Life Care Specialists (LCS) with a Focus on Multi-modal Non-Pharmacologic Strategies for Pain Control in the Aftermath of Orthopaedic Trauma

Principal Investigator: 

Mara Schenker, MD  | Grady Memorial Hospital, Orthopedic Center

Co-Investigators:

Alaina Steck, MD | Grady Memorial Hospital, Emergency Department

Briony Swire-Thompson, PhD |Northeastern University

Cammie Wolf Rice | Christopher Wolf Crusade

Elaine Miller-Karas, MSW, LCSW | Trauma Resource Institute

Research Gap:

Post-trauma pain management is centered on opioid pharmaceutical analgesia with little emphasis on individualized risk assessment including alternative methods of pain control.

Description:

Pain management following trauma continues to be centered around opioid pharmaceutical analgesia with little emphasis on individualized risk assessment for opioid use disorders, nonpharmacologic strategies for pain control, and early intervention by mental health/substance use specialists. To address this gap, we introduced a Life Care Specialist (LCS) as an integral member of our orthopaedic trauma clinical team, with a focus on “pain coaching” for trauma patients. The LCS is based on the Certified Child Life Specialists (CCLS) model, which when employed post surgically, has been shown to lead to increased patient cooperation, reductions in perceived pain, and higher patient satisfaction scores, and fewer opioid prescriptions. In a small pilot study, we demonstrated feasibility and operationalization of the LCS approach in a hospital setting and generated preliminary that demonstrate that the LCS approach increases patient satisfaction and may decrease opioid use. The goal of this study group is to determine which components of the LCS intervention contribute to effectiveness, whether LCS affects long-term abuse risk and overdose-related deaths, and ultimately, to nationally scale this for all patients receiving an opioid prescription. 

Aims:

  1. Evaluate the effectiveness of LCS intervention on trauma patients’ perception of pain and opioid utilization in the immediate aftermath of trauma.
  2. Evaluate the effectiveness of Life Care Specialist interventions on reducing long-term postoperative opioid medication utilization. 
  3. Explore the feasibility of utilizing actigraphy devices to capture postoperative functional outcomes among patients during their hospitalization and up to 2-weeks postoperatively following orthopaedic trauma.  

Why is this study important?

To validate the role of life care specialists for expansion to other sites as clinical standard of care.

Updates and Results
  • Final analyses included 129 participants with complete follow-up data at 3-months with 57 in the control and 72 in the intervention group. The intervention and control groups were well balanced and similar across demographic and clinical characteristics at baseline. Approximately half the sample identified as female (55.8%) and African American or Black (72.9%). A quarter of participants were uninsured (24.8%).  
  • Among the participants randomized to work with a Life Care Specialist, 88.9% reported improved pain scores at 3-months postoperatively compared to participants randomized to the control arm, 73.7% (p=0.035). This translates to participants in the intervention arm having 2.86 higher odds ratio of reporting improved pain compared to the control group (95% Confidence Interval: 1.14-7.67) (p=0.029).  
  • Among those in the intervention arm reporting an improvement in their pain, 88.9% reported their pain improved by 2 or more points, a commonly used minimal clinically important difference (MCID).
  • Of those enrolled, 80% report that the education they received helped them understand the risks and side effects of the pain medication they were discharged with. Additionally, 85% of participants report that resources and training provided to them by LCS were helpful.
  • Participants in the intervention arm were discharged with lower opioid prescription doses, 25% less morphine milligram equivalence daily, than participants in the control arm, however this difference was not statistically significant (p=0.462). 
  • No statistically significant differences were observed in opioid medication utilization.
  • The sample included 145 patients who wore wrist actigraphy devices throughout hospitalization with a high degree of compliance, with an observed average wear time of 70.75% (±25.43).
  • Patients were hospitalized for a median of 4 nights with an average of 3 (±2.97) sleep periods observed.
  • Approximately 15% (N=21) of patients were not observed sleeping at all during hospitalization, with the majority of those patients admitted for only one day (n=11).
  • Among the patients who did sleep during hospitalization, average sleep duration was highly variable at 6.1 hours (±4.2 hours). Sleep was also very fragmented, evident by an average of 8 awakenings per sleep and an average SFI score of 28.39 (±17.06).
  • Regression modeling indicated that higher opioid utilization was associated with more fragmented sleep, with each incremental MME increase associated with increasing Sleep Fragmentation Index, when adjusting for pain score (β=0.02, p=0.0257).
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