The Role of the Advanced Practice Provider in the Acute Care Setting

Author: Theresa Mallick-Searle

Millions of patients each year suffer from acute pain as a result of trauma, illness, or surgery, and pain is the most common reason for presentation to the emergency department. The prevalence of intense acute pain is similarly high among patients undergoing surgery: in the United States, over 73 million surgical procedures are performed annually, and most patients report experiencing a high degree of pain postoperatively. Studies indicate that treatment of acute pain remains suboptimal due to attitudes and educational barriers on the part of clinicians and patients, as well as the intrinsic limitations of available therapies. Inadequate management of acute pain negatively impacts numerous aspects of patient health and may increase the risk of developing chronic pain. This article reviews the role of the advanced practice provider in the acute care setting, focusing on the use of preemptive and multimodal analgesia; imparting an understanding of the importance of identifying patients at risk for poor outcomes regarding pain management in the acute care setting; and helping educate the clinician about tools available for improved pain management outcomes in the hospitalized patient.

There has been much emphasis, recognition, and education on the public health issue surrounding undermanaged chronic pain in the United States. In addition, there has been much reported about the economic impact of undermanaged pain. What is less recognized or emphasized is the impact of undermanaged pain in the acute care setting. A landmark study of the impact of acute pain management in the hospitalized patient over a 10-year period revealed that improvement in pain management has not kept up with other advances in healthcare: reports of “any pain” and “extreme pain” were reported as higher. Pain continues to be a prevalent problem for medical and surgical inpatients. Additionally, Pletcher et al found in their research that 40% of the over 100 million emergency department (ED) visits annually are for acute pain.

The reason for undermanaged pain in the acute care setting is multifactorial. To avoid it, the advanced practice provider (APP) who delivers primary care to the patient in the acute setting—OR, ICU, infusion center, medical/surgical in-patient setting, ED—needs to have a general understanding of basic pain pathophysiology, pain pharmacology, and an appreciation for behavioral management as well as mind-body therapies. APPs working in trauma, oncology, palliative care, and surgery also need to have an awareness of regional analgesic techniques and therapies—a basic understanding of the peripheral and central nervous system is necessary. What must be avoided is providers’ insufficient knowledge of pain pharmacology and other treatment options, fear of medication side effects, not setting expectations or discharge planning, and inadequate initial identification of patients at increased risk for poor outcomes.

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