MUST SEE Anesthesia fellow Brianne Owens, MD, (center) places an ultrasound guided block while Andrews Institute providers and visiting physicians watch her progress.

The world-renowned Andrews Institute ASC in Gulf Breeze, Fla., the winner of this year's OR Excellence Award for Pain Control, has been tracking its use of post-op opioids and routinely challenging its anesthesia providers to keep that use low. How low? Since recordkeeping began in 2010, fewer than 10% of its patients have received opioids in PACU.

Andrews Institute staff began collecting data on the use and comparative effectiveness of opioids to prove a point. "Our consultant pharmacist was the inspiration," says Barbara J. Holder, RN, BSN, LHRM, the ASC's QI and infection control coordinator. "He did not believe how little we were ordering narcotics, especially since we have 8 ORs. He'd say, 'You guys aren't ordering enough.' Then he'd look at our charts and say, 'Are you guys giving enough?' He wondered if we were charting correctly."

Verbal assurances that patients were comfortable upon discharge were not enough. The pharmacist challenged them to prove it with statistical data. The resulting outcomes study demonstrated the effectiveness of regional blocks in keeping pain under control as well as reducing the need to administer opioids in PACU. Over time, that continuing review has shown a significant trend: between 2010 and 2014, only 9.78% of patients have received post-op opioids. "Our patient census is about 550 a month," says Ms. Holder, "and of those, on average, 55 to 70 patients get narcotics."

This proof hasn't been cause for resting on laurels, however. "We keep tweaking," says Ms. Holder. "How can we do better, based on the numbers we see?" As opioid use data are gathered from daily chart audits and automated drug dispensing system records, the goal is to keep these numbers low, to maintain control over and decrease patients' post-op pain.

At Andrews, they even analyze opioid use by specific service or type of surgery. "Whenever anything falls out, QI can take a look and give feedback to anesthesia: Do we need to work on this?" says Ms. Holder.

MAN WITH A PLAN "Regional blocks are a huge part of an ambulatory center's success," says Gregory Hickman, MD, medical director and director of anesthesia at the Andrews Institute.

Alternative approach
How do Andrews' anesthesia providers meet QI's challenge to keep pain and opioid use down? A lot of the credit goes to regional anesthesia. "Regional blocks are the primary foundation of a multimodal approach," says Gregory Hickman, MD, the center's medical director and director of anesthesia. "Our orthopedic surgeries rely heavily on blocks. They make recovery faster, without nearly as much narcotics. Blocks mean less nausea and fewer side effects." In short, he says, "Regional blocks are a huge part of our ambulatory center's success."

By their own count, Andrews' anesthesia team has administered 20,253 blocks between the center's 2007 opening and this past June, for an average of 300 a month. But regional isn't the only route to effective post-op, non-opioid pain control. "Blocks are the way to go, but if you can't give a block, we have protocols set up for alternatives," says Ms. Holder.

A 1,000 mg dose of IV acetaminophen was standard for a range of procedures, she says, until the manufacturer was acquired by a larger firm and the product's price doubled, after which the center switched to an equivalent oral dosage. The anesthesia providers' pain management toolbox also includes the analgesic gabapentin (300 mg orally), the steroid dexamethasone (for its anti-inflammatory and anti-nausea effects) and local anesthetics (both single-shot and continuous catheter infusion pumps), among other options for reaching different pain receptor sites.

Dr. Hickman notes that he and his staff are not opposed to the use of opioids when they're necessary, and on occasion they are. For example, sinus surgeries, tonsillectomies, adenoidectomies and other ENT cases can be quite painful, but there's no regional block for the head. And opioids are an effective remedy when a blocked patient suffers breakthrough pain.

"Five or 6 years ago, we didn't want patients to have any narcotics, zero," he says. "Now, we don't mind giving them a little. Small doses are fine, we just want to keep them small. If we can limit their use, we don't have to totally avoid them."

Spreading the word
The center's 2015 year-to-date opioid administration rate is 12.3%, and Dr. Hickman says he's pleased with that. "In a hospital, it's probably 95%. In a lot of ASCs, it's 60 to 70%." And these efforts have attracted notice from peers as well as patients.

"Blocks are a great patient satisfier," says Ms. Holder. "We've found that people have researched Andrews and our use of blocks. They want them." Adds Dr. Hickman, "We quickly got a reputation for less pain. The word of mouth has been incredible."

He and his anesthesia colleague Brandon Winchester, MD, have made it their mission to bring blocks and improved recoveries to a wider audience of patients (see "Mastering Adductor Canal Blocks" on page 86). Nearly every week the Andrews Institute ASC hosts observing physicians and nurse support teams from across the country and around the world to teach them ultrasound-guided regional block techniques.

"They leave ready to get more consistent, more predictable results," says Dr. Hickman, and this improvement is always welcome in every surgical facility. "Regional is still way underutilized in this country."

— David Bernard