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Penn Nursing, Medicine Collaborate to Improve Post-surgical Pain Management in China

Between 60 and 70 percent of patients who undergo a thoracotomy, or a surgical incision into the chest wall, experience some sort of long-term, post-surgical pain. So that patient population was a natural fit for a study focused on pain management, led by the University of Pennsylvania and taking place at Peking Union Medical College Hospital and Peking University People’s Hospital in China.

“It’s a surgical population most at risk for developing chronic pain,” said Rosemary Polomano, PhD, RN, FAAN, associate dean for practice and a professor of pain practice at Penn Nursing, with a secondary appointment in anesthesiology and critical care at the Perelman School of Medicine.

Together with Penn’s Joshua Atkins, MD, associate professor of anesthesiology and otorhinolaryngology, Renyu Liu, MD, PhD, associate professor of anesthesiology and critical care, and Regina Cunningham, PhD, RN, FAAN, chief executive officer at the Hospital of the University of Pennsylvania and an adjunct Nursing professor, Polomano began what would become this project, aimed at helping the two Chinese facilities develop a new system, using evidence-based guidelines, for how patients progress and receive care following this type of operation.

The collaboration is one of the inaugural group of projects funded by the Penn China Research and Engagement Fund, or CREF. Penn Global launched the fund in 2015, highlighting the opening of the Penn Wharton China Center in Beijing to support, encourage and strengthen existing, institutional and faculty-to-faculty relationships with Chinese partners and to provide professional consultation. CREF is a five-year, $10 million program that matches financing for projects that “stimulate and support activity in China.”

In 2016, Polomano’s group hosted eight visiting scholars from the two Chinese institutions to attend a three-week immersion experience focused on pain care at Penn. This coming summer, a seven-month study will begin at those hospitals, asking health care providers to collect data on length of stay, 30-day readmissions, nurse adherence to monitoring protocols and other key clinical practices.

“This study is new for them because they haven’t been looking at patient outcomes in the same way that we do in the States,” Polomano said. “Part of the project is to strengthen inter-professional collaboration by engaging health care professionals in routinely collecting pain outcomes on their patients. It’s all focused on perioperative pain management.”

Such a collaboration likely wouldn’t have been possible without legwork from Atkins and Liu. In 2008, they co-founded the Penn-China Anesthesia Partnership Program, which they still run today. For the past decade, they’ve been working with colleagues in eastern Asia to increase international academic teamwork, particularly in the field of anesthesia, said Liu, who was an anesthesiologist in China before he came to the States and Penn.

“For this program with Rosemary, we’re trying a new approach to promote pain management in China,” Liu said. “Pain management in the United States is more multi-disciplinary. Some areas of pain management in China may be more advanced than that in the U.S., but in general they are still a little behind. They are catching up.”

Atkins said now is a great time for such a partnership, too.

“If you want to get engaged but the other side isn’t open to that, marching in and trying to tell them how to do something isn’t usually successful,” he said. “But the Chinese are very open to engagement, and we can learn from them in the same way we can teach them.”

For this project, the teaching began with that early-2016 visit, during which four people each from Peking Union Medical College Hospital and Peking University People’s Hospital attended a five-day course called “Pain Science and Practice.” They also spent more than 50 hours training with health care practitioners at HUP and Penn Presbyterian, and experienced a system based around inter-professional practice.

“Its nurses working with nurse practitioners working with anesthesiologists and pain experts working with surgeons working with physical therapists and so on,” Atkins said. “It’s all disciplines and professions working together. [Currently] China has more of a siloed, hierarchical system.”

The point, however, isn’t to make a round U.S-centric peg fit into a square Chinese hole. Rather, it’s to help health care providers determine what’s most effective for the conditions under which they work.

On site there this past November, Polomano helped the hospitals develop an institutional review board protocol. Once approved by each Chinese institution and Penn, the study can officially begin. Polomano said she plans to return to China in May to ensure everything is in order, and then in July, one of her students will go there to offer instruction and guidance on the forms and paperwork necessary to complete the data collection.

“The [study] design is to hit the ground running,” Polomano said.

Ultimately, she said the plan is for three phases, each spanning 50 to 60 days and including 50 patients. “In the final phase, I’m expecting to see the best outcomes,” she added.

The Penn team will help the Chinese researchers analyze the study results. Then it will be up to Peking Union Medical College Hospital and Peking University People’s Hospital to continue the practices, what Polomano describes as preventive multimodal analgesia, a strategy involving careful planning of which drugs to give when and at what dose, to keep pain at bay. The goal is lower dosing of more medications to lessen overall side effects.

“It means starting it early, keeping it going, until the patient’s pain has fully resolved,” she said.

Polomano has implemented such a system before, at a hospital in Botswana’s capital city of Gaborone. Nurses there learned how to better monitor patients and practitioners were enthusiastic about the process, but beyond the short-term, the practices didn’t carry forward.

This time around, however, Polomano suspects outcomes might be different because of the positive reception, enthusiasm and progressive mindset of the Chinese hospitals’ thoracic surgeons and anesthesiologists. “They [already] use multimodal analgesia,” she said. “The recipes for how to put these drugs together could just be better aligned with the evidence. That’s the purpose of this study.”

CREF funding for this work began in 2015 and extends for two years or longer, until project completion.