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

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This introductory presentation outlines the importance of initiating a successful Acute Pain Service (APS) in order to optimize Patient Satisfaction as well as Clinical & Financial Outcomes. The cornerstone of an APS Program that translates into significant outcome differences is a Continuous Peripheral Nerve Block (CPNB). You will not translate your efforts into improved safety or financial gain by taking the 'easy road', by exponentially increasing patient monitoring or by working in a poorly-organized system. If you continue to ignore the consequences of hanging on to the ineffective, costly and dangerous practice of using IV opioids as your primary analgesic agent, you will continue to hemorrhage money from your facility and deliver inferior patient care. There are other important reasons both for Hospital Administrators and Anesthesiologists 'team up' to improve health care in your community. If you are interested in hearing more about how to change your Anesthesia Department from a cost center to a revenue center and provide cutting-edge patient care in your community, contact Dr Jerry Jones at 731-616-8540 or visit our website at CPNBconsulting.com. "Smart Business. Better Care."

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  • Agency for Health Care Policy and Research 1992 aggressive pain treatment, educate pt to speak up if in pain
  • Agency for Health Care Policy and Research 1992 aggressive pain treatment, educate pt to speak up if in pain
  • We had a plan, gave instructions, went home and hurt like hell
  • Look at chronic pain in a little more detail….
  • Diffuse response & often out of proportion especially with ‘intended’ surgical event part of the problem of painNeuroendocrine ResponseHPA axis activated by PAGProportional to stimulus (+/-)‘Recognize, Protect, Escape’Diffuse responseOften undesirable effects
  • Ok, on to it.This is how most people approach it…everyone wants to talk about the needle & the approach and the volume of LANobody thinks about how to keep it goingNeither are minor changes and both cause stress
  • Ctr ‘tough’ person won’t significantly affect outcomeNot chronic painNausea, easy confusion w few pills, very high tolernceRib fx, phantom limb pain, chronic pain sd
  • Ok, on to it.This is how most people approach it…everyone wants to talk about the needle & the approach and the volume of LANobody thinks about how to keep it goingNeither are minor changes and both cause stress
  • Is this not a reasonable goal for us as health care providers?If you are one who says we are doing fine as we are or my pts don’t hurt, pay attention to the next few slides
  • EVERY AREA will be affected positively or negatively when a ‘process’ is addedI SPECIFICALLY DON’T WANT TO SHOW HOW THINGS LOOK B/C IT IS ALWAYS DIFFERENT AND DON’T WANT YOU TO THINK IT NEEDS TO LOOK/BE SOME SPECIAL WAYHeres examples of how goNOT A GREEN BAND ON PRIOR TOCASEod organization will sustain things or how failure can happen if not addressed
  • Works for static & dynamic pain & balanced to prevent serious side effects of therapyLittle/no pain & no significant side effects to achieve this!!X2 inpt to outpt; quicker awake/out the doorSecondary injuries- MI/CVA/blood clots - stayed on vent/icu >> pneumonia - osa!! - prolonged confusion >> fall
  • Its not just for your benefit…and this is a ‘plus’ for everyone!
  • Introductory Lecture to Patients, Hospital Administration & Anesthesia Dept - CPNB Consulting LLC

    1. 1. A NEW ERA IN ACUTE PAIN CONTROL CREATING A NERVE BLOCK PROGRAM Jerry Jones M.D.
    2. 2. OBJECTIVES 1. 2. 3. 4. Is Pain THAT big of a Problem? What is a Nerve Block „Program’? How to develop a successful Program Answer you Questions
    3. 3. 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 Treatment Total Healing for David Stanley, MD 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, board-certified vascular surgeon and medical director of the MMC Wound Treatment Center, patients undergoing radiation therapy may suffer symptoms related to radiation fibrosis—in which tissue become scarred. “Symptoms of radiation fibrosis include cystitis or proctitis, which is a condition characterized by pain and bleeding following radiation for prostate, colorectal, and other pelvic cancers,” says Dr. Stanley. “As time goes by, the fibrosis becomes progressively worse, and even a mild injury to the area can develop into a hard-to-heal wound.” Portable Pain Block How We Can Help Dr. Stanley encourages any patient who has undergone radiation therapy and anticipates surgery in that same area of the body to ask their physician for a referral to the Wound Treatment Center for a consultation. Team members can take a transcutaneous oxygen measurement to determine whether healing will occur following surgery. “Failure to take this precaution before even just a minor procedure can cause serious complications,” Dr. Stanley says. “We want to ensure the health and safety of each of our patients.” Visit us at www.mmcoakridge.com and click on the “What Our Patients Say” tab to see how others have benefited from care at the Wound Treatment Center. Prolongs Relief Many patients who undergo certain surgical procedures at Methodist experience extended pain relief without depending on as much traditional pain medication. Known as the continuous peripheral Jerry Jones, MD nerve block, this new treatment uses nerve-numbing medication that extends the traditional 12- to 15-hour window of pain relief coverage of a “single injection” nerve block to more than two days. The new pain block is not appropriate for every patient that undergoes surgery. However, it can significantly reduce the need for traditional pain medication when it is appropriately used. “We administer the treatment through thin catheters attached to balloon-like pumps,” explains Jerry Jones, MD, board-certified anesthesiologist at Methodist Medical Center of Oak Ridge. “Those pumps are concealed within a fanny pack and drip the medication through the catheter to a nerve bundle just under the skin for two to three days.” 10 MMCO AK RIDG E.CO M FALL/WINTER 2010 .C Providing Exclusive Service According to Dr. Jones, patients can remove the bandage at home and dispose of the entire unit once the treatment 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 superior analgesia pain control through a multimodal regimen,” says Dr. Jones. “We work to offer our patients the most effective pain control with the least side effects.” To read more about this pain block option through the experiences of actual patients, visit www.mmcoakridge.com and click on the “What Our Patients Say” tab.
    4. 4. QUESTIONS? JJONESMD@CPNBconsulting.com
    5. 5. PAIN Management
    6. 6. 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).
    7. 7. 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 issued 77% believed it is necessary to experience pain after surgery 57% 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
    8. 8. 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 pain 23% had pain medication side effects 75% believed it was necessary to experience some pain 90% were satisfied with pain & pain medication
    9. 9. 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 surgery 88% pts indicated analgesic instructions were absolutely clear. Here‟s our plan: Do surgery Send you home You hurt like %!# for 3-5 days. Got it? “Yes, Absolutely clear….. I guess that’s normal ”
    10. 10. IMPACT OF ACUTE PAIN Chronic PainNerve Injury   Spontaneous Transcriptional changes, Changes in neighboring neuron Pain Barrage of nociceptive input & Loss of growth factors, 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 & MortalityMyocardial 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;93:1123-33 G Joshi et al Consequences of Inadequate Postoperative Pain Relief & Chronic Persistent Postoperative Pain Anesthesiology Clinics North Americ2005;23:21-36 R Ritchey Optimizing Postoperative Pain Management Cleveland Clinic Journal of Medicine 2006;73:1: S72-6
    11. 11. IMPACT OF ACUTE PAIN Increased 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;93:1123-33 G Joshi et al Consequences of Inadequate Postoperative Pain Relief & Chronic Persistent Postoperative Pain Anesthesiology Clinics North Americ2005;23:21-36 R Ritchey Optimizing Postoperative Pain Management Cleveland Clinic Journal of Medicine 2006;73:1: S72-6
    12. 12. 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;93:1123-33 G Joshi et al Consequences of Inadequate Postoperative Pain Relief & Chronic Persistent Postoperative Pain Anesthesiology Clinics North Americ2005;23:21-36 R Ritchey Optimizing Postoperative Pain Management Cleveland Clinic Journal of Medicine 2006;73:1: S72-6
    13. 13. 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;111:6:1175-6 Nelson et al Opioid-induced Decreases in Rat Brain Adenosine Levels Are Reversed by Inhibiting Adenosine Deaminase Anesthesiology 2009;111:6:1327-33
    14. 14. 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 OPIOIDS B-blockers good, but limited in scope (too late & affects too few areas)
    15. 15. 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
    16. 16. 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)
    17. 17. 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
    18. 18. 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.
    19. 19. CHALLENGE OF USING OPIOIDS Recognizing 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
    20. 20. AT RISK FOR RESPIRATORY DEPRESSION 1. 2. 3. 4. Obstructive Sleep Apnea Morbid Obesity with high OSA Risk Snoring Older Age    5. 6. 7. 8. 9. 10. 11. 12. 61-70 yo  2.8x higher risk 71-80 yo  5.4x higher risk >80 yo  8.7x higher risk No recent Opioid use Post-Surgery, especially upper abdomen or thoracic Increased Opioid dose requirement or habituation Longer time under General Anesthesia Using other sedating drugs Preexisting Cardiac or Pulmonary disease Other Major Organ disease or dysfunction Smoker The Joint Commission Sentinel Event Alert Issue 49, August 8, 2012
    21. 21. 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
    22. 22. ‘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
    23. 23. EXAMPLES OF OUTCOME SUCCESS A 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)
    24. 24. 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.
    25. 25. WHAT IS A NERVE BLOCK ‘PROGRAM’ ?
    26. 26. 2 PARTS TO DEVELOPING A PROGRAM Thanks for Noticing! Infrastructure Guy with Needle
    27. 27. SINGLE SHOT NERVE BLOCK Minimize 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 intubation Less Work, Maintenance & Cost than CPNB Program Faster than CPNB, minimal pt/staff education, usually no pt follow-up, no pump cost & < materials cost May have to „Guess‟ right dose of local anesthetic/avoid completely Shoulder/arm surgery with COPD Possible Compartment Syndrome Inadequate 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!
    28. 28. CPNB OVERVIEW Continuous: 2 days – > week vs 12 – 15 hrs with single injection vs 4-6 hrs with infiltration Can titrate initial dose Adjust 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
    29. 29. BASIC TECHNIQUES Nerve Stimulation Stimulating Needle Tip+/- Stim Catheter Stimulator shows nerve proximity (??) Does not indicate orientation to nerve Once injection starts, it is no longer reliable Ultrasound Visualize tissues, needle, & spread of local Only a 2D view; may not visualize needle tip Bigger learning curve: Anatomy, Artifacts, Hand-eye, „Knobology‟ Both (Dual Approach) Good when learning or for deep blocks N.S. or USG as primary modality & the other as „alarm‟ or „confirmation‟ Slower than either N.S. or USG alone NOT „double safe‟, maybe < either alone
    30. 30. LAYERED ANALGESIC STRATEGY MULTI-MODAL & OPIOID-SPARING!! IV Opioids (unless NPO) CLINICIAN BOLUS Oral Opioids PRN (then add scheduled long-acting*) CPNB BOLUS SCHEDULED Non-Opioid Rx Oral & IV Tylenol, Ibuprofen, Toradol, Celecoxib (vs Inflammation), Neurontin, Ketamine CPNB
    31. 31. HOW MUCH BENEFIT? Patient Selection Surgical Procedure „Stoic‟ 60 yom, bad airway 40 yom pt 40 yom pt, severe PONV 101 yof pt, mild Alzheimer‟s 60 yom pt, 380 lb, severe OSA 70 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 Second CTR with MAC/local Rotator cuff repair Rotator cuff repair Bimalleolar ORIF Ankle Total shoulder repair (1,200 EBL) ORIF radius/ulna Endo AAA repair Proximal humerus nail BKA for gangrenous foot, signs of sepsis
    32. 32. CPNB COMMONLY USED: Post-operative Pain Control 1.  ‘Moderate’ or ‘Severe’ Pain ‘Problems’ with Traditional Therapy Usually Orthopedic Surgeries 2. 3. 4.  Chest/Breast, Abdominal, Vascular, Hernia Within a Multimodal Therapy Plan 5.  6. or as the primary anesthetic (Avoid G.A.?) P.O. Opioids, NSAIDS, Ice (vs INFLAMMATION) Inpatients & Outpatients
    33. 33. 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;102:248-57 T Winkler Journal of Shoulder & Ebow Surgery 2009;18:4:566-72 2. Less Opioids/Side Effects 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 vs IV PCA, Epidural
    34. 34. 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/Rehabilitation Ilfeld Reg Anesth and Pain Med 2005;30(5):429-33 De Ruyter J Arthroplasty 2006;21(8):1111-7 X Capdevila Anesthesiology 2006;105:566-73 L Kadic et al Acta Anaesthesioogica Scandanavica 2009;7:914-20 N Cohen et al Journal Shoulder and Elbow Surgery 2000;9:268-74 B Williams et al Anesthesiology 2000;93:2:529-38 J Apfelbaum et al Anesthesiology 2002;97:1:66-74
    35. 35. EVIDENCE FOR BENEFIT 7. Outcome -Vascular surgery/Thrombosis AVF/Reimplantation P Inberg et al Acta Anaesthesiol Scand 1995;39:518-22 V Loland et al Pediatric Anesthesia 2009;19:9:905-7 E 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;21:730-3 30% changed from AVG to AVF or proximal to distal with Plexus Block V Yildirim et al Scand Cardiovasc Journal 2006;40:380-4 Stellate block: Increased flow, peak velocity, Successful Access P<0.001 Prevented radial artery spasm due to arterial dilation Maturation 41 days (vs 77) P=0.001 D Shemesh et al Ultrasound Med Biol 2006;32:817-22 Pulsitility Index still low 5 hrs after surgery (vs end surgery with GA) D Shemesh et al Cardiovasc Surgery 2003;11:35-41 AVF lower immediate & early failure rate: 0%, 6.8% AVF lower 1 yr primary & 2 yr secondary patency rate: 81.8%, 98.6% with BPB
    36. 36. EVIDENCE FOR BENEFIT 8. Outcome -Cancer Recurrence & Immune Modulation A Exadaktylos Anesthesiology 2006;105:4:660-4 C Deegan British J Anesthesia 2009;103:5:685-90 C Deegan et al Regional Anesthesia and Pain Medicine 2010;35:6:490-5 Y Tsuchiya et al Surgery 2003;133:5:547-555 D Sessler European Journal Cancer Prevention 2008;17:3: 269-72 D Sessler et al Contemporary Clinical Trials 2008;29:4:517-26*** (5 year, multi-center randomized trial, 1,100 pts underway) Retrospective 129 pts, continuous PVB vs GETA Recurrence- & Metastasis free Survival Rate: 24 months: 94% vs 82% 36 months: 94% vs 77% (P=0.012) IL-10 (at) MMP-3 (t) MMP-9 (t) IL-1B (t) GA -15% 29% 74% -4.2% Paravertebral 10.2 % 2.5% 26% -26% P 0.001 0.011 0.020 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”
    37. 37. EVIDENCE FOR BENEFIT 9. Outcome - Chronic Pain J 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;2:146-51 J Dahl & S Moiniche British Medical Bulletin 2004;71:13-27 G Strichartz IARS Review Course Lectures 2009;14-21 S Ganapathy Regional Anesthesia & Analgesia 2002;1:27-32 S Reuben Anesthesiology 2004;101:5:1215-24
    38. 38. EVIDENCE FOR BENEFIT 10. Fast-Tracking Patients B Williams et al Anesthesiology 2000;93:2:529-38 D Wilmore, H Kehlet British Medical Journal 2001;322:473 J Apfelbaum et al Anesthesiology 2002;97:1:66-74 B Williams et al Anesthesiology 2002;97:4:981-88 B Williams et al Anesthesiology 2004;100:3:697-706* B Ilfeld et al Anesthesiology 2008;105:5:999-1007 E Mariano et al Journal Clinical Anesth 2009;21:4:253-57 P 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)
    39. 39. HEALTH CARE CHANGES Must find ways to accomplish more daily: 1.      < Costs > Patient Satisfaction Minimize Complications Eliminate Patient Care „Outliers‟ Accomplish more & in less time Maintain business & Attract more business: 2.   Stand out from the competition Continue (+) outcomes with new increased volumes
    40. 40. 2 PARTS TO DEVELOPING A PROGRAM Infrastructure
    41. 41. ‘EFFECTIVE’ PAIN CONTROL These 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
    42. 42. BASIC SURGERY DIAGRAM OPERATING ROOM SURGEON‟S OFFICE RECOVERY ROOM (PACU) BLOCK ROOM or HOLDING ROOM FLOOR or SAME DAY SERVICES (SDS) PRE-TESTING CLINIC (PAT) PREP AREA (SDS) REGISTRATION HOME
    43. 43. 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
    44. 44. 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
    45. 45. 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
    46. 46. 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*
    47. 47. Program Development
    48. 48. 3 WAYS TO EXPAND A BLOCK PROGRAM: 1. 2. 3. Increase Costs, Cause Delays, Unreliable System, Stressful Environment, Little Change in Quality of Patient Care „Break Even‟ (but Patients are doing better) VERY Satisfied Patients, Decrease Costs, Increase Efficiency, Greater Safety, Enjoyable Process, Everyone is Proud to be part of the Program
    49. 49. IMPLEMENTING A PROGRAM 1. 2. 3. 4. 5. CLEAR PLAN CLEAR ROLES CLEAR ENDPOINTS CONSERVATIVE PACE WITH SUPPORT
    50. 50. CLEAR PLAN Individualized Course 1.    Established Formula 2.   Literature Review Clinical Experience Comprehensive Approach 3.    4. Current Resources Opportunities for Growth Highest Impact Populations First (High Risk, Case Volume) Infrastructure Patient & Staff Education Maintenance & Growth Adjustments as Needed
    51. 51. CLEAR ROLES Multidisciplinary TEAM Approach 1.   Leadership 2.    3. 4. Input Requested („Our Program‟) Communication „One Trains the Many‟ Approach (Champions) Expand Education in Waves Organizing toward future processes Success in Limited Scope, then Expand Cross-Train staff, not hiring more staff
    52. 52. CLEAR ENDPOINTS Goals defined after Initial Evaluation 1. 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 Monitor Progress 2.   Validate Keep on Track
    53. 53. CONSERVATIVE PACE One Phase at a time 1.    In order to Maintain Safety Have to challenge yourself & learn something new, but… Still stay within your comfort zone (Anesthesia & Staff) Discrete changes in Service Lines („Start Dates‟) 2.   Though we are already planning next steps to change… No one is caught off guard or is unprepared Your Resources  Pace of Changes 3.   Too fast  ERRORS Too slow Forget Processes, Lose Skills & Interest
    54. 54. WITH SUPPORT Hospital-wide Process 1.    Anesthesia Department is only the Start! Meetings, Inservicing & Educational Materials Coordination & Communication GOOD NEWS 2.    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
    55. 55. YOU SHOULD FEEL GOOD ABOUT THIS!! Patient WIN - analgesia, side-effects, home faster, better rehab & sleep, complications, other fewer 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
    56. 56. 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!

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