The benefits of peripheral nerve blocks are many: better outcomes with less post-op pain and nausea as well as improved surgical efficiencies and patient throughput. But they're not automatic. To maximize the benefits of blocks at your facility, follow this advice to make your regional anesthesia program a model of efficiency.

1. Check the charts. To maximize the time-saving benefits of regional anesthesia, you must prepare days before the block is performed. Have your staff review patient charts for any medical issues that might warrant a switch from regional to general anesthesia. For example, patients who are on blood thinners, such as Plavix or Coumadin, should stop taking those medications 7 to 10 days before a block is to be performed. Patients with a history of severe chronic obstructive pulmonary disease or those who have undergone major cardiac procedures, such as valve replacements or bypass surgery, may not be good candidates for certain types of blocks.

None of these conditions will automatically dictate that you switch to general anesthesia, but checking charts ahead of time lets you call patients, spend some time getting additional information about their conditions and settle on the best anesthesia plan — all before they walk through your doors. That saves time on the day of surgery, and also familiarizes your nurses and anesthesia team with each patient's history.

2. Confirm the plan. During pre-op interviews with patients, your nurses should go over the anesthesia plan and make sure patients understand they're getting a nerve block and exactly what that entails. Even if the surgeon has informed them ahead of time, patients are often confused about how regional anesthesia works.

We tell patients that we'll be numbing their extremity and that while they won't be completely under general anesthesia, they'll be sedated during the case. Some patients don't want to hear the drills and saws, they'll tell us. We reassure them that they'll be sedated enough not to hear and that the nerve block will alleviate post-op pain, nausea and vomiting. This often quells any fears, but in the rare case, we may have to honor a patient's wish to have general anesthesia instead. The sooner you can resolve these issues, the sooner you can proceed with the case.

3. Organize the supplies. After starting the patient's IV, gather the equipment and supplies needed for the block. While leaving the patient hooked up to the pulse oximeter and with the blood pressure cuff on in anticipation of the block's placement, set out the following items:

• nerve stimulator and/or ultrasound machine;
• EKG electrode for the nerve stimulator, if you use one;
• needles for performing the block;
• gloves;
• skin prep (we use a betadine swab stick);
• pen to mark the site; and
• some 2x2s so you can apply pressure and prevent hematoma formation.

As you're setting up these supplies at the patient's bedside, explain what the supplies are used for and how they'll help the patient feel more comfortable after surgery. This is also a good opportunity to begin educating patients about how they should handle pain management after the procedure (more on that later).

4. Clear the OR. At our facility, we perform blocks in the pre-op bays. If you have a designated area or room set aside just for blocks, that works, too. Per-forming blocks outside of the OR enhances efficiency because the anesthesia team can begin blocks on the next patient while the previous case is being wrapped up and the OR is turned over. Ideally, you should be able to wheel the patient directly into the OR as soon as the block is set.

As soon as your surgeons complete a case, have them go directly to pre-op, visit with the next patient in line and mark the surgical site so the anesthesia team can get started on the block.

5. Sedate the patient. With the surgical site marked and the regional supplies laid out, the anesthesia team should arrive at the block area with relaxing medication (usually midazolam and fentanyl) and a local anesthetic drawn up and ready to be administered. Once the anesthesia provider has confirmed the surgical site and finished prepping the patient, let family members at the patient's bedside say their goodbyes and usher them back to the waiting room. You don't want them hanging around while you perform the block, as they might become a distraction or faint when they see their loved one being injected.

6. Train the providers. As long as your anesthesia providers have had a chance to learn regional anesthesia techniques in their residency programs and perform blocks in other practice settings, they should have enough proficiency to perform blocks relatively quickly at your facility. However, providers who are new to the technique need to see blocks being performed, perform some under supervision and receive additional training before they begin doing them regularly at your center.

The American Society of Anesthesiologists sponsors regional anesthesia workshops that can be great learning experiences for your anesthesia team to brush up and enhance their skills in performing blocks efficiently. Our anesthesia providers don't use ultrasound guidance to help identify nerves for block placement, but if your providers learned to perform blocks using such guidance, you may want to consider investing in the technology (see "Dual Guidance: Regional Anesthesia's Win-Win" at www.outpatientsurgery.net/issues/2010/07).

7. Pre-empt the pain. While the block is going to keep patients from feeling much pain during, be sure to warn them that it will wear off eventually, and they must follow their post-op instructions faithfully to avoid waking up in the middle of the night with severe pain.

We advise our patients both in writing and in repeated verbal communication before they leave for home to take their pain medications before the onset of pain, as it will take a bit of time for the medication to work, and it's easier to pre-empt pain than to play catch-up. Having clear written and verbal post-op patient instructions also helps avoid follow-up phone calls from patients in pain, thereby securing both patient and physician satisfaction with the outcome of the procedure.

Smooth recovery
Nerve blocks provide patients with the pain-alleviating benefits of pre-emptive analgesia without the uncomfortable side effects associated with general anesthesia that often keep patients in your facility long after a surgery has been completed. Blocks have contributed to the overall efficiency and throughput of our 2-OR facility by expediting patient recovery times. We only have 4 PACU beds and no step-down area, so any discharge delays can quickly clog the whole system. By employing nerve blocks for a majority of our orthopedic procedures, however, those delays are few and far between.