Believe it or not, a surgeon first got us thinking about continuous peripheral nerve blocks. That's right, a surgeon. Surgeons are notoriously intolerant when regional anesthesia backs up their schedule. Yet there was orthopedic surgeon Paul Switlyk, MD, the shoulder revision specialist in our area, asking us a couple years ago to look into offering continuous blocks at our center to help alleviate the lasting pain patients were feeling after more complicated shoulder procedures, which sometimes had them returning to our facility to be re-blocked. We did our first continuous nerve block in October 2009 and, yes, the process at first added a considerable amount of time to our room turnovers. A year and a half and more than 70 blocks later, we couldn't be happier with the results, from both a patient satisfaction and a profitability standpoint. Here's how we made it work.

Equipment and supply needs
Assuming that you already do single-shot regional anesthesia at your facility, there are very few additional supplies and equipment that you need for continuous nerve blocks aside from the pain pumps themselves, which get hooked up to the catheter that's already been placed during the initial block administration in pre-op.

When we first embarked upon this program in 2009, there were very few companies offering pain pumps for continuous nerve blocks, but the options have expanded since then. As with any product, have the reps bring in the pumps and explain how they work, then conduct a trial to see how easy they are to program and operate. Pay particular attention to how patient-friendly the pump is to operate. You want the patient control aspect of the pain pump to be as simple as possible.

One logistical decision you'll need to make is whether to go with pre-filled pumps or have your anesthesia providers or staff fill them on site. We went with the latter option: Our anesthesia providers, who are the ones administering the blocks and following up with patients once they go home, fill the pumps in the OR immediately after the case and then hook them up to patients before they're wheeled into recovery.

All the other supplies and equipment you'll need for continuous blocks are the same as you'd use for regular one-shot blocks: nerve stimulator, needles and medication mix. Continuous blocks require a catheter and the pump in addition to the single-shot block supplies. One piece of equipment that's not considered necessary but that we've found to be a tremendous asset to our regional anesthesia program is an ultrasound machine. We started doing regional anesthesia and continuous blocks before we got an ultrasound machine. Once we got one and our anesthesia providers became proficient in using it for block placement, it really streamlined the process and shaved precious minutes off our block times.

Although it was a surgeon who initially raised the idea of offering continuous nerve blocks at our facility, the anesthesia providers and nursing staff ultimately brought this idea to fruition. Expect turnover delays during the implementation period, as there's definitely a learning curve involved. Here are some tips for a smooth implementation:

• Get buy-in from your medical staff. Even though they were the ones who asked for it, our surgeons weren't keen on the extra time needed to insert the catheter once the single-shot regional block had been performed, particularly in the beginning when this added as much as 15 minutes to our turnover times. Educate your surgeons about why you're offering certain patients continuous nerve blocks, and emphasize that it will mean fewer complaints and middle-of-the-night phone calls from patients in pain after surgery. For their part, your anesthesia providers need to be willing to undergo some additional training to become proficient enough at placing the blocks, filling and programming the pumps, and documenting these steps so they're not slowing down the process too much.
• Enlist your vendor to provide education. To help get over the learning curve associated with adding a new step to your post-op protocols, have your pain pump vendor provide education for your anesthesia providers and staff on how the pumps work and how to handle any problems patients may encounter with the pumps once they're sent home. Overall we've had few problems with our pumps, but occasionally they will fall out or need to be repositioned.
• Consider purchasing an ultrasound machine. As we alluded to before, an ultrasound machine can be a great asset in improving the efficiency and accuracy of your regional blocks. Ultra-sound guidance helps ensure your providers are placing the block correctly the first time, even if patients have unusual anatomies. Ultrasound guidance also helps protect patients from a pneumothorax, a risk associated with interscalene and infraclavicular blocks, and is more effective than nerve stimulation in helping to locate the nerve when a patient requires a re-block in the recovery room, which happens from time to time.

• Educate patients before and after surgery. Patient education is key to the success of your continuous nerve block program, as most of the 3-day duration of the blocks will be taking place at home, where patients are out of your sight. Your surgeons should begin the process by explaining to patients during their office visits that they'll be sent home with a continuous peripheral nerve block and the reasoning behind it. On the surgical facility side, create a detailed set of patient instructions on how to operate the pump, what to expect, how to spot complications and when to remove it (your pain pump vendor should be able to provide you with this information). Have your staff explain these instructions verbally to both the patient and her family members in the recovery room. The anesthesia provider should then call the patient every night over the duration of the block (typically 3 days for our patients) to check up on her progress and provide any counsel as needed.
• Simplify the documentation. The final element in streamlining and expediting the process is to create a form that anesthesia providers can use to easily and accurately document the administration of the initial and continuous nerve block. Our "Regional Anesthesia Procedure Superbill & Procedure Note" (shown on p. 49) contains a series of checkboxes anesthesia providers can select for their pain diagnosis codes, nerve blocks and their corresponding CPT codes, local anesthetics, preps and needles used, and detailed procedure information. Additional areas let them fill in any notes about complications or other comments they may have. (Download a copy of this form at www.outpatientsurgery.net/forms.)

Continuous results
The 2 biggest benefits we've realized from our continuous nerve block program actually go hand-in-hand. First and foremost, the patients who come to our center for some of the most complicated procedures we host are experiencing more comfort and pain relief for longer periods of time after they go home. This prevents late-night phone calls from patients in pain and repeat visits from patients needing additional interventions to control post-op pain days after the procedure. This increased patient satisfaction meant we were able to bring more complicated shoulder procedures to our center last year. Dr. Switlyk's net revenue into our center increased along with the number of complicated surgeries he brought here. (For more on the financial aspects, see "Continuous Nerve Blocks in Dollars and Cents" on p. 46.)

Finally, if you strive to be one of the top orthopedic surgery facilities in your area, you've got to have the top pain management processes in place. After all, it doesn't matter how great a surgery you perform. If patients are going home uncomfortable, that's bad for your facility. As one of the largest orthopedic surgery centers in our community, we strive to be at the forefront of technology. Offering continuous peripheral nerve blocks is just one part of that larger effort to be on the cutting edge.