COORDINATED EFFORTS Anesthesiologist Brandon Winchester, MD, and perioperative nurse Emily Winchester, RN, team up at the Andrews Institute ASC.

We place an average of 300 regional blocks a month here at the Andrews Institute ASC in Gulf Breeze, Fla., so we know a thing or two about keeping cases moving smoothly through the ORs. It requires a dedicated surgical team that buys into the regional program and fully understands how it can improve our overall efficiency. Let's take a closer look at our program and the 5 key elements that make it tick.

1 Flexibility
Nerve blocks are opioid-sparing and therefore decrease a multitude of side effects associated with opioid use that can stall post-op recoveries. Thanks to regional blocks, patients are able to meet discharge criteria sooner. Despite the clear advantages of using regional blocks, many facilities still hesitate to add a program. Barriers to implementation exist on several fronts — surgeons, nurses, anesthesia providers and administrators might resist change and it's not an easy status quo to break.

Surgeons might be the toughest to convince. Many have been taught that blocks will ruin surgical efficiencies, delay case start times and potentially decrease the amount of procedures they can do in a day. That's a common misconception. Blocks might appear to delay the start of cases, but the time used to place a block before surgery is more than made up for on the back end through faster PACU recoveries. The overall efficiencies of the facility improve.

We make sure surgeons understand that their efficiencies remain a top priority and that we're not placing blocks at the expense of their operating room time. We make them understand that we're all pulling in the same direction and striving toward a common goal.

Placing blocks before procedures in a dedicated area outside the OR can help maintain perioperative efficiencies, but isn't essential to ensuring cases start on time. In general, we try to perform blocks in pre-op before procedures, but if the surgeon is significantly ahead of schedule or if placing the block before the procedure will cause a significant delay in the operating room, we won't hesitate to place a recovery block. Some experts argue that patients should always receive nerve blocks pre-operatively for the hypothetical benefit of preemptive analgesia, but in reality a block placed immediately post-operatively results in a similar patient experience. Some experts even argue that patients who have the brief experience of pain followed by treatment are actually better able to appreciate the pain relief.

VISUAL AID Providers who use ultrasound guidance can place tough blocks faster and easier.

The overall efficiency of the facility remains our focus, so we have no problem performing blocks in the immediate post-anesthesia period shortly after the patient emerges. It's a compromise made by the anesthesia team in order to maintain efficiencies and show surgeons that we won't impede their case throughput just for the sake of placing blocks.

2 Block nurses
Having a dedicated block nurse — not a pre-op nurse who gets pulled once in a while to help out — who specializes in supporting a regional anesthesia program is an important part of maintaining efficiencies. Block nurses educate patients about block procedures and ensure they know to look for potential side effects when they're recovering at home. They make sure anesthetics, supply trays and equipment are accounted for before blocks are placed. They draw the local anesthetic into syringes and connect a needle to the syringe, readying it for injection. They bring the ultrasound machine to the bedside and make sure the area is set and ready, so the anesthesia provider can focus solely on administering the block when he arrives.

During the block placement, block nurses aspirate to ensure an extravascular needle location then inject the local anesthetic with a low amount of force in order to avoid high-pressure injuries. They monitor vital signs while the anesthesia provider remains focused on the procedure. After the block is placed, the nurses complete procedural paperwork. The anesthesia provider reviews it quickly for accuracy before adding his signature. Instead of filling out and rechecking boilerplate forms, anesthesia providers are free to focus on starting blocks and other clinical tasks.

3 Sufficient staffing
A regional program must have an adequate ratio of nursing FTEs to blocks performed, so nurses aren't tasked with more than they could reasonable manage. For example, 1 block nurse FTE to every 1,000 to 1,500 blocks performed per year is acceptable. If the ratio moves to 1 FTE per 3,000 blocks, the workload becomes unmanageable.

Anesthesia providers also need to be available to place blocks at a rate that maintains overall efficiencies — 3 providers to 1 OR (or a 4-to-1 ratio at worst) helps maintain efficiencies. A staffing model involving anesthesiologists supervising CRNAs is an important element of efficient success. When anesthesiologists work alone, they may be stuck in the OR until the end of a case that runs long and have only a brief window of opportunity to perform a block on the next patient. The supervision care team model (MDs overseeing the work of nurse anesthetists) frees up anesthesiologists to perform blocks in advance of cases, as opposed to trying to squeeze them in between procedures.

4 The "90-minute rule"
We bring all patients, regardless of whether they have planned blocks, into the facility 90 minutes before their scheduled start times. That gives us plenty of time to place blocks and ensures that non-block patients won't spend too much time waiting for their cases to begin. From a logistical standpoint, it's best to maintain a standard arrival time for all patients, one in which non-block patients arrive early enough for the pre-op staff to address unforeseen issues and block patients arrive far enough in advance to avoid delaying the OR.

5 Ultrasound guidance
Imaging technology can speed the placement of blocks, depending on the skills and experience of the anesthesia provider. Someone who has spent his entire career performing landmark-based femoral nerve blocks for total knee replacement is going to be less efficient with ultrasound. It's a tricky comparison, because many factors contribute to the overall efficiencies of a regional program. But if all else is equal, ultrasound guidance in the hands of a skilled provider definitely speeds things along. A straightforward block is relatively easy to perform, whether the landmark technique or ultrasound guidance is used. But when trying to place blocks in difficult anatomy, when you're otherwise fishing in and out with the needle trying to find the nerve, ultrasound can "turn the lights on" and make those cases faster.

The adductor canal block (osmag.net/nJC4Tc) is an example of a nerve block where ultrasound has been instrumental in achieving optimal success. Plenty of evidence has emerged in the past 2 years that shows adductor canal blocks control pain after major knee surgery as effectively as femoral nerve blocks, so there's a clear clinical motive to perform them. Without ultrasound, it's a challenging block to place since there is typically no motor response elicited even when the stimulating needle is in the correct location. With ultrasound, however, it's an easy block to perform.

Adding image guidance to a regional program requires patience. The initial learning curve is steep, but you're essentially taking one step backward with the long-term goal of taking several steps forward. Over time and with the right anesthesia providers operating the probes, there's no doubt the technology makes a regional program more efficient.