A BETTER WAY Ultrasound isn't the only option for peripheral nerve block placement, "but once you start using it, you become hooked," says David Rosen, MD, president of Midwest Anesthesia Partners.

Ask any anesthesia provider: The major motivation for the use of regional anesthesia techniques — whether peripheral nerve blocks for surgery or continuous local anesthetic infusions for managing pain afterwards — is the improvements they bring to the patient's post-op experience. These improved outcomes result directly in efficiency gains, and time is money.

"The biggest risk of post-op complications in outpatient surgery is that the patient will be nauseated, they'll stay in PACU and take up space. Maybe they'll even have to be admitted. This costs money for patients and insurers," says David Rosen, MD, president of Midwest Anesthesia Partners of Naperville, Ill.

However, regional's post-op analgesic effects lower pain scores, which decreases the need for opioids, which cuts the risk of grogginess, nausea, vomiting, delirium, respiratory depression or other recovery-prolonging side effects, which speeds discharges. "For an outpatient facility, any technique that avoids the use of opioids is advantageous," says Mark E. Hudson, MD, MBA, associate professor of anesthesia at the University of Pittsburgh School of Medicine.

"Under regional, within minutes after surgery they're having 7-Up and crackers. In 20 to 25 minutes they're dressed. In 30 minutes, they're in a wheelchair, heading for the car," says Dr. Rosen. "Regional changes the culture of recovery."

Specifically, it can let your patients skip Phase 1 PACU. "There's no emergence time if a patient never has to wake up from anesthesia," says Eric Crabtree, MD, of Sheridan Healthcare, who directs anesthesia services at the Sanford-Bemidji Medical Center in Bemidji, Minn. "Going straight to Phase 2 recovery, that's several minutes of throughput time saved there."

Rules for a modern process
In fact, recovery criteria should be updated to accommodate changes in surgical anesthesia and facilitate accelerated discharges, says Brian A. Williams, MD, MBA, director of acute pain medicine, regional anesthesia, ambulatory anesthesia and pre-operative evaluation at the VA Pittsburgh HealthCare System. "Do what you can to jettison old criteria that don't address the details of modern anesthesia use," he says.

For a 2011 article published in the journal Anesthesia Clinics, he and a colleague developed the WAKE score, a patient-centered ambulatory anesthesia and fast-tracking outcomes criteria that monitors respiration and oxygen saturation, among other factors, to replace the Aldrete scoring system.

Such fast-tracking may be a lucrative move. In a 2004 study in the journal Anesthesiology, Dr. Williams and his co-authors calculated that regional anesthesia could save surgical facilities $800 per patient ("In late '90s dollars," he says, "which could only have gone up since then"): $400 through bypassing PACU and $400 through avoiding standard hospital admission in cases which could have been done outpatient.

"That may have been the spark that encouraged regional anesthesia among providers who weren't performing it already," he says. "You could finally go to administrators and say, 'This could pay for itself, and then some.'"

PLACING THE BLOCK Dr. Rosen says regional anesthesia "changes the culture of recovery."

Resources reconsidered
The difference between the cost of drugs used for general anesthesia and those used in regional techniques is negligible, and outside of one exception (a nerve block administered expressly to manage post-op pain is separately billable), the two methods are reimbursed under the same code.

However, anesthesia's use of resources, directly or indirectly, still plays a role. "Anything that reduces the time the patient spends in the facility is going to save the facility dollars," says Dr. Hudson, most notably in its nurse staffing. Awake, alert patients with less post-op pain and fewer side effects to treat, a shortened PACU stay and earlier discharges mean fewer nursing hours on the clock. "When people are out in under an hour, as opposed to 2-plus hours, you're saving a lot of money on your personnel costs," agrees Dr. Rosen.

It's not just about staffing, though. "Often with regional anesthesia, you're utilizing fewer resources and consumables. As a result, depending on the procedure and depending on how you're reimbursed for things, you can see a small upside in your cost margin through the choices you make," says Dr. Crabtree.

For example, using a nerve block instead of a sedative such as propofol can keep case costs down. Additionally, following surgery, regional doesn't require much in the way of NSAIDs or anti-emetics. And most budgets don't even account for the goodwill arising from good outcomes. "Patient satisfaction is correlated not only to how well we do, but also to how we're going to get paid," says Dr. Rosen, noting quality of care's impact on value-base payment systems.

What you need
Granted, in order to take full advantage of the efficiency gains and cost savings of regional anesthesia, investments of time and money may be required. You'll need more than just the drugs and catheterization kit to run a successful regional program. You'll also need:

• Surgeons' interest. "Do your surgeons want it?" asks Dr. Rosen. "Can you get a commitment from key surgeons with case volume?" Anesthesia providers may be enthusiastic about regional, but without surgeons' say-so, it won't be the method of choice.
• Skilled hands. Whether you should recruit a team of specialists to administer nerve blocks exclusively or assign the utility players handling every case to brush up their knowledge base depends on the size of your facility and its demand for regional, says Dr. Hudson. Either way, you'll need anesthesia providers who have the skill sets to perform advanced regional techniques. The pre-op nurses who'll assist them should have an understanding and comfort with the process. They don't require special training, but if the volume is high enough, consider hiring a dedicated block nurse.
• A block room. "One issue that often comes up is the additional time associated with placing blocks," says Dr. Hudson. "We all know that these techniques can improve patient care, but they can also impact surgical time and efficiency, and if they do, you're going to meet some resistance from surgeons and administrators." A block room or designated induction area for anesthesia providers and nurses to work in can help to ensure timely block placement that doesn't encroach on surgical start times.
• Ultrasound guidance. Blocks can be effectively placed with electrical stimulation, and $30,000 to $50,000 for ultrasound technology is a sizable investment, "but once you start using it, you become hooked," says Dr. Rosen. The imaging increases the quality of a block, decreases the failure rate, and lets you block anatomy that stimulation can't confirm. "It's not the right way, but it is a better way."

Highlighting the results of these requirements can boost the appeal of starting a regional program. "From the administrator's side, all they see is the additional costs of personnel, more monitoring, the cost of the ultrasound machine," says Dr. Hudson. "But they might not see the other end, the savings in PACU and timely discharge, a reduced chance of unexpected admissions. We have to make them understand the financial impact. It's less tangible, but it is real."