From single-shot peripheral nerve blocks to continuous local infusion pumps, regional techniques offer a range of options for patient care. But the process is not without the occasional obstacle, such as uncooperative anatomy, unforgiving schedules or unconvinced physicians. We asked our readers for their experiences with regional anesthesia, and they shared their advice for ensuring that it remains effective, efficient, safe and possibly even profitable every time.
The case for regional
Nothing slams the brakes on ambulatory surgery's much-touted efficiency like a patient that you can't discharge on time. Post-op drowsiness, nausea and vomiting from the general anesthesia that patients received in the OR or from the narcotics you administered in PACU to manage their lingering pain have an adverse impact on throughput, staffing and case costs. They don't do much for patient satisfaction, either.
The ability of regional anesthesia techniques to target the surgical site with few side effects and to preemptively and reliably treat patients' post-op pain, in PACU and even for the first several days of recovery, seems nothing short of miraculous. The Kenwood Surgery Center in Cincinnati, Ohio, has put them to good effect.
"Ninety-five percent of our foot and ankle patients receive peripheral nerve blocks in the pre-op area," says Carol Wenzel, RN, the center's director of nursing. "These patients receive less narcotics intraoperatively and post-operatively. Most patients leave the center without receiving any pain medication in the immediate post-op phase. This also reduces nausea and vomiting issues." Follow-up phone calls have determined that most of these patients don't require pain medications for 8 to 12 hours after discharge, she adds.
Sidestepping general anesthesia and its attendant complications can also in many cases speed patients toward those discharges by eliminating long wake-ups. "There's a decreased recovery phase as most receive light sedation. The patient is awake and ready to leave sooner," says Diane Gress, RN, the OR and PACU manager at Memorial Hospital and Health Care Center in Jasper, Ind.
Surgical patients don't keep an eye on the clock the way your staff does, but you can rest assured that they appreciate these efficient routes. "Post-op pain control with regional anesthesia not only is safer for patients, it improves patient satisfaction scores through the roof when a patient is wide awake in PACU with absolutely no pain," says Darren Long, MSN, CRNA, from Avita Health Care System in Galion, Ohio. This patient comfort and clarity stands to boost your bottom line by delivering more referrals to your surgical schedule.
Regional techniques also mean business for your facility in expanding your potential case volume and case mix during the surgical day, says Sundar Rajendran, MD, an anesthesiologist at the Surgical Center at Premier in Colorado Springs, Colo. "Continuous peripheral nerve blocks enable us to perform more complicated cases on an outpatient basis, and allow us to do more cases with less resources," he says.
Build on experience
Regional anesthesia carries many advantages for patients, providers and facilities, but the techniques won't reach their full potential for optimal outcomes and efficient throughput if they're administered or mishandled, or sparsely applied or avoided entirely by inexperienced hands. Training, confidence and the acquisition of skill are at the foundation of a successful nerve block program.
"Make sure your anesthesia group has been properly trained to perform these blocks," says Angie Reynolds, RN, nurse administrator at NorthWest Plaza Ambulatory Surgery Center in Albany, Ga. Providers who have your outpatient efficiency interests in mind should be practicing regional techniques or at least open to educating themselves. If they're not, seek out a service whose staffers are. Fellowship training through the American Society of Regional Anesthesia and Pain Medicine (asra.com) is one sign of experience.
In addition to training, the ideal providers will be frequently putting the techniques into practice. "You need to have anesthesiologists that routinely give the regional anesthesia," says Karen E. Sullivan, RN, BSN, assistant nurse manager at the Marymount Ambulatory Surgery Center in Garfield Heights, Ohio. "Our biggest challenge is when an anesthesiologist comes to help out at our facility who does not routinely do these procedures, and as a result we have block failures."
In order to encourage the use of regional, Gary Friedman, MD, vice president of Nashua (N.H.) Anesthesia Partners, recommends including it in surgical pathways through a multi-disciplinary protocol for anesthesia, surgery and administration, namely "developing programs that all stake-holders agree to and effectively integrate into their care plans and management."
Dr. Friedman admits that this can be a big challenge and demands major cooperation. But cooperative education and effort are critical factors in making regional anesthesia work at your facility, since administering effective blocks, as with the delivery of most aspects of perioperative care, requires participation from more than just one player.
"Most failures occur because of system problems, providers and patients at all levels not being 'on the same page,'" notes Carrie L. Frederick, MD, director of anesthesia services for the Plastic Surgery Center in Portland, Maine. "Everyone needs to be educated about the process, and understand their roles in it."
Selling regional to surgeons
"Undoubtedly, our surgical colleagues need to be on board and help us lead these initiatives in order to have a comprehensive regional anesthesia program," says Dr. Friedman.
But there's a problem. The perception among many surgeons is that nerve blocks take too much time to set up. That they prolong case turnovers and delay start times. That, no matter what benefits they contribute to the patient experience, they're not absolutely necessary in order to achieve the targeted operative outcomes, when general anesthesia works fine. For many surgeons, regional administration time is wasted time.
"The biggest obstacle for regional anesthesia is a lack of knowledge about its safety and efficiency on the part of our surgeons," says Edwin J. Villamater, MD, chief of anesthesia at the University of Maryland Rehabilitation and Orthopedic Institute in Baltimore. And institutional anesthesia is a powerful force.
The thing is, if your providers' nerve blocks aren't a consistently coordinated effort, your surgeons are right, at least until your patients reach PACU. Regional anesthesia success is all in the timing. Planning ahead goes a long way toward preventing delays. And the ability to keep blocks on schedule, even more than the amount of experience providers have with them or building them into care plans, is the key to overcoming surgeons' opposition.
One way to keep regional anesthesia from holding up the surgical schedule is to make a note of it on the surgical schedule as soon as it becomes a possibility. "If you know up front at the time of scheduling, it will allow for easier access and time for the block to be placed," says Pamela Ledger, RN, MSN, director of nursing at the Ambulatory Surgery Center at St. Mary in Langhorne, Pa. "Plan with your anesthesia provider so that they have adequate help and the equipment they need."
Early cases present an ideal opportunity for a head start at the Illinois Sports Medicine and Orthopedic Surgery Center in Morton Grove. "We have developed a policy that a first-case-of-the-day block does not have to wait for the surgeon, as long as it was requested by the surgeon on the scheduling sheet and the attending anesthesiologist is OK with the surgeon not being present," says Judith Manley-Plum, RN, MS, the center's director of nursing. "But we do have to wait for the surgeon to arrive before blocks are done for any later day cases that have requested one."
Prove to your physicians that regional anesthesia can deliver effective results without postponing their incision times, and you'll see more and more of them give up their opposition and welcome the techniques to their cases, says Mr. Long, the Ohio CRNA. "We pretty much have free rein in doing the blocks, as long as we do not delay the surgeon," he says.
Team and space
The best patient care is accomplished by a team, and even anesthesia providers with years of experience placing nerve blocks work more efficiently with assistance. That's why high-volume orthopedic surgery centers swear by the concept of the block team. Anesthetists working in dedicated groups or with trained perioperative nurses can prepare and monitor the patients who are next in line for surgery while the current case is still underway, ensuring that regional won't be to blame if there's a delay.
Building a block team may require investments in additional staffing or education sessions for some of your nurses, but it'll pay off: not just in saved time, but also in the quality of pre-surgical care. "In the ASC arena, communication between anesthesia and nursing is a must," says Annette Svagerko, RN, BSN, CNOR, the OR program manager at the Westerville (Ohio) Surgery Center. "When all groups work together, the throughput is optimized and is safer."
If you're able to designate a space for your block team to set up and work in, so much the better. "There are things that are best accomplished before surgery," says Ms. Frederick, "and a block room can help you to formulate your regional anesthesia before everybody is waiting for you."
A block room doesn't necessarily have to be a room. A pre-op bay set aside for the morning will do. As an added bonus, "patients receiving a block in a dedicated block room do not count as 'patient in the room' for the purposes of reporting," says Kerry Cook, clinical director of perioperative programs at Queensway Carleton Hospital in Ottawa, Canada.
SAME-DAY HIPS & KNEES
Total joint replacement has a reputation for being one of the most painful surgeries to recover from. If you're hosting it as an outpatient procedure, as an increasing number of facilities are, your pain management plan had better be bulletproof. According to a recent Outpatient Surgery Magazine Instapoll, 62% of facilities that perform same-day hips and knees rely on regional anesthesia to keep post-op pain under control. For more on outpatient total joints, please see "3 Key Debates in Same-Day Knee Replacement" on page 94.
Anesthesia providers and physicians can select the patients who will make the best candidates for regional anesthesia during their pre-surgical assessments, but on the day of surgery, clinical realities sometimes throw a curve.
What causes nerve blocks to fail? There are a number of potential factors. An incorrect amount of anesthetic agent or an improperly placed injection can deliver a less-than-effective attempt. Morbid obesity and anatomical variations can make it difficult to accurately locate nerve structures.
"If we are aware of the block failure before the surgical procedure, the surgeon will sometimes supplement it with local anesthetic," says Ms. Wenzel of Kenwood Surgery Center. "Anesthesia will sometimes re-block the patient in the post-op area." But even the existence of a "Plan B" can slow the efficiency that regional techniques are intended to bring.
What can prevent block failure? In a word, ultrasound. Equipping your providers with the technology gives them the ability to visualize neural anatomy and deliver an effective amount of anesthetic directly to the targeted site for a high block success rate. "Ultrasound guidance makes the blocks safer and faster, and allows us to completely surround the nerve bundles, ensuring a dense and long-lasting block," says Mr. Long.
Whether used in conjunction with electrical nerve stimulation for verification or on its own, ultrasound technology has become a driver of nerve blocks' benefits, experts say. "To be successful, a regional anesthesia program must demonstrate improvement in effectiveness, patient pain scores, safety and efficiency," says Dr. Friedman. "These can be achieved in large part due to advances in ultrasound-guided regional anesthesia techniques."
Just be sure you have enough of the devices on hand to serve all your providers during all the cases that demand regional. Don't let a tight equipment budget bottleneck the workflow by making "all of anesthesia share one ultrasound machine," which more than one facility named as an obstacle to an effective regional program.