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How Regional Anesthesia Helped Us Cut Costs and Improve Patient Satisfaction In Our ASC
Nathan Schwartz, MD, and Emil Dilorio, MD,
The Ambulatory Surgery Center, Lehigh Valley, PA
To study the effects of regional anesthesia on patient care and costs, we completed a 16-month, non-randomized study of regional anesthesia techniques at our ASC. Our study included 1,626 outpatient orthopedic surgical cases, including 1,044 knee arthroscopies, 136 ACL repairs, 89 shoulder surgeries, 212 hand procedures, and 145 podiatric surgical procedures.
During the study, we analyzed the incidence of PONV, inpatient admissions, and patient satisfaction. We defined PONV as the presence of nausea or vomiting in the early postoperative period until discharge requiring anti-emetics or a prolonged stay beyond two hours.
We measured patient satisfaction by calling patients within 48 hours after discharge and asking for their overall level of satisfaction.
Prior to surgery, we sedated patients using a benzodiazepine agent, and if necessary, a low-dose, short-acting intravenous induction agent such as propofol or brevital. We then performed nerve regional anesthesia according to the following protocol:
- Knee arthroscopies: Intra-articular knee and portal block.
- ACL reconstruction: Femoral 3:1 block and intra-articular knee and portal block.
- Shoulder surgeries: Interscalene or brachial plexus block; suprascapular and superficial cervical plexus block.
- Hand surgery: Brachial plexus or intravenous regional anesthesia (Bier Block) or selective peripheral nerve block.
- Foot surgery: Ankle block.
We performed the femoral 3:1 block, interscalene, or brachial plexus block with the aid of a peripheral nerve stimulator (Stimuplex - Burron) using a standardized mixture of 20 cc of 2% lidocaine with 1:200,000 epinephrine and 20 cc 0.2% of ropivacaine. We performed Bier Blocks with 30-50 cc of 0.5% lidocaine. Peripheral nerve blocks were non-standardized; however, typically we used less than 10 cc of diluted lidocaine or ropivacaine.
We used minimal sedation on most knee arthroscopies and hand and foot cases. For patients undergoing ACL or shoulder surgeries, we administered nitrous oxide via LMA or endotracheal intubation, incorporating inhalational agents, muscle relaxants, and other agents as required for the safe completion of the procedure. Because of the effectiveness of the regional anesthesia we were generally able to use light levels of anesthesia and extubate the patients rapidly at the conclusion of the surgery. Very few patients experienced significant postoperative pain; we were able to move most patients directly to our Level 2 PACU. If necessary, especially in the case of prolonged surgeries, we administered a "touch-up" of the block in the PACU with the initial or lower local anesthetic dosages. We evaluated street-readiness according to the Alderete score.
During the 16 months of the study, there were no hospital admissions for PONV or pain. Only eight patients, representing 0.3 percent of all the surgeries, required a PACU stay beyond two hours (these patients had received general endotracheal anesthesia). Sixty-seven patients, or about 3 percent, required rescue anti-emetic therapy during the PACU stay, and several patients noted late postoperative nausea, which we attributed to oral opioids prescribed by the surgeon. Significantly, all patients rated their satisfaction as "excellent" during the post-procedure telephone call.
We estimate that we saved $75 per procedure due to reduced use of post-op pharmacological agents such as analgesics and antiemetics, decreased nursing and ancillary personnel care, and decreased PACU stay.
Dr. Schwartz is board certified in anesthesiology, pediatrics, and pain management. He is chief of the anesthesia and pain management departments at Coordinated Health Systems (CHS) in Lehigh Valley, Pa.
Dr. DiIorio is board certified in orthopaedic surgery. He is the medical director of CHS. The ambulatory surgery center is a joint venture of CHS and St. Luke?? ?s Hospital and Network, Lehigh Valley, Pa.
How We Use Local Blocks in Office-Based Orthopedic Surgery
Jack M. Bert, MD
Since 1995, we have performed more than 7,200 surgical and pain control cases in our office orthopedic surgery center, which consists of one OR and a procedure room. Our total perioperative time, which we define as the time from when patients enter the admitting area to when they leave the recovery area, is 2.51 hours - half the time it takes to accomplish the identical procedures at the private city hospital adjacent to our office. Aside from the obvious efficiencies of having a small, contained area (approximately 4,000 feet) for the operating room, storage, procedure room, admitting and recovery area, we also save costs, increase efficiency, and promote patient satisfaction by using local and extremity blocks.
We currently do interscalene blocks for shoulder surgery, axillary blocks for upper extremity surgery, knee blocks for all arthroscopies, and ankle blocks for ankle and foot surgery. Here are the details on each of these blocks and how we ensure that they are effective:
Interscalene blocks:
To date, we have performed more than 950 interscalene blocks for open and arthroscopic shoulder procedures, without having to use general anesthesia. These blocks last an average of four to five hours postoperatively. To help the patient relax, we administer Monitored Anesthesia Control (MAC), consisting of Versed and Diprovan. Several of our patients actually watch the television monitor while we?? ?re doing their procedures.
Axillary blocks:
Axillary blocks, which we use for most procedures distal to the shoulder, require almost no MAC assist during the operative procedure. The recovery time is extremely rapid and the duration of the block is approximately 4 hours.
Knee blocks:
We have performed more than 2,250 knee blocks for knee arthroscopy. To do a knee block, we inject 50 ccs of marcaine with 0.5% epinephrine into the knee joint and arthroscopic portal sites 30 minutes prior to the surgical procedure. It is very important to inject the local anesthesia at least 30 minutes prior to the time of surgery, simply because it takes that long for the anesthetic to infiltrate the synovium and joint surfaces. By using epinephrine in the marcaine, we avoid having to use a tourniquet when performing the
surgery.
We proved that epinephrine helps avoid the need for a tourniquet in a study that we performed in 1997. We did 400 cases without tourniquet control using marcaine and epinephrine and did another 400 under general anesthesia using marcaine without epinephrine and with tourniquet control. We documented the visualization of the procedure with serial intraoperative pictures. The patients that had the procedure performed with the epinephrine and marcaine block statistically had clearer intraoperative images than the group using tourniquet control without epinephrine. The epinephrine constricted the blood vessels so that there was no bleeding.
Even though our local knee block technique results in a thoroughly anesthetized joint, we often also use MAC assist to help relieve the pain associated with the stress placed on the thigh by the knee holder in a tight joint when we are attempting to resect the posterior horn of the meniscus.
Ankle blocks:
We use ankle blocks for ankle and bunion surgery. This block involves infiltrating the nerves at the ankle joint anteriorly, laterally, and medially with marcaine without epinephrine (we do not use epinephrine to avoid constricting major blood vessels to the foot). It is helpful to inject the anesthetic at least 15 to 30 minutes prior to the onset of surgery for the block to have maximal effect. We have also been able to perform ankle procedures such as a lateral ligamentous reconstruction and open reduction of lateral and bimalleolar fractures using this technique with MAC assist.
The time required for an average surgical procedure in our office breaks down as follows: 72 minutes for pre-op, 41 minutes for the procedure, and 38 minutes for post-op care. Patients who have interscalene, axillary, and knee blocks literally walk into and out of the operating room pre- and post-operatively with nursing assistance.
We have only had one complication in five years. This occurred when our board certified anesthesiologist (whom we use exclusively) accidentally injected local anesthesia into the thecal sac while performing an interscalene block. The patient experienced incomplete respiratory paralysis requiring transfer to the hospital via ambulance (fortunately, we did have an emergency transfer agreement, which is required by most states for ASCs). The patient had an uneventful recovery and rescheduled his rotator cuff surgery the following week. His surgery went well and he has had no residual complaints.
In the vast majority of cases, local blocks have helped us produce excellent results. We believe that they are the reason that our patient satisfaction rate, as measured by postoperative callbacks and surveys, has been over 98 percent. When performed by an experienced anesthesiologist, local blocks are safe, effective, reliable, and should be the anesthesia of choice for office-based orthopedic surgery.
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