It was early on during the launch of our facility's orthopedic program when we recognized the importance of relying on regional anesthesia to ensure patients go home sooner, recover more effectively and experience less pain and nausea.

About a decade ago, a group of our surgeons, anesthesia providers, nurses and physical therapists collaborated on how to best manage the pain of orthopedic patients. We created a nurse-led team that makes sure nerve blocks are administered consistently, safely and efficiently.

The block program has been a boon. Surgeons prescribe fewer opioids to manage post-op pain and patients who have had previous surgeries without regional anesthesia are often astounded at the difference a nerve block makes. The number of patients who request blocks and the number of blocks we place have increased each year, and we're now looking to expand their use beyond orthopedic patients to general abdominal, gynecological and breast surgeries. We've learned that a multimodal pain management plan will improve orthopedic outcomes and increase patient satisfaction if it's built on these 5 pillars of nerve block success.

1. Facility-wide buy-in
To make a regional anesthesia program work, be as inclusive as possible of all the staff across the many disciplines who are involved, including, nurses, anesthesia providers and surgeons. You need to create a united, team atmosphere.

Your surgeons might push back against your efforts to standardize the block-placing process in a dedicated procedure room, preferring instead to place the blocks in the OR. They might even want to avoid blocks altogether, thinking the time it takes to place blocks will delay the start of their cases. That's OK. A very important part of establishing a successful block program is to acknowledge and address each surgeon's concerns, preferences and needs. Assure them that a well-run block program can actually increase overall surgical efficiencies.

Our nurses are trained on how to use ultrasound machines, nerve stimulators and other equipment needed to place blocks. They also have significant training in pain management, and acquire competencies in administering sedation.

The importance of maintaining patient safety, particularly after a nerve block, is one of our prime concerns. Communication — through verbal handoffs and charting regarding the blocks performed — ensures continuity of care, as nurses and staff are aware of mobility and weight-bearing concerns. Physical therapists tailor their post-op rehab program for each patient based on the type of block performed.

The number and types of blocks we perform change over time related to increased knowledge, research and newly identified best practices.

2. Pre-op planning
Begin preparing for block placement a couple days before surgery, when you're reviewing the surgical schedule. The selection of nerve blocks performed are individualized to each practitioner and patient, based on the surgeon's technique and the patient's unique medical history. When a surgeon books a case, we look at the surgeon's preferences and the patient's health history to determine which nerve block will be most effective, and what kind of needles and supplies will be needed. This advanced information and planning reduces delays in surgical start times. We also worked with our team of anesthesiologists to standardize the local anesthetic they administer and the supplies they use. Because so much of the process has been standardized, our team is very efficient in preparing the sterile field for the anesthesiologist who will administer the blocks.

3. Keeping patients informed
Educating patients about how blocks are placed and keeping them informed throughout the process are important elements of a successful regional anesthesia program, because it can be a little disconcerting and frightening to be told you're going to get a nerve block. Patients often say they feel overwhelmed and rushed into making decisions, with mass amounts of information being given in the short amount of time before surgery. The more information you provide ahead of time, when the patient is less apprehensive, the more the patient will be able to understand and participate in their pain management plan. Giving patients time to verbalize questions or concerns is also key to ensuring they have a good surgical experience.

That's why, for us, patient education begins in the surgeon's office when cases are scheduled, and continues in an educational seminar, which all joint patients must attend before undergoing surgery. Nerve block-specific education is expanded upon by the block room nurse in the pre-op area, including details on how the block is performed, expectations during the procedure and pain management techniques to use after surgery. This education is continually improved upon based on patient feedback. The goal is to provide patients with tools to optimize good outcomes.

We tell patients a nerve block is similar in experience to getting dental work with Novocain, but lasts longer. We explain that safety and effectiveness are improved by use of ultrasound, nerve stimulators and sedation. Ultrasound helps anesthesia providers locate the best place to deliver the local anesthetic, while the stimulator is a secondary safety check for motor nerve blocks used to ensure the nerve that's stimulated — to the patient, the sensation is similar to a doctor checking knee reflexes with a hammer — is the nerve we're intending to numb. We tell patients they'll be sedated, so they'll be relaxed and probably won't remember anything, but will still able to communicate with us about what they're feeling.

Patients who will have a catheter placed during the nerve block to continuously administer numbing medication also receive instructions on the management of the pain pump and catheter, and potential signs of complications to watch for during recovery. We also provide a 24-hour phone number they can call with any questions.

We're currently in the process of working with our orthopedic surgeons on developing pamphlets and information they can provide to patients who will be having non-joint replacement orthopedic surgeries and who could benefit from a nerve block being part of their pain management plan.

4. Dedicated block room
Identify cases that might be appropriate for a block and plan staffing assignments and the surgical schedule accordingly to ensure patients who will receive blocks arrive earlier than normal, and allot extra time on the front end of cases to place the blocks.

If possible, administer blocks outside of the OR. We have a dedicated space and dedicated staff that set up for and administer nerve blocks outside of the OR. This decreases patient time in the OR and improves workflow, as the nerve block is performed while the OR is being turned over.

The dedicated block area is outfitted specifically for pre-op procedures, with additional lighting and well-organized carts that hold all the equipment and drugs we need to support blocks. A sterile field is set up. A dedicated nurse monitors the patient with sedation until the circulating nurse arrives to get the hand-off report and take the patient to the OR.

There are always risks associated with placing nerve blocks, but those risks are minimized by following accepted best practice safety measures: a dedicated staff; sterile fields set up to minimize chance of infection; ultrasound guidance utilized for site location in administering the local anesthetic; and the monitoring of a sedated patient by nurses with competency in providing sedation. Ultimately, the benefits of a nerve block outweigh the risks associated with placing it when the accepted standards of safety for the procedure are followed.

5. Patient-friendly post-op follow-ups
Reinforcing and expanding on patient education is just as important after the surgery. We follow up with patients the next day to see how they're feeling, answer any questions and review pain management strategies. We also ask if there's any information they want that wasn't covered previously or if their pain is more than they can handle. That last question is important because it can lead to improvements in our patient education efforts. If what we're doing is working, we don't change it; if it isn't, we can brainstorm a plan to get patients to a tolerable pain level. Usually they are doing well and are thankful for the follow-up phone call.