BLOCK JOCKS Having a senior expert on each block team who works as part clinician, part educator will improve your block placement success.

The Andrews Institute for Orthopaedics & Sports Medicine is known for treating many famous athletes, but many of our patients choose us for surgery because we offer continuous nerve blocks that help reduce their post-op pain as they recover at home. You might be hesitant to start a CNB program due to the time, effort and complications associated with placing blocks, but you can develop an efficient program if you follow the 5 keys to our success.

1. Have a dedicated block team
If you're starting a regional anesthesia program, begin by hiring and training the very best staff. There's nothing wrong with the "everyone does everything" mentality of ambulatory surgery centers, but when it comes to a perineural catheter team, everyone should be specialized.

I recommend a dedicated block team and block nurse to help with placing catheters. A one-to-one ratio of a block nurse to an anesthesia provider tends to work best. Our block nurse helps with setting up catheter trays, leading time-outs, educating patients, preparing local anesthetics, completing documentation and assisting with block placement.

While everyone on the team should be trained in placing CNBs, not everyone needs to be an expert. Aim to have at least one senior member on every block team. In our 8-OR facility, there's at least one expert per block team who acts as part-clinician, part-educator when the patient is receiving the block.

Your anesthesia staff can stay up-to-date about placing blocks by attending lectures, visiting other facilities to watch experts, using online resources like nysora.com, usra.ca and ultrasoundblock.com, and seizing every opportunity they can to practice catheter placement.

2. Take advantage of ultrasound
I'm a firm believer that anesthesia providers should use ultrasound for every catheter placement. Not only does it make the procedure more efficient, but we're also starting to see data that show that there are safety benefits as well, such as decreased incidence of vascular puncture and decreased risk of systemic toxicity. It's also a big draw for your facility. Many anesthesia providers, especially younger ones, expect ultrasound to be available for block placement. This doesn't mean that you need to run out and purchase a $100,000 machine. The latest portable ultrasound machines are more streamlined, have a smaller footprint and offer much higher quality images — all at a lower price tag.

Technique is important when performing ultrasound-guided blocks. Inserting the needle right next to the probe makes the needle much harder to visualize with ultrasound, due to the steep insertion angle. To see the needle better, insert the needle much farther from the ultrasound probe.

BLOCK ECONOMICS
When Done Right, CNBs Can Boost Revenue

MISPERCEPTION Continuous nerve blocks have an unfair reputation for being a revenue drag.

Continuous nerve blocks have a bad reputation for adding costs to cases, but CNBs don't have to hurt your facility financially. Here are 3 ways they can boost your bottom line.

• Improved patient satisfaction. Perhaps one of the biggest changes you'll see after adding a continuous nerve block program is an increase in your patients' overall satisfaction. Keep in mind that patients who receive a single-shot block and are awakened at 2 a.m. by the excruciating pain of their surgical site are going to be the ones filling out their patient satisfaction surveys. CNBs prolong their comfort, which often means higher AHPS/OAS-CAHPS scores, which, in turn, will translate to higher Medicare reimbursements and possibly higher payments from private payers down the road.
• Increased case volume. Continuous nerve blocks also let you perform surgeries in an outpatient environment that may not have always been possible. They are part of the reason why we're seeing patients head home just a few hours after procedures like knee replacements and advanced shoulder surgeries.
• Better word-of-mouth. A robust CNB program also boosts your facility's reputation among potential patients, driving more business to your center. We routinely get patients that say they come to Andrews specifically because they've heard how great our pain control is after knee, ankle and shoulder surgeries. That's a reputation that's hard to put a price tag on.

— Brandon Winchester, MD

3. Find the right pain pump
Your choices in pain pumps are endless, which can make the task of choosing the right one for your patients overwhelming. Typically, it's best to first break down your options into either elastomeric or electronic categories. Elastomeric are often more simple and disposable and don't require a battery or other electronic feature to deliver the anesthetic, while electronic pumps are programmed specifically for the patient and when finished are often mailed back to the company or facility to be cleaned and reused on future patients. Disposable electronic pumps are also available.

There are benefits and disadvantages to both. Typically in most outpatient environments, a simple, disposable elastomeric pump will work well, especially if it has a bolus feature, which some studies have shown improve pain management for post-op patients. However, disposable, elastomeric pumps can be less accurate at providing precise amounts of local anesthetic to the patient. Electronic pumps often have useful features like 24-hour delays that can prolong post-op analgesia, but remember that the more features a pump has, the more that can potentially go wrong with it.

Benefits of one pump type versus another may vary depending on the surgery. For blocks that tend to have a high success rate with a continuous infusion, like interscalene catheters and femoral catheters, the best option might be a simple elastomeric disposable pump with no bolus feature that is very easy for patients to understand and manage. For more complex blocks like adductor canals, where success can be improved with intermittent large 8 to 10 ml boluses (scheduled or patient controlled), you might consider an elastomeric or electronic pump that offers these added features.

4. Multi-media patient education
Even with the latest and greatest technology, one of the best ways to ensure your block program is successful is to ensure that patients understand what the CNB is and how it will impact them post-operatively before they even step foot in the surgical facility.

At our center, we do this using a multi-stage, multi-media patient education program. First, patients receive a brochure at their surgeon's office when they schedule surgery. The brochure goes over the procedure and what to expect in the days after the operation. This is key: You want to set patients' expectations clearly before their day of surgery, so they know that they will often experience some pain, but that the block will help minimize it.

In pre-op, we show patients a homemade "basics of blocks" video on an iPad. After the video, a block nurse gives patients a hands-on lesson on the pump they'll receive, including how to care for it at home, and answers any questions. After the procedure, the recovery room nurse reviews things once more and gives patients written discharge instructions that include a link to the video they saw in pre-op so they get to re-watch it at home.

5. Own patient complaints
One of the things that makes our program stand out from other facilities that place CNBs is that if a patient ever has a problem — and there will be problems, even in our program where we're placing dozens of blocks a week — we don't shy away from bringing the patient back in and fixing it.

Part of placing continuous nerve blocks is understanding that there are inherent risks associated with the procedure and that the success rate is not 100%. But what's more important is how you handle these issues. For example, if a catheter comes loose or migrates, impacting the patient's comfort, we don't simply tell the patient, "Sorry, take your pain medications. There is nothing we can do," as some facilities may do. Rather, we bring them back in and will either replace the block or adjust the catheter until they're no longer in pain.

For facilities interested in adding CNBs to their program, I highly recommend that you not only have a plan in place for patients presenting with emergency complications (which are exquisitely rare), but also for the more minor issues like the ones above that may be an inconvenience for the patient. Not only could you help reduce the risk of hospital readmissions for pain or catheter problems, but patients will also take notice of the extra effort you put into their care. OSM