed in adults with a patient self-reported, unidimensional pain scale (eg, 0–10, 11-point numerical rating scale).1 This approach was reinforced by the “Pain as the 5th Vital Sign” initiative that was extensively promulgated by the American Pain Society and the Department of Veterans Affairs, when The Joint Commission first established standards for routine pain assessment and consistent treatment in 2001, in response to “the national outcry about the widespread problem of undertreatment of pain.”2

Clinical practice has subsequently typically focused on reducing the patient’s self-reported acute pain intensity to below a certain cut-point score (eg, a “5 out of 10” on a numerical rating scale). While ostensibly patient centered and efficient, the use of a unidimensional pain scale is a rather simplistic way to assess the complex biopsychosocial construct and very individual human experience of pain.3 This approach can also inadvertently result in large cumulative opioid doses and greater dose-dependent side effects and complications.4

Developing a more comprehensive tool for patient assessment is fundamental in delivering effective yet safe acute pain management.5 As recently noted by the Acute Pain Medicine Shared Interest Group of the American Academy of Pain Medicine, multidimensional pain measurement strategies offer major advantages by measuring the important domains of functionality; pain interference; perceptions of pain relief; quality and character of pain; psychological experiences; social roles, functioning, and interactions; sleep; and satisfaction with pain care.6

As part of our broad institutional pain management improvement initiative, we have thus created the Therapeutic Activity Goal (TAG) as an alternate, more comprehensive way to assess acute postoperative pain, and even more so, to define and determine adequate postoperative analgesia.

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DESCRIPTION

The TAG comprises several components, all mutually agreed on by the multidisciplinary perioperative care team members and their shared patient; specifically, the level of acceptable pain intensity, the level and types of desired activities, and accomplishing other patient-centered functional goals. Analgesic goals hence include not only simply pain intensity, but also the level and specific types of activity and function. The TAG provides the patient and the care team with target activities that advance the healing and rehabilitation necessary for discharge from the hospital but that cannot be readily accomplished due to pain. Along with an assessment of the patient’s pain intensity, the TAG especially and practically helps the bedside nurse determine the optimal analgesic dosing regimen.

A given patient’s individualized pain management plan is based on an initial and on-going evaluation of and discussions with the patient about the importance of accomplishing this plan. The treating physician has primary responsibility for creating, ordering, and updating the TAG, but as part of the process, works closely with all the multidisciplinary care team members as well as the patient and family.

The first step in creating the TAG is an assessment of the patient’s expected type(s) and locations(s) of acute pain and preoperative, baseline activity level. The provider indicates in the TAG: (1) the patient’s pain characteristics and the corresponding pain-related goals; (2) the patient’s level of mobility (independent/limited assistance, moderate assistance, total dependence); and (3) the patient’s activities of daily living (ADLs) (self-sufficient/minimal assistance, moderate or extensive assistance, or total dependence). The patient’s baseline status determines the TAG options for the domains of mobility, ADLs, and psychosocial elements, including self-determination and self-efficacy (eg, selecting and participating in nonmedication pain treatment methods) (Figure).

Figure

Figure

The specific metrics and outcomes contained in the preliminary version of our TAG were primarily identified by a multidisciplinary development team, which comprised an anesthesiologist with acute pain management experience, a physiatrist with inpatient rehabilitation experience, an orthopedic surgeon specializing in lower extremity arthroplasty, and 2 advanced practice nurses and a physical therapist with postoperative inpatient care experience. To further confirm its content validity, the TAG was comprehensively reviewed and vetted by our institutional pain management committee. We elected to focus on physical activity rather than directly on medication side effects. However, inherent to achieving these activity goals is a lower, tolerable medication side effect profile.

The TAG can be as simple as undertaking 1 or more specific ADLs or as complex as completing all the elements of a postoperative total joint replacement care pathway. For example, for a patient who is unable to walk unassisted and needs assistance to stand and pivot, the TAG mobility goals can include dangling at edge of bed, sitting in a bedside chair several times per nursing shift, and sitting in a chair or at the edge of the bed for meals. The same patient would need moderate assistance but mutually agrees to 1 or more of the ADL goals of transferring to a bedside commode, undertaking personal hygiene, getting dressed, and feeding one’s self, all with an appropriate setup.

The TAG also focuses on the equally important psychosocial aspects of pain.6 These psychosocial elements of the TAG include the patient’s self-determination and self-efficacy, mood, sleep hygiene, social roles and interactions, discharge planning and trajectory, and nonpharmacologic pain treatment and distraction techniques, including spiritual and mind–body comfort measures (Figure).

It is vital that all these TAG elements are agreed on by and reinforced by the entire care team and the patient and family to level-set expectations and guidance on the real-time postoperative recovery goals and needed analgesia and pain treatment options. Once the TAG is initially created, it evolves throughout the course of the patient’s surgical recovery, ultimately returning the patient close enough to baseline status to allow for timely hospital discharge. The details of the TAG are clearly communicated, because it is (1) posted on a large, colorful, and highly visible dashboard on the wall in the patient’s room; (2) discussed at least daily during multidisciplinary rounds and at each nursing shift change; and (3) documented in the electronic medical record. It serves as a shared set of specific goals for the patient and care team and a guide to identify pain therapies and define adequate analgesia.

At our institution, the TAG is closely coupled with an evidence-based, opioid-sparing, multimodal treatment protocol6 and a standardized electronic order set. The TAG serves as the end point that orders treat toward. Rather than simply treating to some arbitrary and often ambiguous number on a pain intensity scale, the provider team and patient are focused on achieving a mutually agreed upon set of activity goals.

The TAG is iterative as the patient’s recovery progresses toward individualized discharge criteria. Therefore, once the initial set of postoperative goals are achieved (eg, on postoperative day 1), the patient, primary physician, and care team sequentially determine a new set of goals and acceptable pain level and then modify as needed the analgesic orders in the electronic medical record. Based on his or her individual progress, the TAG evolves throughout the patient’s hospitalization to promote timely acute care discharge.

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DISCUSSION

While opioids can demonstrate a variable patient-to-patient minimum effective analgesic concentration, there is an equally important, dynamic relationship between time, baseline pain, incident pain, and rate of recovery, and an individual patient’s consumption of opioids.7 Furthermore, valid pain assessment has been described as a social transaction that entails a more complex communication process between the patient and clinician, which is composed of diverse interpersonal and intrapersonal dimensions that interact and affect each other.3,8

We developed our TAG to improve pain assessment as well as to achieve more effective pain treatment by involving patients in planning and implementing their pain care. The adage, “Tell me I forget—Show me I remember—Involve me I learn,” seems quite apropos to pain management. Including patients as a member of their health team maintains lines of communication to meet their specific needs by individualizing care and actively involving them in their pain treatment. While focused here on acute postoperative pain, with some modifications, the TAG could also be applied with acute-on-chronic pain and chronic pain patients.

Patient-reported outcomes are increasingly expected to be measured, which will place increasing demands on health care systems and their delivery teams. By equally involving the patient and multidisciplinary care team in goal setting, the TAG seeks to create an atmosphere and relationships that promote clinical success and mutual satisfaction. The TAG may help address the current, equally loud outcry about the opioid epidemic and crisis in the United States.9

However, the ability of our nascent TAG to achieve its desired primary outcomes must be confirmed. We thus plan to undertake an extensive proof-of-concept study of the TAG, likely initially in lower extremity total joint arthroplasty patients. This will also entail confirming the construct validity (ie, the degree to which it measures what it purports to be measuring) of our preliminary TAG.

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DISCLOSURES

Name: Chad Dieterichs, MD.

Contribution: This author helped write and revise the manuscript.

Name: James D. Davis, RN, MSN, MAHCM.

Contribution: This author helped write and revise the manuscript.

Name: Lauren Uhler, MPH.

Contribution: This author helped write and revise the manuscript.

Name: Thomas R. Vetter, MD, MPH.

Contribution: This author helped write and revise the manuscript.

This manuscript was handled by: Mark C. Phillips, MD.

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REFERENCES

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