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Our regional anesthesia program ran like a well-oiled machine when we put a point person in charge.
MISSING LINK With the addition of Ted Link, RN, our full-time regional block nurse coordinator (second from left), the efficiency of our block program has dramatically improved. | Cleveland Clinic Hillcrest Hospital
When it comes to administering regional anesthesia blocks, we're big believers in the invaluable role a dedicated block nurse coordinator can play. It wasn't always that way, though.
Here at the Cleveland Clinic Hillcrest Hospital, we were faced with what was essentially a good problem to have: a growing anesthesia team that was more than willing and certainly able to provide regional blocks so we could reduce the number of
opioids we were giving our patients. What wasn't good, however, was how unprepared we were for such growth. We went from doing just a few blocks in a day to up to 20. That's when things got chaotic.
We were trying to do too many things at once: prep patients for surgery, perform nerve blocks and epidurals, and bring patients from the floor for pain blocks. Did I mention that we also run an ambulatory eye center in the same area where all
of this intermingling of activity was happening?
There was only one solution to restore order: standardize our block procedures and develop clear protocols on preparing and performing blocks.
Our block process used to be as follows: On the day of surgery, an anesthesiologist would determine whether we were going to do a block. More often than not, that would delay getting the patient into surgery on time and cause anxiety for the patient
because no one had discussed the block with him.
Plus, it wreaked havoc on our staffing. Nurses would get pulled out their 3-person assignment to give the block, and the team leader would then have to oversee that nurse's patients and staff would often wind up getting more patients.
Order in the midst of chaos
Because of all these issues, we decided to create a brand new position to ensure standardization and order for our regional blocks: We hired Ted Link, RN, to be a full-time regional anesthesia block nurse coordinator. We added a part-time
anesthesia tech, as well.
While this full-time position includes an array of responsibilities, perhaps none are more important than coordinating block scheduling with our physicians. Instead of just having choice anesthesia written on our erase board before our procedures,
Ted now specifies the anesthetic — for example, spinal width nerve block or general width epidural.
Ted reviews the schedule anywhere from several weeks in advance up until the night before the surgery to determine whether a nerve block should be an option. If something seems off about the schedule, he'll call up the physician and say, "Hey, I see you're doing this big belly case tomorrow. Would you like an epidural?" Often, this quick check-in is enough for the physician to see a block is really the way to go. On top of determining how many blocks we need to do, Ted decides how many nurses we'll need to assist with those blocks (in addition to himself).
He also meets with all of our total joint patients to tell them what to expect with the block process. And for any patient who's undergoing a nerve block, he'll call the night before to say, "Hi, my name is Ted. You're on the schedule for X, Y and Z. I just wanted to let you know we're bringing you in 2 hours early because we're performing a regional block before your trip to the OR."
Ted also assists our anesthesiologists with blocks, teaches and trains our nurses on block protocols (at least annually) and sits on our procedural sedation team.
MAKING THE ASK
How to Justify a Block Coordinator
KEY METRIC A well-run block program will boost your first case on-time starts.
Anytime you're proposing an investment to leadership as significant as a new full-time position or, in our case, a full-time nurse and part-time tech tandem, you need to go in ready with hard data.
When we made our case to our president and chief nursing officer (CNO) about the need for the dedicated positions in anesthesia, we made it crystal clear why the move was necessary — in terms they were sure to understand. First, we got
all of the key stakeholders to come to the table. On top of the president and CNO, I had our director of surgical services and one of our block anesthesia providers there to present evidence-based data on why what we were proposing was
so critical.
And we leaned heavily a metric we knew would hit home with our leadership: first case on-time starts (FCOTS). Ours were the worst for our orthopedics department. Drilling down into the data a little further, we were able to show that the reason
our FCOTS were so bad was because of all the delays to our regional blocks. That sure got everybody's attention.
If you want leadership to buy into what you're proposing, start by presenting evidence-backed data that's guaranteed to elicit some type of visceral reaction in them.
— Amy Berardinelli, DNP, RN, CPAN, NE-BC
Is it worth it?
If you're on the fence about dedicating a full-time position to your anesthesia blocks, listen to what happened after we put Ted in charge of coordinating every aspect of our blocks.
1We began using our pre-op space more efficiently. Before we decided on adding a full-time coordinator for our regional block program, we conducted a S.W.O.T. (Strengths,
Weakness, Opportunity and Threats) analysis. The weakness — lack of standardization and scheduling problems — were apparent before we ran the analysis, but what we uncovered during the Threats check was a real eye-opener.
We have 4 dedicated block rooms. In these rooms, our anesthesia documentation system feeds directly into our nursing system. The 2 systems will talk to each other and information will flow seamlessly. Plus, the rooms are fully stocked with
all the equipment we need to do a block. Before adding our coordinator, scheduling issues resulted in patients getting blocks down in any of our 20 pre-op rooms. Not only did this lead to a lot of unnecessary movement and special challenges
— navigating a small room, moving patients around unexpectedly and transporting equipment back and forth — it also led to documentation issues. In rooms where the systems didn't synch up, we'd wind up doing part of the documenting
on paper and part electronically and then filling in gaps later. Not good.
2We started standardizing our blocks. Good communication is contagious. Another huge benefit of adding a block coordinator was the increased communication among our anesthesia
providers.
Brandon Winchester, MD AMBULATORY ANESTHESIA Unlike femoral blocks, adductor canal blocks spare the quadriceps so the leg can maintain motor strength.
Before we added Ted to our team, our providers were doing different blocks for the same surgery. One would do an adductor canal block and one would use a femoral and sciatic block for the same surgery. Now, our anesthesiologists are very active
about discussing the blocks and trying whenever possible to give each patient the same block for the same procedure. Not only has this improved communication and led to a standardization of our blocks, it's also helped us get patients
ambulating faster by killing unnecessary multi-shot procedures.
Case in point: We realized when we were doing both a femoral and sciatic block on patients, our patients couldn't get up to walk afterward. Result: People wound up staying in the hospital overnight. In the vast majority of cases, we'll now
do a single adductor canal block in place of the femoral/sciatic combo. With this approach, we give patients essentially the same pain relief, but they're able to ambulate faster and be discharged sooner. Similar to traditional femoral
nerve blocks, adductor canal blocks provide rapid-onset analgesia. But unlike femoral blocks, they spare the quadriceps so the leg can maintain motor strength.
3We stopped using unnecessary opioids. Because we're located in a state that's disproportionally hard-hit by the opioid crisis (Ohio leads the nation in opioid overdose deaths),
we feel a responsibility to be part of the solution. And in many ways, having the perspective of a regional block nurse coordinator lets us do just that. Cutting fentanyl out of our sedation process is a prime example of how we're working
to reduce opioid usage. With his spot on the procedural sedation team, our coordinator is well-positioned to ask whether adding fentanyl was essentially just adding an unnecessary opioid to a process that would work just fine without a
narcotic. After all, patients were receiving a local anesthetic first, so the effects of the opioid weren't even felt. We now only use Versed (midazolam) instead of the Versed and fentanyl, and everything works out just fine.
OSM
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