“Early to Rise, Early to Home” Standing Patients on Day of Surgery Trish Davidson, PT Langley Memorial Hospital

Mobilizing Patients on Day 0 Communicate plans with nursing staffCommunicate plans with nursing staff Physiotherapist: Altered hours of work for the last 3 monthsPhysiotherapist: Altered hours of work for the last 3 months Transfer/mobilize patients: with RN/LPN instead of PTATransfer/mobilize patients: with RN/LPN instead of PTA

Mobilizing Patients on Day 0 Developed criteria for safely mobilizing patients on Day 0Developed criteria for safely mobilizing patients on Day 0 PO Day 1: get patients up closer to lunch timePO Day 1: get patients up closer to lunch time Book patients 60 days in advance of surgeryBook patients 60 days in advance of surgery

Post-Operative Pain Control Langley Memorial Hospital

Multi- modal approach Non-narcotic analgesic Nonsteroidal anti- inflammatory Narcotics Sustained Release ATC Immediate Release PRN

Non-narcotic analgesic Acetaminophen □650 mg po q6h X 72 hrs then change to 650 mg po q4-6h PRN □975 mg po q6h X 72 hrs the change to 975 mg po q6h PRN □650 mg suppository pr q6h X 72 hrs then change to 650 mg pr q4-6 h PRN

Nonsteroidal anti-inflammatory Celecoxib OR Diclofenac □Celecoxib 200 mg po daily X 3 days (contraindicated in SULFA allergy) □Diclofenac 50 mg po q8h X 3 days (may give first dose PR □Diclofenac 50 mg pr q12h X 3 days

Sustained Release Preparation □OXYCOCONE SR 10 mg po q12h (if less than 60 kg or opioid sensitive) – if necessary after 18 hours may increase to 20 mg q12h OR □OXYCODONE SR 20 mg po q12h – if necessary after 18 hours may increase to 30 mg q12h

Sustained Release Preparation □HYDROMORPHONE SR 3 mg po q12h (if less than 60 kg or opioid sensitive) OR □HYDROMORPHONE SR 6 mg po q12h – if necessary after 18 hours may increase to 9 mg po q12h

Breakthrough Analgesia □Oxycodone immediate release 5 – 10 mg po q3 – 4 h prn for Break Through Pain (BTP) – if less than 60 kg or opioid sensitie □Oxycodone immediate release 10 – 20 mg po q3-4h prn for BTP □Hydromorphone immediate release 1 – 2 mg po q4h prn for BTP – if less than 60 kg or opiod sensitive □Hydromorphone immediate release 1 – 4 mg po q4h prm for BTP if > 60 kg

Advantages to Oxycodone SR  Around the Clock (ATC) Dosing  prevents pain  maintains a pain rating that is satisfactory to the patient  maintains a stable analgesic blood level  based on the knowledge that less drug is needed to prevent the recurrence of pain than to relieve it  prevents the undertreatment of pain in patients who are hesitant to request medication  eliminates delays patients encounter waiting for caregivers to prepare and administer pain medication

Advantages to Oxycodone SR  Reduced incidence of nausea and vomiting  Reduced need for antiemetics  Oral administration  I.V. can be discontinued or converted to a saline lock – one less hindrance to mobilization

Adjustments to the Regime  Medications ordered q12h are automatically given at 1100 and 2200  ↑ need for PRN medications  Rapid response from anesthesiology resulted in specific direction to administer the Oxycodone SR at 0800 and 2000 hours

Pain – the fifth vital sign A study in which 353 hospitalized patients were experiencing painA study in which 353 hospitalized patients were experiencing pain Fewer than half the patients with pain (45%) had a member of the health care team ask them about their paitn or not it in the recordFewer than half the patients with pain (45%) had a member of the health care team ask them about their paitn or not it in the record Donovan, Dillon, McGuire 1987

Pain – the fifth vital sign A study of 242 hospitalized patients with pain, a review of their records revealed that no assessments of pain intensity were documented by any caregiver.A study of 242 hospitalized patients with pain, a review of their records revealed that no assessments of pain intensity were documented by any caregiver. Gu, Belgrade 1993

Discharge Pain Regime Why change what is working?