LOCAL HERO Regional anesthesia expert Gregory Hickman, MD, places a femoral block at the famed Andrews Institute Ambulatory Surgery Center.

When the Andrews Institute Ambulatory Surgery Center opened in 2007, my goal was to minimize to the greatest degree possible the use of opioids to control orthopedic patients' post-op pain. Today, fewer than 10% of our patients end up receiving narcotics in the PACU, which speeds their recoveries and improves our case efficiencies. What's not to like?

1. Grasp the potential
An effective multimodal approach to managing post-op pain is best built with regional anesthesia as the cornerstone but, in my opinion, more facilities should be taking advantage of blocks' many benefits. My sense is there's still some resistance at the front line from facility leaders who erroneously believe placing blocks is an added cost for which they can't get reimbursed. Medicare won't reimburse for block placements, and third-party payors won't pay for individual supplies and medications, but you can bundle those expenses and get paid by private payors by billing the procedure as a separate charge for the sole purpose of preempting post-op pain.

In addition, veteran anesthesia providers who've never incorporated regional into their practices are sometimes hesitant to try a technique they believe increases intraoperative risks without adding a significant financial payoff.

But regional can improve outcomes. For example, because pain is controlled with fewer narcotics, our PONV rate is less than 1%, significantly lower than the reported national average of 37%. That lets us send happy patients home sooner, which has increased surgeon and patient satisfaction.

Regional is primarily most effective in orthopedics, especially with the added use of continuous catheters, which let our surgeons perform more invasive cases such as major knee and shoulder cases in the outpatient setting.

It's no surprise, then, that our regional program has also helped recruit surgeons, including 2 physician-owners of a local surgery center who used to send us patients for placement of continuous catheters. The docs eventually decided to reap the rewards of our regional program on a full-time basis.

2. Create a block team
We have 2 anesthesiologists and a regional anesthesia fellow, who alone placed 1,553 blocks of the more than 3,200 our team placed last year. Together, we place between 30 and 35 on a busy day.

Block nurses are critical to our high-volume success. We're fortunate our facility's administrator realized early on that dedicating members of the pre-op nursing staff to our regional program would improve its overall efficiency.

Anesthesia providers are often pulled in multiple directions on the day of surgery and can be easily distracted from placing blocks on time. So each anesthesiologist here is assigned a block nurse who helps him stay on track and perform all his blocks. The nurses ensure the ultrasound units, needle trays, local anesthetics and pain pumps are set up and ready to go as soon we arrive in pre-op to place the blocks, which saves us 15 to 20 minutes between cases and keeps the program from grinding to a halt.

CONTINUING EDUCATION
Learning the Art of the Block

EXPERT ADVICE Dr. Hickman conducts 8 ultrasound-guided regional anesthesia workshops each year.

Gregory Hickman, MD, wants more facilities to incorporate regional anesthesia into their pain management protocols, and he's hitting the road to spread the word. He and several colleagues conduct a series of 2-day CME regional anesthesia courses in major cities across the country.

The courses involve 8 hours of didactics and 7 hours of hands-on training in ultrasound scanning. "We teach basic sonoanatomy, and show attendees best scanning practices and how to position patients for optimal outcomes," says the director of anesthesiology and medical director at the nationally known Andrews Institute Ambulatory Surgery Center in Gulf Breeze, Fla.

Anesthesiologists are also invited to the Andrews Institute for a 2-day preceptorship worth 20 CME hours. "They can watch patient flow, how the block team interacts and how blocks are placed," explains Dr. Hickman. "They really get a feel for how it all works."

For information about the courses and to check out several well-produced educational videos about regional anesthesia, check out Dr. Hickman's website: blockjocks.com

— Daniel Cook

3. Invest in ultrasound
It's hard to call ultrasound imaging the standard of care in block placement, because that phrase carries a lot of weight in clinical circles, but the technology is critical to regional's success.

Placing consistently effective blocks is challenging, which is a drawback that prevents some anesthesia providers from adding the technique to their pain control repertoire. Ultrasound eliminates that variability. It lets providers watch the donut of local anesthetic encircle the nerves they're targeting, so they feel confident in knowing blocks will be fast-acting and long-lasting.

Yes, there is a learning curve to incorporating ultrasound-guided blocks into everyday practice. Early research conducted at Dartmouth College showed anesthesia residents became comfortable with the technique after 60 attempts. But once you've mastered the technique, ultrasound can also improve block placement efficiencies by letting providers direct needles straight to the nerve.

KEY PLAYERS Block nurses prepare needed supplies and ready the ultrasound unit to keep regional programs on track.

4. Pump up the potential
Sending patients home with pain pumps full of local anesthetic extends the pain control benefits of regional programs and lets surgeons schedule more complex cases in outpatient facilities.

Providers who use blind approaches to place catheters don't know how close the tip is to target nerves. Stimulating catheters are better options for a more targeted approach, but still not the most effective. Confirming the placement of continuous catheters with ultrasound has similar benefits to using the technology to place single-shot blocks.

Block nurses can hold the ultrasound probe as providers thread catheters into place, which lets them track the tip in real-time. They can watch the catheter come out of the needle's tip and know exactly how close it is to the target nerve before pulling the needle out, injecting local anesthetic through the catheter and watching it spread around the target nerve. Ultrasound provides confidence in knowing the continuous blocks will have the desired effect.

There are inherent dangers in sending patients home with pain pumps — toxicity and potential nerve damage if too much local anesthetic is delivered to pain sites — although the risks are relatively rare. Still, our block nurses do a tremendous job educating patients about how blocks work, what to expect during recovery and how to operate pain pumps once they're home.

The nurses review the block procedure, discuss how continuous catheters are placed, describe what the sensation will be like and show patients actual pumps to demonstrate exactly how boluses of the local anesthetic are delivered.

Recovery room nurses go over the same information before patients are discharged home. We've also added a QR code to patients' discharge sheets, which they can scan with smartphones to watch a short educational video we produced, showing one of our nurses reviewing the discharge instructions.

Patients are sent home with pumps attached but inactive, because they still feel the numbing effects of the single-shot block delivered before surgery. We tell them to activate the pump before they go to sleep, so its analgesic effects will kick in when the block wears off in the middle of the night. We also instruct patients to adjust the infusion of local anesthetic as needed to find the sweet spot between pain and over-numbing the surgical site.

Finally, each patient is given the cell phone numbers of our facility's 3 anesthesia providers. Patients can contact us at any time with questions about the pumps' use or the effects of the local anesthetic. Patients rarely call, but knowing the communication lines are open once they leave our facility is an important safeguard that gives us all peace of mind.