The new pain control paradigm in outpatient surgery is shifting away from opioid-based analgesia and toward a more multimodal approach emphasizing peripheral nerve blocks. To highlight the efficacy of peripheral blocks, here are identical surgeries, performed by identical teams, resulting in two very different patient experiences.

A tale of two patients
Two patients present for shoulder arthroscopies and rotator cuff repairs. Both are healthy male adults. A general anesthetic is planned along with the option of placing a post-operative pain control nerve block. The first patient, Mr. Johnson, had the same surgery on his other shoulder last year, after which he suffered extreme pain and needed to be admitted overnight for pain control. He didn't have the option of a pain control block then and became instantly intrigued by the idea.

The intended interscalene block, you tell him, will result in numbing-type pain relief for 10 hours to 24 hours with the single-shot technique and several days of relief with the continuous catheter technique (pain pump). You tell Mr. Johnson that you'll administer a little anti-anxiety medication through the IV before you place a small needle in the side of his neck. The needle, you explain, is attached to a nerve stimulator that will make his arm twitch slightly during the placement of the block.

You discuss the procedure's risks, including the possibility of bleeding, infection, nerve damage and adverse reaction to the medication. Typical side effects include Horner's Syndrome, hoarseness and a numb diaphragm. Mr. Johnson eagerly agrees to the single-shot interscalene block.

As you remove the drapes, Mr. Johnson is gently awakened from general anesthesia and taken to PACU. He is immediately sitting upright and talking with the PACU nurses. The nurses assess his pain control and Mr. Johnson states that he has no pain except for a slight tickle in his throat; 35 minutes later, he is smiling, dressed, discharged and in his car on the way home.

The second patient, Mr. Smith, scheduled for the same surgery, is anxious and apprehensive. You prep him and advise him of the plan for a general anesthetic and offer a post-op pain control interscalene block. Because the block would require another needle, he adamantly declines the offer. Mr. Smith is taken to the suite and anesthetized.

The surgery is uneventful. He's taken to the PACU in a somnolent, barely arousable state. He awakens from anesthesia and relays a pain scale that uses a stream of unhappy expletives rather than numbers. Despite pre-op NSAIDs and the heavy use of narcotics during the case and in PACU, Mr. Smith's discomfort continues for most of his two-hour stay in recovery. After several rounds of different pain control drugs and the treatment of the associated nausea, Mr. Smith is finally somewhat more comfortable and deemed coherent enough to be discharged.

A peripheral plan
It was the best of times for Mr. Johnson; it was the worst of times for Mr. Smith. The take-home point is clear: All post-op pain control modalities aren't created equal and there's no one right way to minimize a patient's post-op pain. The key is to assess and determine which approach, selected from a wide array of options, will economically and efficiently provide the best possible pain control. Here are some key components.

Strategic preparation. Set the stage for your post-op pain control and peripheral nerve block program well before the patient reaches your facility. Instill surgeons and staff with the mindset that post-op pain control is one of the key components that will impact the efficiency of your organization and the satisfaction of your patients. Highlight the economic impact of extended PACU stays and the treatment of opioid side effects and compare them to the minimal additional costs you'll incur by using peripheral nerve blocks.

Quantify for your staff the cost of decreased patient satisfaction and the extended PACU time (to include nursing, pharmacy and supply costs) and contrast that with the marginal incremental cost increases and the greater patient satisfaction encountered with the placement of peripheral nerve blocks. Keep in mind, though, that a uniform value is nearly impossible to calculate; I've asked for and received five different amounts from the five centers at which I provide anesthesia.

Your anesthesia providers must have a proven track record of peripheral nerve block success in an outpatient setting. Each provider should have expertise in a wide variety of both single-shot and, if applicable, continuous-catheter techniques. Anesthesia firms that have experience with peripheral block programs also recognize that the programs, when properly implemented and with appropriate patient documentation, can result in increased anesthesia revenue opportunities. If a peripheral nerve block is employed and is not the primary mode of anesthesia - in conjunction with general anesthesia, for example - the provider can submit a separate bill for the block. That can amount to two hours of anesthesia time. Separate billing of blocks accounts for roughly 10 percent to 15 percent of my revenue. Your anesthesia firm should share your enthusiasm for the program as an opportunity for increased patient satisfaction and an enhanced revenue source.

Systems analysis. One of the greatest obstacles to the adequate use of peripheral nerve block techniques is the fallacy that the blocks will impede the progress of the schedule. Design your program so that it removes barriers and captures opportunities for efficiency.

Schedule cases to minimize possible delays due to the placement of blocks. Consider alternating cases in a manner that will provide built-in time for blocks to be placed. Their length will depend on the skill and experience of the anesthesia provider, but should average between five and 10 minutes.

Timely initiation of the blocks is critical and requires coordination with your anesthesia providers and staff. Consider the use of a dedicated block area where your staff can prepare the patient and place the block without delaying another procedure. Encourage your providers to develop strategies to decrease the possibility of delays and increase efficiencies within the center.

These strategies should include adequate and appropriate staffing levels to minimize the possibility of delays. Consider placing one anesthesia provider in each procedure room. Some facilities shy away from paying for extra providers, instead opting to have one jump from room to room when needed. That can be done, but the costs incurred by having a provider in each room will be offset by a more efficient surgical schedule. The full clinical utilization of each type of provider - including CRNAs - in the placement and management of the peripheral nerve blocks will increase flexibility, maximize efficiency and minimize delays.

Evaluation and results
Program realistic expectations regarding peripheral nerve blocks into every patient encounter before the day of surgery. Surgeons should discuss the options when scheduling the patient; staff should explain the techniques when completing the pre-op nursing and pre-certification process; and anesthesia providers should discuss the blocks in detail during the pre-op anesthesia visit. Celebrate and publish the successes and acknowledge the failures with plans for improvement.