Episode 5: The Role of the Surgical Nurse in Opioid Stewardship

Opioid Conversations with Surgeons

Christine Schleider:

Thank you, Judy, Kathy, and Lee, for being here today. I appreciate the opportunity to get together and talk about this very important topic of surgical opioid stewardship. The climate today around surgical prescribing is so different than it was when we all started as nurses. As surgical nurses, we were the ones who took care of patients before surgery and after surgery, and who prepared them for surgery. We were involved in all phases of patient care. And, we helped treat their pain. So, let’s think about opioid stewardship now, in 2022.

I think we’ve all struggled with patient communication at times, during our careers. For this surgical opioid stewardship program, we’ve developed different brochures. There are videos we can show to patients. Can we talk a little about patient communication? Especially when we’re short on time, what’s the best way to get a message across to a patient?

Lee Holman:

Having the surgeon tell them. If the surgeon sets the expectation, that's sort of the highest bar, the gold standard.

Judith DellaPorta:

And I also think having a family member there when you discuss pain management. We've all been there where the patient's yelling in pain, the family member is yelling at you… So, if the family knows ahead of time that it's not going to be perfect post-op, but we're going to try and do everything we can to manage this, I think they can reinforce to the patient sometimes that you'll get through this.

Kathleen Shindle:

That's so true. I think in that pre-op education with the family involved and also maybe setting some guidelines such as, "I'd like you to walk today every day before surgery for 30 minutes," or "I'd like you to do this." So that you have some kind of guideline, not just to say, "Okay. I want you to walk more or I want you to do what do you normally do." And asking a patient, "What can you do that you think that could increase your mobility?" and then say, "Well, do you think you could walk maybe 30 minutes today?" And go from there.

And I also always like the statement, "And I also want you to bring your sneakers.” So that way that gives that patient the thought in their mind, "Oh yeah. I got to get up out of bed. As soon as I have my surgery… that's a good thing they're going to expect me to get up." I think you have to really weigh how we say to a patient, "You're going to have pain." Try to make it more... Turn that into more of a positive, right? "You might have some pain. This is what you can do to...

Christine Schleider:

A lot of patients and even people that I know and family members, when they need to have a hip replaced or a knee replaced, they put it off for so long because they're so afraid of the pain that they're going to have afterwards. And so many people always say afterwards, "I shouldn't have waited this long. I should have done it sooner."

Lee Holman:

Yep.

Judith DellaPorta:

And I think with the advent of minimally invasive surgery, that's just going to get better and better and better and better. So hopefully, pain won't be as difficult to control for these patients.

Christine Schleider:

So, what we’re talking about here is communication and honesty.

Judith DellaPorta:

I think it's important to have a conversation even preoperatively in the surgeon's office and be open and honest with them that, "You will have pain. We will try our best to relieve it to the best of our capabilities." And, you're working as a team, and you're going to help them get through this. I think that supports them and gives them some confidence going into the surgery.

Christine Schleider:

Judy, I agree. Pre-op, I think, is very important to reach out to a patient or even at the time of getting ready for surgery in the surgical clinic… having a whole conversation and education session about the expectations of pain. You're going to have discomfort, but you're going to be able to do all the things that you need to do to help you recover."

Judith DellaPorta:

I think the appendectomies, the choles, they really come down on our opioid discharge medication. But patients that have major abdominal surgery, major vascular surgery, they have acute pain and it needs to be relieved. So, I think we have to look at this individually—you have to look at every patient. They're all different. They’re not just a surgical patient. So we have to take a lot into consideration and make sure that they are getting what they deserve.

Kathleen Shindle:

And knowing their history. I think we all need to know, "Does this patient have a history of opioid use or abuse and is pain service on board? Is this someone that maybe should have a pain consult prior to surgery?"

Judith DellaPorta:

I know what we're doing here is anybody who's opioid tolerant is seeing anesthesia preoperatively, and they're making up a plan for the postop care. And I remember when I was a PACU nurse, we dreaded getting an opioid-tolerant patient. And because they stopped their opioids before they came in, it was terrible what some of these patients went through. Now that has changed and that's all for the good.

Kathleen Shindle:

For me, coming from an orthopedic unit of 27 years as a nurse, working with our data and also as a nursing supervisor for 14 years on the weekend, working with patients. I always feel nurses are an advocate for the patient, whether it's for pain medication or something else. And when I first started, patients were actually on pain medication for a while. Now, as nurses, we can advocate more for that multimodal. We're more educated on opioids. And I feel now we can better take care of our patients, just being that cheerleader, educator, and keeping a great rapport with the patient's surgeon. And I think looking at the patient as a whole, knowing their history, what is going on with that patient? What is that size of that patient? Are they really receiving the amount of pain medication? Are they receiving too much, too little? So there’s just a lot to me as a nurse that we can do to help out in the healthcare system.

Lee Holman:

I think you also have to have a conversation with your patients when you're on the floor, instead of just sort of throwing the maximum dose at them, asking them, especially if they've already had some pain medication and have gone through maybe one physical therapy session. Ask them and look at the chart, "What did you take last time? Did it work for you? Did it not work for you?" We also have a problem around here with a lot of elderly patients don't want to take pain medication because they're so fearful of becoming addicted. And so you have to really counsel them because there's so much misinformation out there, you have to give them good information.

Christine Schleider:

Lee, tell us more about that. You have relevant teaching experience, were there any tactics you used in teaching nurses about opioids that you think were particularly effective or useful?

Lee Holman:

I was a nurse educator for a while, sort of bounced around a bit. I was the pain teacher guy. And what I did was I actually, it was like 2018, probably 2017, 2018, the height of the opioid epidemic. I had the whole first row of the class, each one of them set a timer for eight minutes. And then when that alarm went off, I had the person next to them put on their timer. And in about an hour, you'd rip through about nine people. And at that point, once every eight minutes, somebody was dying… was dead from an opioid overdose. So I tried to say, "Since we've been talking, this many people have died. Be aware that without educating patients, you could send them down this road. You would never know it because they probably end up overdosing after they were out of your care."

Christine Schleider:

I bet that was a powerful lesson. I’m sure it really affected how those nurses thought about pain management in their day-to-day interactions. Are there any personally stories any of you can share about being a patient in pain? Has anyone been on the receiving end of wonderful or terrible patient management practices?

Kathleen Shindle:

I will talk about a positive experience. A year and a half ago, I had emergent surgery on an incarcerated hernia that caused a small bowel obstruction. It was emergent. I was actually working the weekend. I ended up in the ED and ended up 12 hours later having surgery at our hospital. And I had excellent care all the way through, but one of the important things that they did for me, they did it for all patients, so it wasn't just me, is that on the board, they put when I last had the pain medicine. And so that if I woke up and I saw, I feel okay, I have another hour or two, I'm going to try to push that a little bit further just to see. And I just thought that was great, ideal for me. And I could see, "Okay. Let me push it a little bit." I didn't want to take it every three hours. I was in a lot of pain after surgery I have to say I was fortunate, but this floor, I think, also does it for all their patients, from what I can see.

Christine Schleider:

I had surgery years ago and it was a major surgery and I was prescribed an opioid and I had no real education about it. And about three days later, I decided on my own that I was going to stop taking it and start taking Tylenol. And I felt weird. I had this weird feeling. I remember calling my husband saying, “I don’t feel right.” And he’s like, “It’s probably because you stopped taking the opioid.” And I got scared. I got really, really scared - Oh my God, I don’t want to be addicted.

Lee Holman:

I don’t recommend being hospitalized for anybody, but as a nurse, you can learn a heck of a lot if you spend a little bit of time in the hospital.

Christine Schleider:

Yeah. Agree.

Lee Holman:

I’m sure Kathleen learned a lot.

Kathleen Shindle:

Oh yeah. I had a nurse that was my age actually. And I remember back in my day, nobody could say no about getting out of bed. Now you’re getting out of bed. And she said to me the next morning, “Well, if you want your breakfast, you’re going to sit in that chair.” And then she walked out of my room, and I was like, “well, I want breakfast, but I really want to sit here in bed, I just had surgery less than twelve hours ago!” And guess what? I got in that chair because I wanted to eat. She was good; she was excellent.

Christine Schleider:

Kathy, it seems like you already were comfortable with the idea that some pain is normal and acceptable. That’s a relatively new way of thinking about pain and recovery.

Judith DellaPorta:

I was a young nurse and a case came out of California. The patient sued for multimillion dollars, because the family member didn't get adequate pain control. So that started an era of, you gave your patients lots of opioids. They had respiratory depression. They had to be monitored. They were in the hospital for a long time. And now, everything obviously has changed; the pendulum has definitely swung and I hope we're on the upswing of pain control and opioid control for patients.

Christine Schleider:

Everybody jumped on the bandwagon and all the governing bodies said, remember the Joint Commission and the American College of Surgeons and everyone just said, "Pain is the fifth vital sign. We have to manage the patient's pain” and opioids were the only intervention for that as far as my experiences. We believed based on what they were telling us that the risk of addiction was rare. And then we told our patients that: "Oh, make sure you take your Percocet as directed. Don't skip any doses, because once the pain gets ahead of you, it's harder to control it. So, make sure you take it, you'll be fine. You won't get addicted." It's crazy. It's sad.

Kathleen Shindle:

I know when I started Percocet with orthopedics, Percocet and Tylenol #3 were usually the drug of choice. And then they felt that was too addicting. And then they went to oxycodone. I think they would give you like 30, 40, 50 pills when I started. And I think now the decrease now, if someone goes home, they're going home with anywhere from 6 to 10 tablets, which I think is going to make a big difference. It’s not that maybe a patient doesn’t need an opioid, but it’s actually for a very short time. And then knowing how to dispose of them, how to get rid of them properly and safely is important.

Christine Schleider:

I think that's a big deal.

Judith DellaPorta:

And I think the surgeons, I think they're definitely coming around. My daughter had her wisdom teeth pulled and he ordered her 60 Percocet. And I'm like, "What?" We didn't even fill it. I guess their radar is not up yet about the consequences of this, but hopefully the surgical practices… it will move on to the dental practices.

Kathleen Shindle:

I started nursing in 1980 at Jefferson in the orthopedic unit and there was one physician who, upon discharge, would not give an opioid and that was back in the 80s because of the feeling he didn't want to get in trouble for a patient becoming addicted to an opioid. So, the patients were never happy and very upset when they left. And there was no talking to the physician at that time.

It's more open now. I think there’s better communication between nursing and physicians now. And at times, I am called to go up to talk to a patient on the weekend because the nurse will call me and say, "The patient's very upset. They're not getting pain medication, they're not getting enough medication." So, again, I talk to the patient. I'll talk to the physician. I'll look at the patient's history. And then we have a conversation.

Christine Schleider:

And I feel like part of that, not to scare a patient, but it should be part of that education: You're going to feel these things, and you're going to have constipation, or you're going to have all these side effects from taking opioids. And that's another reason why we want to try to manage your pain with maybe alternating Tylenol and Advil and ice packs and whatever else."

Lee Holman:

We, at one point, had a nurse that is also certified in Reiki. And so she would be more than willing to go in and do that. And that worked really, really well with our patients.

Kathleen Shindle:

I think there’s so much more we can do other than medication. But to have that resource, how do we do that. I mean, I would be someone who would love music. Who wouldn’t want a massage. There’s so much I think we could add to assist with someone’s pain management.

Judith DellaPorta:

We do have therapy dogs here go to the rooms, which is very nice, really nice puppies. And it's really nice.

Kathleen Shindle:

Yeah. We had that too. Judy, we do have that.

Christine Schleider:

Let’s end with one last question. Let’s talk about the future – how do we prepare our nursing students and medical students for the future… how do we make sure they understand the impact of surgical opioid stewardship? And, what’s the bigger picture?

Kathleen Shindle:

Probably, Christine, as we have done in the past. We did education, what I call, for nursing students. And as I was listening today, I was thinking, "Wow. What a great topic to actually reach out to the nursing school to talk about." And it could even be all of us. But I was just thinking that when we talk about nursing students, med students, and all that, that would be a great topic as we did with pulmonary complications. And we talked about ICOF and getting patients out of bed and preventing complications, but I just think we need to get into the schools somehow.

Judith DellaPorta:

I think in the bigger picture, if the hospital staff is cohesive and happy and has some quality of life and has some decision making over their schedules and they feel good about coming to work and taking care of their patients, that is all going to be a good thing for the people they're taking care of. So I think it’s very complicated and complex, and I think we need to try to figure it out.

Christine Schleider:

I want to thank all of you for joining today’s conversation on the surgical nurses’ role in opioid stewardship. We all are surgical nurses, but have come from different organizations and have different experiences. And I think it’s made for a great discussion today. We covered a lot of topics, so I would like to take a moment to summarize the key points I heard.

First, we talked about the many changes in surgical care over the years and how that’s affected the way that pain is managed, including shorter lengths of stay in the hospital after surgery, the shift from giving opioids liberally to now giving opioids cautiously, and the other types of pain management strategies that we’re now using. We also talked a lot about the important role of surgical nurses in communication with patients and families, such as helping to set expectations about pain, including families in our discussions; beginning to talk about pain management pre-operatively; knowing that each patient’s pain is different and requires different interventions; and lastly, we shared our own stories about surgery and how that’s helped us become a better advocate for patients.

I really enjoyed today’s conversation; I hope you do too!