Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process.

In many countries, liberalisation of the legislation regulating the use of cannabis has outpaced rigorous scientific studies, and a growing number of patients presenting for surgery consume cannabis regularly. Research to date suggests that cannabis can impact perioperative outcomes. We present recommendations obtained using a modified Delphi method for the perioperative care of cannabis-using patients. A steering committee was formed and a review of medical literature with respect to perioperative cannabis use was conducted. This was followed by the recruitment of a panel of 17 experts on the care of cannabis-consuming patients. Panellists were blinded to each other's participation and were provided with rater forms exploring the appropriateness of specific perioperative care elements. The completed rater forms were analysed for consensus. The expert panel was then unblinded and met to discuss the rater form analyses. Draft recommendations were then created and returned to the expert panel for further comment. The draft recommendations were also sent to four independent reviewers (a surgeon, a nurse practitioner, and two patients). The collected feedback was used to finalise the recommendations. The major recommendations obtained included emphasising the importance of eliciting a history of cannabis use, quantifying it, and ensuring contact with a cannabis authoriser (if one exists). Recommendations also included the consideration of perioperative cannabis weaning, additional postoperative nausea and vomiting prophylaxis, and additional attention to monitoring and maintaining anaesthetic depth. Postoperative recommendations included anticipating increased postoperative analgesic requirements and maintaining vigilance for cannabis withdrawal syndrome.

Medial Open Transversus Abdominis Plane (MOTAP) Catheters Reduce Opioid Requirements and Improve Pain Control Following Open Liver Resection: A Multicenter, Blinded, Randomized Controlled Trial.

OBJECTIVE: Conventional management of pain following open liver resection involves intravenous, patient-controlled analgesia (IV PCA) or epidural analgesia. The objective of this trial was to assess the efficacy of a regional technique called Medial Open Transversus Abdominis Plane (MOTAP) catheter analgesia compared with IV PCA. METHODS: This was a blinded, randomized, controlled parallel-arm trial conducted at 2 high-volume centers. Patients undergoing liver resection through a subcostal incision were enrolled. Using a standardized technique, 2 catheters were placed after resection: one in the plane between internal oblique and transversus abdominis and the other in the posterior rectus sheath. Patients were randomized to receive ropivacaine 0.2% (ROP) or saline (NS) through both catheters for 72 hours. All patients received IV PCA with hydromorphone as part of a multimodality analgesia program. Primary outcome was opioid use over the first 48 hours. RESULTS: One hundred fifty-three patients were included in the analysis (71 ROP, 82 NS). Patients receiving ROP used significantly less opioid than patients with NS at 48 hours (median 39.6 mg morphine-equivalent vs 49.2 mg, P = 0.033) and at 72 hours (median 50.0 vs 66.4 mg, P = 0.046). Pain scores at rest and with coughing were significantly lower at all time points in patients who received ROP (P = 0.002). Median length of hospital stay was 5 days in patients receiving ROP and 6 days in patients who received NS (P = 0.035). There was no difference between groups in complications [ROP 20 (28.2%) vs NS 26 (31.7%), P = 0.63]. CONCLUSION: MOTAP catheter analgesia reduces opioid requirements, pain, and length of hospital stay compared with IV PCA following open liver resection with subcostal incisions.

Smoking, Pain Intensity, and Opioid Consumption 1-3 Months After Major Surgery: A Retrospective Study in a Hospital-Based Transitional Pain Service.

Introduction: The present study investigated the associations between smoking, pain, and opioid consumption in the 3 months after major surgery in patients seen by the Transitional Pain Service. Current smoking status and lifetime pack-years were expected to be related to higher pain intensity, more opioid use, and poorer opioid weaning after surgery. Methods: A total of 239 patients reported smoking status in their presurgical assessment (62 smokers, 92 past smokers, and 85 never smokers). Pain and daily opioid use were assessed in hospital before postsurgical discharge, at first outpatient visit (median of 1 month postsurgery), and at last outpatient visit (median of 3 months postsurgery). Pain was measured using numeric rating scale. Morphine equivalent daily opioid doses were calculated for each patient. Results: Current smokers reported significantly higher pain intensity (p < .05) at 1 month postsurgery than never smokers and past smokers. Decline in opioid consumption differed significantly by smoking status, with both current and past smokers reporting a less than expected decline in daily opioid consumption (p < .05) at 3 months. Decline in opioid consumption was also related to pack-years, with those reporting higher pack-years having a less than expected decline in daily opioid consumption at 3 months (p < .05). Conclusions: Smoking status may be an important modifiable risk factor for pain intensity and opioid use after surgery. Implications: In a population with complex postsurgical pain, smoking was associated with greater pain intensity at 1 month after major surgery and less opioid weaning 3 months after surgery. Smoking may be an important modifiable risk factor for pain intensity and opioid use after surgery.

Surgically placed abdominal wall catheters on postoperative analgesia and outcomes after living liver donation.

Living donor liver resections are associated with significant postoperative pain. Epidural analgesia is the gold standard for postoperative pain management, although it is often refused or contraindicated. Surgically placed abdominal wall catheters (AWCs) are a novel pain modality that can potentially provide pain relief for those patients who are unable to receive an epidural. A retrospective review was performed at a single center. Patients were categorized according to their postoperative pain modality: intravenous (IV) patient-controlled analgesia (PCA), AWCs with IV PCA, or patient-controlled epidural analgesia (PCEA). Pain scores, opioid consumption, and outcomes were compared for the first 3 postoperative days. Propensity score matches (PSMs) were performed to adjust for covariates and to confirm the primary analysis. The AWC group had significantly lower mean morphine-equivalent consumption on postoperative day 3 [18.1 mg, standard error (SE)=3.1 versus 28.2 mg, SE=3.0; P=0.02] and mean cumulative morphine-equivalent consumption (97.2 mg, SE=7.2 versus 121.0 mg, SE=9.1; P=0.04) in comparison with the IV PCA group; the difference in cumulative-morphine equivalent remained significant in the PSMs. AWC pain scores were higher than those in the PCEA group and were similar to the those in the IV PCA group. The AWC group had a lower incidence of pruritus and a shorter hospital stay in comparison with the PCEA group and had a lower incidence of sedation in comparison with both groups. Time to ambulation, nausea, and vomiting were comparable among all 3 groups. The PSMs confirmed all results except for a decrease in the length of stay in comparison with PCEA. AWCs may be an alternative to epidural analgesia after living donor liver resections. Randomized trials are needed to verify the benefits of AWCs, including the safety and adverse effects.

Transversus abdominis plane blocks: an overview of indication and nursing care.

Transversus abdominis plane (TAP) blocks are an evolving regional anesthesia technique used as part of postoperative pain management regimens after major abdominal surgery. This article reviews TAP block insertion techniques, commonly used local anesthetics, and recommends nursing care related to TAP blocks.

A Randomized Controlled Trial of Clinical Hypnosis as an Opioid-Sparing Adjunct Treatment for Pain Relief in Adults Undergoing Major Oncologic Surgery.

Clinical hypnosis is an effective strategy for managing acute pain in the surgical setting. However, the opioid sparing effects of clinical hypnosis are not as well understood. This pre-registered (NCT03730350) randomized, controlled trial (RCT) examined the impact of clinical hypnosis, pre- and post-surgery, on opioid consumption during hospitalization as well as on measures of pain intensity, pain interference, depressed mood, anxiety, sleep, and pain catastrophizing. Participants (M = 57.6 years; SD = 10.9) awaiting oncologic surgery were randomized to treatment-as-usual (n = 47) or hypnosis (n = 45). Intent-to-treat analyses were conducted using linear mixed effects modeling. A significant Group × Time interaction, F(6, 323.34) = 3.32, p = 0.003, indicated an opioid sparing effect of clinical hypnosis during the acute postoperative period. Hypnosis also protected against increases in pain catastrophizing at one-week after surgery, F (1, 75.26) = 4.04, p = 0.048. A perioperative clinical hypnosis intervention had a sparing effect on opioid consumption in-hospital after major oncologic surgery. These findings extend the efficacy of clinical hypnosis as an adjunct tool for perioperative pain management.

The journey of the pain resource nurse in improving pain management practices: understanding role implementation.

Pain assessment and management continues to be challenging for many nurses. Single educational interventions have proven to be unsuccessful in knowledge retention. This study will assist leaders in nursing in understanding how a 4-day educational program delivered to self-selected pain resource nurses (PRNs) could improve pain assessment and management practices. A focus group study was undertaken at a trisite academic health science center to understand the role implementation of the PRNs and required resources to sustain the role at a unit level. To evaluate the PRN role, a qualitative descriptive study design using focus group interviews was used to answer the following questions: What was the experience of the PRN during role implementation? What barriers and enablers affected the implementation of this role? Organizational support, integration within the interdisciplinary team, and organizational role awareness were key themes highlighted in the focus group results. This article will describe how the three-site academic health science center used the PRN role to foster practice-related change and enhance current knowledge of evidence-based pain management.

Prevention and Management of Chronic Postsurgical Pain and Persistent Opioid Use Following Solid Organ Transplantation: Experiences From the Toronto General Hospital Transitional Pain Service.

BACKGROUND: With >700 transplant surgeries performed each year, Toronto General Hospital (TGH) is currently one of the largest adult transplant centers in North America. There is a lack of literature regarding both the identification and management of chronic postsurgical pain (CPSP) after organ transplantation. Since 2014, the TGH Transitional Pain Service (TPS) has helped manage patients who developed CPSP after solid organ transplantation (SOT), including heart, lung, liver, and renal transplants. METHODS: In this retrospective cohort study, we describe the association between opioid consumption, psychological characteristics of pain, and demographic characteristics of 140 SOT patients who participated in the multidisciplinary treatment at the TGH TPS, incorporating psychology and physiotherapy as key parts of our multimodal pain management regimen. RESULTS: Treatment by the multidisciplinary TPS team was associated with significant improvement in pain severity and a reduction in opioid consumption. CONCLUSIONS: Given the risk of CPSP after SOT, robust follow-up and management by a multidisciplinary team should be considered to prevent CPSP, help guide opioid weaning, and provide psychological support to these patients to improve their recovery trajectory and quality of life postoperatively.

Epidural analgesia provides better pain management after live liver donation: a retrospective study.

Despite the increase in surgical volumes of live liver donation, there has been very little documentation of the postoperative pain experience. The primary aim of this study was to examine the difference in acute postoperative pain intensity and adverse effects between patients who received intravenous patient-controlled analgesia (IV PCA) or patient-controlled epidural analgesia (PCEA) for pain control after live liver donation surgery. A retrospective chart review was performed of 226 consecutive patients who underwent right living donor hepatic surgery at the Toronto General Hospital, Toronto, Canada. Patients who received as their primary postoperative analgesic modality IV PCA (n = 158) were compared to patients who received PCEA (n = 68). Demographic profiles for the 2 groups were similar with respect to age, sex, and body mass index at the time of surgery. For the first 3 postoperative days, pain intensity was significantly lower in patients who received epidural analgesia (P < 0.01). Clinically significant moderate pain (defined as a Numeric Rating Scale pain score >4) was reported more frequently in the IV PCA group (P < 0.05) along with increased sedation (P < 0.05). Pruritus was reported more frequently in the PCEA group of patients compared to the IV PCA group (P < 0.05). Significant between-group differences were not found for the incidence of postoperative vomiting, the time at which patients began fluid intake, the time to initial ambulation, or the length of hospital stay. In conclusion, epidural analgesia provides better postoperative pain relief, less sedation, but more pruritus than IV PCA after live liver donation.

Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery.

This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence.

Cette déclaration de consensus fait des recommandations pour la prescription d'analgésiques à la sortie de l'hôpital pour les patients adultes n'ayant jamais pris d'opiacés et qui subissent une intervention chirurgicale non urgente. Elle encourage les prestataires de soins de santé (chirurgiens, anesthésiologistes, infirmières et infirmiers, infirmières et infirmiers praticiens, équipes antidouleur, pharmaciens, professionnels de la santé et stagiaires) à (1) utiliser des traitements non opiacés et à réduire la prescription d'opiacés afin de réduire le nombre de pilules opiacées pouvant être détournées; et (2) à éduquer les patients, ainsi que leurs familles et soignants, sur les options de prise en charge de la douleur après l'opération afin d'optimiser la qualité des soins pour la douleur postopératoire.Ces recommandations s'appliquent aux patients adultes n'ayant jamais pris d'opioïdes et qui subissent une intervention chirurgicale non urgente. Cette déclaration de consensus est destinée à être utilisée par les prestataires de soins de santé impliqués dans la prise en charge des patients opérés et les soins qui leur sont apportés.Un processus Delphi modifié a été utilisé pour parvenir à un consensus sur les recommandations. Tout d'abord, les auteurs ont procédé à une de la portée de la littérature afin de déterminer les pratiques exemplaires actuelles et les lignes directrices existantes. À partir de la littérature disponible et de l'expertise des auteurs, une liste provisoire de recommandations a été créée. Ensuite, les auteurs ont demandé aux principales parties prenantes d'examiner et de commenter plusieurs versions préliminaires du document et d'assister à une réunion de consensus en personne. Le groupe des parties prenantes du processus Delphi modifié comprenait des chirurgiens, des anesthésiologistes, des résidents, des fellows, des infirmières et infirmiers, des pharmaciens et des patients. Après de multiples itérations, le document a été jugé complet. Les recommandations n'ont pas été notées car elles étaient fondées sur un consensus plutôt que sur des données probantes.

Comparison of epidural and intravenous patient controlled analgesia in patients undergoing radical cystectomy.

OBJECTIVE: Postoperative analgesia is an important factor influencing surgical outcomes. We aimed to evaluate the role of patient controlled epidural analgesia (PCEA) versus intravenous (IV) patient controlled analgesia (PCA) in patients undergoing radical cystectomy. METHODS: We reviewed data from consecutive patients who had a radical cystectomy at our institution between 2003 and 2007 to evaluate the effect of either PCEA or IV PCA on the patients' postoperative pain--the primary outcome--as well as secondary outcomes including time to begin eating solid food, time to ambulation, and length of hospital stay. The patients received either hydromorphone or morphine via IV PCA, or bupivacaine and hydromorphone or ropivacaine via PCEA. Pooled t tests and Wilcoxon rank sum tests were used to compare outcomes. A mixed model regression analysis was used to compare pain scores. RESULTS: Data was analyzed from 131 patients to compare 73 patients (56%) who received PCEA versus 58 patients (44%) who received IV PCA. No significant differences in patient mobilization, progress to eating solid food, or length of hospital stay were detected, although there was a trend for earlier progress to eating solid food for patients in the PCEA group (p = 0.09). Using a mixed model analysis, we found no significant difference in pain scores at rest (p = 0.11). However, pain scores during activity were significantly lower for patients in the PCEA group, (p = 0.02), with a significant interaction effect (p = 0.03), indicating that the benefit with PCEA occurred in the early postoperative period. CONCLUSION: Our findings suggest that compared with IV PCA, PCEA for radical cystectomy patients can result in lower immediate postoperative pain during activity, with a trend to earlier progress to eating solid foods, but no shortening of hospital stay.

Incidence of urinary retention in patients with thoracic patient-controlled epidural analgesia (TPCEA) undergoing thoracotomy.

Up to 100% of patients treated with epidural analgesia can experience urinary retention, which may be related to dermatomal level of the epidural block, epidural medication, and surgical procedure. This study was designed to identify the incidence of urinary retention in patients who receive thoracic patient-controlled epidural analgesia (TPCEA) after thoracotomy. Forty-nine patients were enrolled and received epidural infusion of ropivacaine 0.2% or mixture of bupivacaine 0.1% with hydromorphone 0.015 mg/mL. Epidural catheter placement level was verified by chest X-rays. Indwelling urinary catheters were removed between 12 and 48 h after surgery when no longer required for fluid monitoring. Four hours later, patients were assessed for urinary retention using bladder ultrasound. Residual bladder volume was recorded, and urinary retention was defined as an inability to void or a bladder volume of greater than 600 mL at 4 h. Twenty-four hours after the catheter removal, patients completed a questionnaire to assess their perception of the indwelling catheter before and after its removal. Five participants (approximately 10%) with epidural catheters between T3 and T5 with bupivacaine/hydromorphone epidural solution were recatheterized. No association was established between catheter level, drug type, infusion rate, and urinary retention. Although 76% of patients did not report any physical discomfort with the indwelling urinary catheter, 66% felt relief after its removal and 18% did not ambulate with the inserted urinary catheter. The incidence of postoperative urine retention was low (10%), indicating that unless required for other purposes, indwelling urinary catheters may be removed between 12 and 48 h after surgery while receiving TPCEA.

In-hospital opioid consumption, but not pain intensity scores, predicts 6-month levels of pain catastrophizing following hepatic resection: A trajectory analysis.

BACKGROUND: The study aims were to model acute pain intensity and opioid consumption trajectories up to 72 hr after open hepatic resection, identify predictors of trajectory membership and examine the association between trajectory memberships and 6-month pain and psychological outcomes. This is a long-term analysis of a published randomized controlled trial on the impact of medial open transversus abdominis plane catheters on post-operative outcomes. METHODS: A total of 152 patients (89 males; mean age 63.0 [range: 54-72]) completed questionnaires on pain and related characteristics pre-operatively and 6 months post-operatively. Total opioid use was recorded several times over a 72-hr period while self-reported pain intensity scores were collected multiple times until hospital discharge. Analyses were carried out using growth mixture modelling, logistic regression and general linear models. RESULTS: Both pain intensity and opioid consumption showed that a four-trajectory model best fits the data. Patients in the lowest opioid consumption trajectory were more likely to be classified in the constant mild pain intensity trajectory. Age and baseline levels of anxiety significantly predicted opioid trajectory membership while baseline depressive symptoms significantly predicted pain intensity trajectory membership. Patients in the two highest opioid consumption trajectories reported significantly higher levels of pain catastrophizing at 6 months compared to patients in the other 3 trajectories (all p < 0.05). CONCLUSION: High consumption of opioids after surgery is associated with higher levels of pain catastrophizing 6 months later. Identification of patients within these trajectories may lead to the development of early interventions targeted to high risk individuals. SIGNIFICANCE: Differences in initial levels of opioid consumption and rates of change in opioid consumption shortly after surgery can help predict long-term psychological responses to pain. Identifying key characteristics associated with initial opioid consumption can lead to the development of cost-effective early interventions targeted to high risk individuals.

Opioid weaning and pain management in postsurgical patients at the Toronto General Hospital Transitional Pain Service.

BACKGROUND: The perioperative period provides a critical window to address opioid use, particularly in patients with a history of chronic pain and presurgical opioid use. The Toronto General Hospital Transitional Pain Service (TPS) was developed to address the issues of pain and opioid use after surgery. AIMS: To provide program evaluation results from the TPS at the Toronto General Hospital highlighting opioid weaning rates and pain management of opioid-naïve and opioid-experienced surgical patients. METHODS: Two hundred fifty-one high-risk TPS patients were dichotomized preoperatively as opioid naïve or opioid experienced. Outcomes included pain, opioid consumption, weaning rates, and psychosocial/medical comorbidities. RESULTS: Six months postoperatively, pain and function were significantly improved. Opioid-naïve and opioid-experienced patients reduced consumption by 69% and 44%, respectively. Forty-six percent and 26% weaned completely. Consumption at hospital discharge predicted weaning in opioid-naïve patients. Pain catastrophizing, neuropathy, and recreational drug use predicted weaning in opioid-experienced patients. CONCLUSIONS: The TPS enabled almost half of opioid-naïve patients and one in four opioid-experienced patients to wean. The TPS successfully targets perioperative opioid use in complex pain patients.

Contexte: La période périopératoire constitue un créneau déterminant pour s'attaquer à la consommation d'opioïdes, en particulier chez les patients qui ont une histoire de douleur chronique et de consommation préopératoire d'opioïdes. Le Service de la douleur transitionnelle de l'Hôpital général de Toronto a été mis sur pied pour s'attaquer au problème de la douleur et de la consommation d'opioïdes après une chirurgie.But: Présenter les résultats de l'évaluation du programme du Service de la douleur transitionnelle à l'Hôpital général de Toronto en mettant l'accent sur les taux de sevrage des opioïdes ainsi que sur la prise en charge de la douleur chez les patients n'ayant jamais consommé d'opioïdes et ceux qui en avaient déjà consommé.Méthodes: Avant d'être opérés, 251 patients à haut risque du Service de la douleur transitionnelle ont été séparés en deux groupes, l'un réunissant les patients n'ayant jamais consommé d'opioïdes et l'autres réunissant ceux qui en avaient déjà consommé. Les résultats portaient sur la douleur, la consommation d'opiodes, les taux de sevrage, ainsi que les comorbidités psychosociales et médicales.Résultats: Six mois après l'opération, la douleur et le fonctionnement s'étaient améliorés de manière significative. Les patients qui n'avaient jamais consommé d'opioïdes et ceux qui en avaient déjà consommé avaient réduit leur consommation de 69 % et 44 % respectivement, et 46% et 26 % d'entre eux étaient complètement sevrés. La consommation au moment du congé de l'hôpital prédisait le sevrage chez les patients qui n'avaient jamais consommé d'opioïdes auparavant. La catastrophisation de la douleur, la neuropathie et l'usage de drogues récréatives prédisaient le sevrage chez les patients qui avaient déjà consommé des opioïdes.Conclusions: Le Service de la douleur transitionnelle a permis le sevrage de près de la moitié des patients qui n'avaient jamais comsommé d'opioïdes auparavant et à un patient sur quatre parmi ceux qui avaient déjà consommé des opoïdes auparavant. Le Service de la douleur transitionnelle cible avec succès la consommation préopératoire d'opioïdes chez les patients souffrant de douleur complexe.

A case report on the treatment of complex chronic pain and opioid dependence by a multidisciplinary transitional pain service using the ACT Matrix and buprenorphine/naloxone.

In an era of growing concern about opioid prescribing, the postsurgical period remains a critical window with the risk of significant opioid dose escalation, particularly in patients with a history of chronic pain and presurgical opioid use. The purpose of this case report is to describe the multidisciplinary care of a complex, postsurgical pain patient by an innovative transitional pain service (TPS). A 59-year-old male with complex chronic pain, as well as escalating long-term opioid use, presented with a bleeding duodenal ulcer requiring emergency surgery. After surgery, the TPS provided integrated pharmacological and behavioral treatment, including buprenorphine combined with naloxone and acceptance and commitment therapy (ACT) using the ACT Matrix. The result was dramatic pain reduction and improved functioning and quality of life after 40+ years of chronic pain, thus changing the pain trajectory of a chronic, complex, opioid-dependent patient.

Chronic postsurgical pain and persistent opioid use following surgery: the need for a transitional pain service.

AIM: To identify the 3-month incidence of chronic postsurgical pain and long-term opioid use in patients at the Toronto General Hospital. METHODS: 200 consecutive patients presenting for elective major surgery completed standardized questionnaires by telephone at 3 months after surgery. RESULTS: 51 patients reported a preoperative chronic pain condition, with 12 taking opioids preoperatively. 3 months after surgery 35% of patients reported having surgical site pain and 13.5% continued to use opioids for postsurgical pain relief. Postoperative opioid use was associated with interference with walking and work, and lower mood. CONCLUSION: Chronic postsurgical pain and ongoing opioid use are concerns that warrant the implementation of a Transitional Pain Service to modify the pain trajectories and enable effective opioid weaning following major surgery.

Technology-Enabled Remote Monitoring and Self-Management - Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol.

BACKGROUND: Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT-VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom. OBJECTIVE: Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT). METHODS: CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise-death, myocardial infarction, and nonfatal stroke- all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups. RESULTS: Study start-up is underway and usability testing is scheduled to begin in the fall of 2016. CONCLUSIONS: Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.

Unit manager's role with family members of clients in complex continuing care settings: An untold story.

Most literature on staff-family relationships has come from studies of long-term care settings, has focused mainly on the families' perspectives on factors affecting their relationships with staff, and has included scant findings from the staff's perspective. No studies that examined staff-family relationships in complex continuing care (CCC) environments from the perspective of staff were found in the literature. A qualitative study that draws on a grounded theory approach was conducted to explore staff-family relationships in CCC, and the findings presented in this article illuminate the unit manager's role. Data were collected through in-depth interviews with nine unit managers and a follow-up focus group with five unit managers who work in three CCC facilities. Three categories reflecting the unit manager's role with family members of clients in CCC settings were derived: establishing supportive entry; building and preserving relationships; and closing the loop. Implications of the findings for practice and future research are presented.

The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain.

Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5-10% of patients one-year after major surgery. Substantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients' pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth.