Introductory Lecture to Patients, Hospital Administration & Anesthesia Dept - CPNB Consulting LLC

A NEW ERA IN ACUTE PAIN CONTROLCREATING A NERVE BLOCK PROGRAM

Jerry Jones M.D.

OBJECTIVES

1. Is Pain THAT big of a Problem?2. What is a Nerve Block ‘Program’?3. How to develop a successful Program4. Answer you Questions

WHO AM I? Private Practice for 11 years Got interested in CPNB in 2007 Developed two CPNB Programs ‘from scratch’ Affiliate Faculty at Union University Speaker & Consultant to: B Braun, I-Flow, Ambu,

others CPNB CONSULTING LLC T reatm ent

Da vid St an le y, M D

For many patients with cancer, radiation therapy is a lifesaving treatment—but killing cancer cells frequently doesn’t come without adversely affecting healthy tissue. Fortunately, Methodist Medical Center of Oak Ridge’s Wound Treatment Center offers hyperbaric oxygen therapy that can help many patients make a total recovery.

According to David Stanley, MD, How W e Can Help

board-certified vascular surgeon D r. Stanley encourages any patient a n d m e d ic a l d ir e c to r o f th e M M C w h o h a s u nd e r g o n e r a di a tio n t he r ap y W o u n d T r e a tm e n t C e n te r, p a t i e n t s a n d an t ic ip ate s su rg e ry in th at sa m e a re a u n d e rg o in g ra d ia t io n t h e ra p y of the body to ask their physician for a may suffer symptoms related to re fe r ra l to th e W o u n d Tre atm e nt C e n te r radiation fibrosis—in which tissue for a consultation. Tea m m e m b e rs b e c o m e sc a r r e d . can take a transcutaneous oxygen

“Symptoms of radiation fibrosis m e a su rem e n t to d ete rm in e w h e th er include cystitis or proctitis, which is healing will occur following surgery. a c o n d i tio n c h a r a c te ri z e d b y p a in “Failure to take this precaution before and bleeding following radiation e ve n ju st a m ino r p ro c e d ure c a n ca u se fo r p ro s t a te , c o lo r e c ta l , a n d o th e r serious complications,” Dr. Stanley says. pelvic cancers,” says Dr. Stanley. “As “ W e w a n t to e n su re th e h ea l th a n d time goes by, the fibrosis becomes safety of each of our patients.” progressively worse, and even a mild in ju r y to th e a r e a c a n d e v e lo p in to a Visit us at www.mmcoakridge.com and click on the h a rd - to - h e a l w o u n d . ” “What Our Patients Say” tab to see how others have

benefited from care at the Wound Treatment Center.

Portable Pain Block Many patients who undergo certain surgical procedures at Methodist experience extended pain relief without depending on as much traditional pain medication.

Providin g Exclusive Service A c c o rd in g to D r. Jo n e s, p a t ie n t s c a n re m o v e th e b a n d ag e

a t h o m e a n d d is p o s e o f th e e n t ir e u n it o n c e th e t re atm e n t is complete. As the only local healthcare provider that makes the continuous peripheral nerve block service available, Dr. Jones says patient satisfaction at Methodist is our highest priority.

“Our facility optimizes patient treatment by providing s u p e r io r a n a lg e s ia p a in c o n t ro l th r o u g h a m u l t im o d a l re g im e n ,” says Dr. Jones. “We work to offer our patients the most effective pain control with the least side effects.”

To read m or e abo u t th is pa in b lock o pt io n thr ough the ex per ien c es o f

actual patients, visit www.mmcoakridge.com and click on the “What Our Patients Say” tab.

MM MM CC OO AA KK RR II DD GG EE . CC OO MM FAL L/W IN T E R 2 01 0 .

H ealing for T otal

n e r v e - n u m b in g m e d ic a t io n th a t e x te n d s the traditional 12- to 15-hour window of pain relief coverage of a “single injection” nerve block to more than two days. T h e n e w p a in b lo c k is n o t a p p r o p r ia te f o r e v e r y p a t i e n t th a t u n d e rg o e s surgery. However, it can significantly reduce the need for traditional pain medication when it is appropriately used.

“ W e a d m in iste r th e t re a tm e n t th ro u g h thin c ath e te r s a tta ch e d to balloon-like pumps,” explains Jerry Jones, MD, board-certified anesthesiologist at Methodist Medical Center of Oak Ridge. “ T h o s e p u m p s a re c o n c e a le d w i th in a f a n n y p a c k a n d d r ip th e m e d ica t io n th ro u g h th e ca th e t er to a n e rv e b u n d le ju s t u n d e r th e skin for two to three days.”

J er ry Jo nes , MD K n o w n a s th e c o n tin u o u s p e r ip h e r a l

nerve block, this new treatment uses

P ro lo ng s R elie f

10

QUESTIONS?

[email protected]

PAIN Management

WHY PAIN CONTROL IS IMPORTANT Patient satisfaction has always been important, but with

Medicare reimbursement being partially dependent on HCAHPS scores, failure to address pain management could literally be detrimental to a hospital’s bottom line.

Clear correlations between satisfaction with pain control and overall patient satisfaction are abundant in the literature.

Hospitals with the top 15% of HCAHPS scores had 26% more patients reporting pain well controlled than the bottom 15% (Healthgrades Press Release, 6-2-09).

HOW ARE WE DOING?Acute Pain Management: Programs in U.S. Hospitals and Experiences and Attitudes among U.S. Adults Warfield, Kahn Anesthesiology 1995;83:5:1019-94

500 Adults interviewed 1 year after AHCPR guidelines issued77% believed it is necessary to experience pain after surgery57% cited pain after surgery as primary fear (51% whether surgery improve

condition) 77% reported pain with 80% of those reporting moderate to extreme! Despite this, pts often reported satisfaction since they expected pain

HOW ARE WE DOING?Postoperative Pain Experience: Results from a National survey Suggest Postoperative Pain Continues to Be Undermanaged

Apfelbaum et al Anesthesia & Analgesia 2003;97:534-40

250 adults who had surgery within 5 years ‘representative of U.S.’80% had acute pain after surgery, 58% before & 75% after D/C home*86% was moderate, severe, extreme, 39% severe (same if >1 yr

ago<)*59% were most concerned about pain (whether surgery would help 51%)

8% delayed surgery due to fear of pain23% had pain medication side effects75% believed it was necessary to experience some pain90% were satisfied with pain & pain medication

HOW ARE WE DOING?30% of Patients have Moderate to Severe pain 24 hours after Ambulatory Surgery: a survey of 5,703 patients.

B McGrath et al Canadian Journal Anaesthesia 2004;51:9: 886-91 Most painful: Microdiscectomy, Lap Chole, Shoulder, Elbow/Hand, Ankle, Inguinal Hernia & Knee surgery88% pts indicated analgesic instructions were absolutely clear.

Here’s our plan: Do surgerySend you homeYou hurt like %!# for 3-5 days. Got it?“Yes, Absolutely clear….. I guess that’s normal ”

IMPACT OF ACUTE PAINChronic Pain-

Nerve Injury Barrage of nociceptive input & Loss of growth factors, Spontaneous Transcriptional changes, Changes in neighboring neuron Pain

At Particular Risk: Thoracotomy, Breast Surgery, Inguinal Hernia, Amputation The more intense and prolonged acute pain is, the more likely it is to develop.

Morbidity & Mortality-Myocardial Ischemia, DVT, Pulmonary Complications, Ileus,Emesis, Oliguria, Increased Infection, Muscle Atrophy, Bone loss, Tumor Spread or Recurrence, Impaired Nutritional Intake

F Perkins, H Kehlet Chronic Pain as an Outcome of Surgery A Review of Predictive Factors Anesthesiology 2000;93:1123-33G Joshi et al Consequences of Inadequate Postoperative Pain Relief & Chronic Persistent Postoperative Pain Anesthesiology Clinics North Americ2005;23:21-36R Ritchey Optimizing Postoperative Pain Management Cleveland Clinic Journal of Medicine 2006;73:1: S72-6

IMPACT OF ACUTE PAINIncreased Use of Health Care Resources

- Unplanned Admissions, Readmissions - Longer Stay - More Co$tly Stay - More Follow-up Visits & Care

Anxiety- Increases Pain Perception

Patient Dissatisfaction #1 Driver of Patient Satisfaction: PAIN CONTROL F Perkins, H Kehlet Chronic Pain as an Outcome of Surgery A Review of Predictive Factors Anesthesiology 2000;93:1123-33G Joshi et al Consequences of Inadequate Postoperative Pain Relief & Chronic Persistent Postoperative Pain Anesthesiology Clinics North Americ2005;23:21-36R Ritchey Optimizing Postoperative Pain Management Cleveland Clinic Journal of Medicine 2006;73:1: S72-6

IMPACT OF ACUTE PAIN

Delayed Discharge: PACU & Hospital - > use of supplies, medications - > manpower (time & interventions)

Prolonged Recovery/Return to ADL - Greater bone/muscle loss- Opportunity for ‘secondary complications’

F Perkins, H Kehlet Chronic Pain as an Outcome of Surgery A Review of Predictive Factors Anesthesiology 2000;93:1123-33G Joshi et al Consequences of Inadequate Postoperative Pain Relief & Chronic Persistent Postoperative Pain Anesthesiology Clinics North Americ2005;23:21-36R Ritchey Optimizing Postoperative Pain Management Cleveland Clinic Journal of Medicine 2006;73:1: S72-6

IMPACT OF ACUTE PAIN

Delays in Wound Healing- Catabolic state, Vasoconstriction, Collagen Deposition,

Immobilization, Low- O2 Tension L McGuire et al Pain & Wound Healing in Surgical Patients. Ann Behavioral Medicine 2006;31:165-72 K Woo; R Sibbald The Improvement of Wound-Associated Pain and Healing Trajectory With a Comprehensive Foot and Leg Ulcer Care Model. Journal of Wound, Ostomy & Continence Nursing 2009; 36:2: 184-91 Nimmo WS, Duthie DJ. Pain relief after surgery. Anaesth Intensive Care 1987; 15(1): 68-71.

Disrupted Sleep & Worsened Pain- Opioids Disrupt Sleep Further, Worsening Pain

Moore & Kelz Opiates, Sleep, and Pain: The Adenosinergic Link Anesthesiology 2009;111:6:1175-6Nelson et al Opioid-induced Decreases in Rat Brain Adenosine Levels Are Reversed by Inhibiting

Adenosine Deaminase Anesthesiology 2009;111:6:1327-33

NEUROENDOCRINE ‘STRESS’ RESPONSE CARDIOVASCULAR*

(>BP, HR, SVR, CVA & ischemia risk)

RESPIRATORY*(> work of breathing)

GASTROINTESTINAL (ileus, nausea)

URINARY (retention)

HEMATOLOGIC (hypercoagulable, > DVT/PE risk)

IMMUNE*(depressed, > cancer spread/recurrence)

ENDOCRINE (> Cortisol, ADH, Epi = catabolic state, negative N balance & nutrition status)

WELL-BEING (anxiety, poor sleep, worsened pain perception, immobility)

AROUSAL & ENDOGENOUS OPIOIDSB-blockers good, but limited in scope (too late & affects too few areas)

CHALLENGE OF PAIN MANAGEMENT BALANCE: the pain problems & the pain treatment

problems No objective monitor for pain! Want to minimize Negative Side-Effects of Opioids Avoid ADE & Safety Issues Inter-patient response to Opioids is very variable As well, Avoid Side-Effects of Adjunct therapies

GI, Renal, Coagulation, Fracture-Healing, Sedation Epidural: immobility, coagulants, infection, hypotension, foley

GOAL: Optimize recovery economically & D/C early

COST OF HOSPITAL COMPLICATIONS Acute mental health changes - $3,206 In-hospital trauma & fractures (fall)-

$5,370 Renal failure without dialysis - $9,934 Venous thrombosis - $15,976 Pneumonia - $16,901 Decubitis ulcer - $28,272

(Healthcare Financing Review, Summer 2009, Vol. 30, #4, 17-32)

CHALLENGE OF USING OPIOIDS Central effect, so helpful for pain anywhere Central effect, so side-effects are everywhere

Hypotension, Respiratory, Ileus, PONV, Confusion, Sedation, Itching

Easier to titrate for static conditions (like convalescing)

Difficult for dynamic pain (cough, OOB, ambulating, active P.T.)

Enough to tolerate P.T. = Too sedated to do P.T.

Higher doses lead to > Monitoring & > Cost

ECONOMICS OF USING OPIOIDS

Opioid-Related Adverse Drug Events in Surgical Hospitalizations: Impact on Costs and Length of Stay. Ann Pharmacother, 2007, Odera, G.M. et.al.

RESULTS: Patients experiencing opioid-related ADEs had significantly increased median total hospital costs (7.4% increase; 95% CI 3.83 to 10.96; p < 0.001) and increased median LOS (10.3% increase; 95% CI 6.5 to 14.2; p < 0.001) compared with matched non-ADE controls. Higher doses of opioids were associated with increased risk of experiencing ADEs (OR 1.3; 95% CI 1.07 to 1.60; p = 0.01)

CONCLUSIONS: These ADEs occurred more frequently in patients receiving higher doses of opioids.

CHALLENGE OF USING OPIOIDSRecognizing opioid prescribing risks:

Addiction: In a study of 28,000 patients who had minor surgery who received opioids for <7 days, 10% were identified as long term opioid users at 1 year*

Side effects: nausea and vomiting, over-sedation & respiratory depression**, leading to other complications and increased LOS Enormous implications for OSA & other at risk patients

Prolonged & Increased Inpatient monitoring as Inpatient Discharging as an Outpatient

** The Joint Commission Sentinel Event Alert Issue 49, August 8, 2012*Source: outpatientsurgery.net/news/2012/03/16-Study-Opioids-After-Minor-Surgery-Can-Lead-to-Addiction

AT RISK FOR RESPIRATORY DEPRESSION

1. Obstructive Sleep Apnea2. Morbid Obesity with high OSA Risk3. Snoring4. Older Age

61-70 yo 2.8x higher risk 71-80 yo 5.4x higher risk >80 yo 8.7x higher risk

5. No recent Opioid use6. Post-Surgery, especially upper abdomen or thoracic7. Increased Opioid dose requirement or habituation8. Longer time under General Anesthesia9. Using other sedating drugs 10. Preexisting Cardiac or Pulmonary disease11. Other Major Organ disease or dysfunction12. Smoker

The Joint Commission Sentinel Event Alert Issue 49, August 8, 2012

NEED FOR AN OPIOID ALTERNATIVE

Relying on Opioids as the primary analgesic, especially for moderate to severe pain is inadequate, unsafe & costly

Multimodal Regimens: Opioid-sparing Minimize side-effect profiles of individual

therapies

‘EFFECTIVE’ PAIN STRATEGY

Depth- intensely block nociception (NSAIDS are inadequate for major surgery) Width- to block entire surgical area (incisional Ropivicaine for ORIF inadequate) Length- to last long enough into postoperative period

(s.s. interscalene block inadequate for total shoulder replacement)

I Kissin Preemptive Analgesia Anesthesiology 2000;93:1138-43

EXAMPLES OF OUTCOME SUCCESSA continuous infusion fascia iliaca compartment block in hip fracture patients: A pilot study Dulaney-Cripe et al Journal of Clinical Medicine Research, 4(1): 45-8; 2012

Algorithmic plan: early aggressive pain management and <24 hours door to OR

Aggressive post-operative pain management with a focus on opioid reduction and continuous regional block infusion

First year after implementation: saved average of $2350 per patient

Continuous intercostal nerve blockade for rib fractures: ready for primetime? Truitt, M.S. & Murry, J. et.al., Journal of Trauma, 71(6): p. 1548-1552; 2011

Comparison study of epidural to continuous nerve block infusion Numeric pain score at rest dropped from 7.5 to 2.6 Average LOS dropped 3 days (2.9 days from 5.9 days from historical

control)

BOTTOM LINE… Poor control of acute pain has negative

physiologic and financial consequences.

Optimizing acute pain control can lead to improvement in patient outcomes and to increase revenue.

WHAT IS A NERVE BLOCK

‘PROGRAM’ ?

2 PARTS TO DEVELOPING A PROGRAM

Guy with NeedleInfrastructure

Thanks forNoticing!

SINGLE SHOT NERVE BLOCKMinimize opioids & other medications Less Side-effects (nausea, confusion, somnolence) Fewer ‘slow’ emergences (shorter turnover time) Quicker Discharge home RN’s work decreased (more efficient system)‘Avoid’ General anesthetic Avoid Airway concerns (bad AW, full stomach, sore throat, dental damage) No Volatiles/Ventilator effects (nausea, atelectasis, hypotension) Minimize/avoid hemodynamic changes of intubationLess Work, Maintenance & Cost than CPNB Program Faster than CPNB, minimal pt/staff education, usually no pt follow-up, no pump cost & < materials costMay have to ‘Guess’ right dose of local anesthetic/avoid completely Shoulder/arm surgery with COPD Possible Compartment SyndromeInadequate length of analgesia less translation into (+) outcomes Often wear off in the middle of the night Worse on outpatients Better than incisional local anesthetics or not doing anything at all!

CPNB OVERVIEWContinuous: 2 days – > week

vs 12 – 15 hrs with single injectionvs 4-6 hrs with infiltrationCan titrate initial doseAdjust rate of infusion to effect Add bolus intermittently

Catheter is Perineural NOT intraarticular (permanent injury) NOT subcutaneous (soft tissue spread)

Local anesthetics only OK to add pain pills/IV pain meds OK to take it home/disposable No abuse potential & No tolerance No inter-variable patient response

BASIC TECHNIQUES Nerve Stimulation

Stimulating Needle Tip+/- Stim CatheterStimulator shows nerve proximity (??)Does not indicate orientation to nerveOnce injection starts, it is no longer reliable

UltrasoundVisualize tissues, needle, & spread of localOnly a 2D view; may not visualize needle tipBigger learning curve: Anatomy, Artifacts, Hand-eye, ‘Knobology’

Both (Dual Approach)Good when learning or for deep blocksN.S. or USG as primary modality &the other as ‘alarm’ or ‘confirmation’ Slower than either N.S. or USG aloneNOT ‘double safe’, maybe < either alone

LAYERED ANALGESIC STRATEGY MULTI-MODAL & OPIOID-SPARING!!IV Opioids (unless NPO) CLINICIAN BOLUSOral Opioids PRN (then add scheduled long-acting*)

CPNB BOLUSSCHEDULED Non-Opioid RxOral & IV Tylenol, Ibuprofen, Toradol, Celecoxib (vs Inflammation), Neurontin, Ketamine

CPNB

HOW MUCH BENEFIT? Patient Selection‘Stoic’ 60 yom, bad airway40 yom pt40 yom pt, severe PONV101 yof pt, mild Alzheimer’s60 yom pt, 380 lb, severe OSA70 yom pt, MI 8/2013 EF 20%75 yof pt, 6 mo POCD after L1-L5 lami in 2012 (No GA please!)

80 yof home O2, COPD exac & just extubated, has M.H.60 yom in CHF, home O2, OSA non-operable CAD, Plavix

Surgical ProcedureSecond CTR with MAC/localRotator cuff repairRotator cuff repairBimalleolar ORIF Ankle Total shoulder repair (1,200 EBL)

ORIF radius/ulnaEndo AAA repair

Proximal humerus nail

BKA for gangrenous foot, signs of sepsis

CPNB COMMONLY USED:1. Post-operative Pain Control

or as the primary anesthetic (Avoid G.A.?)

2. ‘Moderate’ or ‘Severe’ Pain3. ‘Problems’ with Traditional Therapy4. Usually Orthopedic Surgeries

Chest/Breast, Abdominal, Vascular, Hernia

5. Within a Multimodal Therapy Plan P.O. Opioids, NSAIDS, Ice (vs INFLAMMATION)

6. Inpatients & Outpatients

EVIDENCE FOR BENEFIT

1. Best Analgesia vs IV PCA, intraarticular, incisional, selective or single nerve blocks Singelyn Anesth Analg 1999;89:1216-20 Chelly J Arthroplasty 2001;16(4):436-45 Eledjam Reg Anesth Pain Med 2002;27(6):604-11 White Anesth Analg 2003;97:1303-9 Salinas Anesth Analg 2006;102:1234-9 Richman Anesth Analg 2006;102:248-57T Winkler Journal of Shoulder & Ebow Surgery 2009;18:4:566-72

2. Less Opioids/Side Effects vs IV PCA, Epidural Ilfeld Anesthesiology 2002;96(6):1297-1304 Horlocker Reg Anesth Pain Medv2002;27(1):105-8 Capdevila Anesthesiology 1999;(1):8-15 De Ruyter J Arthroplasty 2006;21(8):111-7 Singelyn Reg Anesth Pain Med 2005;30(5)452-57 Barrington Anesth Analg 2005;101:1824-9

3. Improved Sleep Ilfeld Anesthesiology 2002;96(6):1297-1304 Ilfeld Anesthesiology 2002;97(4):959-65 Zaric Acta Anaesth Scand 2004;48:337-41

Nelson Anesthesiology 2009;111:6:1327-33

EVIDENCE FOR BENEFIT

4. Outpatient instead of Inpatient ABUNDANTLY CLEAR for multiple procedures sited in the literature Ilfeld et al Reg Anesth and Pain Med 2006;31:172-76 (Total Elbow) ILfeld et al Reg Anesth Pain Med 2005;101:1319-22 (Total Shoulder)

5. Patient Satisfaction I’ve never seen a study ranking any other modality higher than CPNB Buckenmaier Best Practice and Clin Anesth 2002;16(2):255-70 Singelyn Reg Anesth Pain Med 2005;30(5):452-57 Singelyn Anesth Analg 2001;92:455-9 Ilfeld Anesthesiology 2002;97(4):959-65

6. Outcomes – ROM/RehabilitationIlfeld Reg Anesth and Pain Med 2005;30(5):429-33De Ruyter J Arthroplasty 2006;21(8):1111-7X Capdevila Anesthesiology 2006;105:566-73L Kadic et al Acta Anaesthesioogica Scandanavica 2009;7:914-20N Cohen et al Journal Shoulder and Elbow Surgery 2000;9:268-74 B Williams et al Anesthesiology 2000;93:2:529-38J Apfelbaum et al Anesthesiology 2002;97:1:66-74

EVIDENCE FOR BENEFIT

7. Outcome -Vascular surgery/Thrombosis AVF/Reimplantation

P Inberg et al Acta Anaesthesiol Scand 1995;39:518-22V Loland et al Pediatric Anesthesia 2009;19:9:905-7E Malinzak Analgesia & Anesthesia 2009;109:3:976-80$600 million/yr for interventions to MAINTAIN access (1/4 fail – stenosis, low flow)I Laskowski et al Ann Vasc Surgery 2007;21:730-330% changed from AVG to AVF or proximal to distal with Plexus BlockV Yildirim et al Scand Cardiovasc Journal 2006;40:380-4Stellate block: Increased flow, peak velocity, Successful Access P<0.001 Prevented radial artery spasm due to arterial dilation Maturation 41 days (vs 77) P=0.001D Shemesh et al Ultrasound Med Biol 2006;32:817-22Pulsitility Index still low 5 hrs after surgery (vs end surgery with GA)D Shemesh et al Cardiovasc Surgery 2003;11:35-41AVF lower immediate & early failure rate: 0%, 6.8%AVF lower 1 yr primary & 2 yr secondary patency rate: 81.8%, 98.6% with BPB

EVIDENCE FOR BENEFIT

8. Outcome -Cancer Recurrence & Immune ModulationA Exadaktylos Anesthesiology 2006;105:4:660-4C Deegan British J Anesthesia 2009;103:5:685-90 C Deegan et al Regional Anesthesia and Pain Medicine 2010;35:6:490-5Y Tsuchiya et al Surgery 2003;133:5:547-555D Sessler European Journal Cancer Prevention 2008;17:3: 269-72D Sessler et al Contemporary Clinical Trials 2008;29:4:517-26*** (5 year, multi-center randomized trial, 1,100 pts underway) GA Paravertebral P

Retrospective 129 pts, continuous PVB vs GETA IL-10 (at) -15% 10.2 % 0.001Recurrence- & Metastasis free Survival Rate: MMP-3 (t) 29% 2.5% 0.011 24 months: 94% vs 82% MMP-9 (t) 74% 26% 0.02036 months: 94% vs 77% (P=0.012) IL-1B (t) -4.2% -26% 0.003

In vitro study of serum from breast cancer patients who underwent PVB for surgery reduces proliferation of breast cancer cells significantly when compared with GA/opioid serum. Rate proliferation: -24% vs 73% (P=0.01) “Alters cellular milieu”

EVIDENCE FOR BENEFIT

9. Outcome - Chronic PainJ Katz et al Clinical Journal of Pain 1996;12:1:50-55 “Early post-op pain is the only factor that significantly predicts long-term pain after thoracotomy.”P Kairaluoma et al Anesthesia & Analgesia 2006; 103:3: 703-8 (ss* PVB)G Iohom et al Anesthesia & Analgesia 2006;103:4:995-1000 (Cont. PVB) No pts (0/14) with CPNB had Chronic pain vs 80% (12/15) standard therapy “Post-operative analgesia is an important determinant of CPSP after breast surgery” J Eisenach Regional Anesthesia & Pain Medicine 2006;2:146-51J Dahl & S Moiniche British Medical Bulletin 2004;71:13-27G Strichartz IARS Review Course Lectures 2009;14-21S Ganapathy Regional Anesthesia & Analgesia 2002;1:27-32S Reuben Anesthesiology 2004;101:5:1215-24

EVIDENCE FOR BENEFIT

10. Fast-Tracking PatientsB Williams et al Anesthesiology 2000;93:2:529-38D Wilmore, H Kehlet British Medical Journal 2001;322:473J Apfelbaum et al Anesthesiology 2002;97:1:66-74B Williams et al Anesthesiology 2002;97:4:981-88B Williams et al Anesthesiology 2004;100:3:697-706*B Ilfeld et al Anesthesiology 2008;105:5:999-1007E Mariano et al Journal Clinical Anesth 2009;21:4:253-57P White IARS Review Course Lectures 2009

948 ACL patients over 4 years (5 anesthetic types)Reduced PACU admissions TO 18% for nerve block (to 98% w

GA)Reduced unplanned admissions from 17% to 3 or 4% (with

block)Only 3 pts with nerve blocks admitted for pain (block wore off)

PACU Bypass & < admissions reduced costs by 12% ($98,600/yr) (P=0.0001)

HEALTH CARE CHANGES1. Must find ways to accomplish more daily:

< Costs > Patient Satisfaction Minimize Complications Eliminate Patient Care ‘Outliers’ Accomplish more & in less time

2. Maintain business & Attract more business:

Stand out from the competition Continue (+) outcomes with new increased volumes

2 PARTS TO DEVELOPING A PROGRAM

Infrastructure

‘EFFECTIVE’ PAIN CONTROLThese improved outcomes and reduced morbidities are much more likely to manifest when used in a system-wide recovery strategy.

“Importantly, there is a critical need for collaborations between the various healthcare providers involved in perioperative patient care (e.g., anesthesiologists, surgeons, nurses, & physiotherapists) to integrate improved perioperative pain management with the recently described fast-track recovery paradigms. This type of combined approach is well documented to improve the quality of the recovery process and reduce the hospital stay and postoperative morbidity, leading to a shorter period of convalescence after surgery.

P White, H Kehlet Improving Postoperative Pain Management Anesthesiology 2010;112:1:220-5

BASIC SURGERY DIAGRAMSURGEON’S

OFFICE

PRE-TESTING CLINIC (PAT)

REGISTRATION

PREP AREA (SDS)

BLOCK ROOM or HOLDING

ROOM

OPERATING ROOM RECOVERY

ROOM (PACU)

FLOOR or SAME DAY SERVICES

(SDS)

HOME

NERVE BLOCK PROGRAM

Patient Satisfaction Better experience with effective analgesia (& tell their friends) I would argue this alone is an adequate reason to pursue

Improve Safety Respiratory Depression/Airway Issues (OSA, COPD, full stomach) Secondary Injuries (MI, CVA, blood clots, pneumonia) Confusion/POCD (Elderly)

Affect Outcomes Decrease Length of Hospital Stay (Faster Day Surgery, Fewer days) Improve Early Range of Motion Improve Mobility & Hasten Recovery Minimize Inactivity-induced Muscle and Bone Loss Decreased Persistent Pain Decreased Cancer Spread and Recurrence

NERVE BLOCK PROGRAM

Decreased Length of Stay Hospital $$ Savings Avoid Inpatient Events (nosocomial pneumonia)

Faster O.R. Turnover Fewer ‘slow’ wake ups Less Overtime Surgeons like this, too

Faster Outpatient Discharge Can Skip PACU completely & drops SDS time to D/C as well Shorter PACU times & less O.R. Bottle-necking Decreased Staffing Needs for Hospital/Surgery Center

Outpatient instead of Inpatient Case

NERVE BLOCK PROGRAM

Decreased RN Workload R.N.’s can perform job more effectively & more

safely Less interventions

Our Hospital’s Image New Surgeons Attracted Public more cases!

Job Satisfaction YOU Your O.R. staff Your Hospital Staff

ANESTHESIA SERVICE Seeing a big difference in patient

outcomes by your effort is very satisfying Less ‘problems’ to tend to in the PACU &

floor Perioperative role of anesthesia service

recognized by hospital & public Appreciation from surgeon colleagues,

nursing staff and administration*

ProgramDevelopment

3 WAYS TO EXPAND A BLOCK PROGRAM:

1. Increase Costs, Cause Delays, Unreliable System, Stressful Environment, Little Change in Quality of Patient Care

2. ‘Break Even’ (but Patients are doing better)

3. VERY Satisfied Patients, Decrease Costs, Increase Efficiency, Greater Safety, Enjoyable Process, Everyone is Proud to be part of the Program

IMPLEMENTING A PROGRAM

1. CLEAR PLAN2. CLEAR ROLES3. CLEAR ENDPOINTS4. CONSERVATIVE PACE5. WITH SUPPORT

CLEAR PLAN1. Individualized Course

Current Resources Opportunities for Growth Highest Impact Populations First (High Risk, Case Volume)

2. Established Formula Literature Review Clinical Experience

3. Comprehensive Approach Infrastructure Patient & Staff Education Maintenance & Growth

4. Adjustments as Needed

CLEAR ROLES1. Multidisciplinary TEAM Approach

Input Requested (‘Our Program’) Communication

2. Leadership ‘One Trains the Many’ Approach (Champions) Expand Education in Waves Organizing toward future processes

3. Success in Limited Scope, then Expand4. Cross-Train staff, not hiring more staff

CLEAR ENDPOINTS1. Goals defined after Initial Evaluation

Ex: FNB for TKA Initial Goals Check Box to Surgeon Orders: “[ ] Request Nerve Block” 2 RN trained to assist with blocks 1 RN Champion for every shift on Orthopedics Floor < PACU time by 75% Eliminate PCA use & ICU transfers due to ADE’s < PONV treatments by 75% 100% pts to 90 degree ROM on DOS < LOS by 1 day 90% Pt Satisfaction rating of ‘Excellent’ this population All returning TKA pts asked to do 3 Q survey to compare stay

2. Monitor Progress Validate Keep on Track

CONSERVATIVE PACE1. One Phase at a time

In order to Maintain Safety Have to challenge yourself & learn something new, but… Still stay within your comfort zone (Anesthesia & Staff)

2. Discrete changes in Service Lines (‘Start Dates’)

Though we are already planning next steps to change… No one is caught off guard or is unprepared

3. Your Resources Pace of Changes Too fast ERRORS Too slow Forget Processes, Lose Skills & Interest

WITH SUPPORT1. Hospital-wide Process

Anesthesia Department is only the Start! Meetings, Inservicing & Educational Materials Coordination & Communication

2. GOOD NEWS It CAN be done! In fact, I’ve even done this where it was “IMPOSSIBLE” This process is NOT Theoretical:

Built ‘from scratch’ twice, influenced Programs nationally

‘REAL WORLD’ Private Practice Methods & Results Model being requested by B Braun nationally

YOU SHOULD FEEL GOOD ABOUT THIS!!Patient WIN - analgesia, side-effects, home faster, better rehab & sleep, fewer complications, other

Nurses WIN- happier patients, less issues to fix, easier to get job done

Hospital WIN- patient satisfaction, length of stay, staffing cost, more pts, staff satisfaction, compliance, supply cost

Surgeons WIN- Happier patients, more referrals, less ‘issues’ to address, less rounds

Anesthesia WIN- image with admin/surgeons, satisfaction, safety, new revenue

Healthcare WIN- resource utilization, avoid complications, less cost

FINAL THOUGHTS… Beyond the humanitarian interest in patient comfort, PATIENT SAFETY & IMPROVED OUTCOMES have an important impact on health care utilization and cost.

This is one more cog in the wheel to improve patient care, satisfaction and safety!