1. Nurse Inservice Series
Evolution of Nerve Block Program
Jerry Jones M.D.
CPNB Consulting LLC

3. 2 PARTS TO DEVELOPING A PROGRAM
Infrastructure
Guy with Needle

4. EVOLUTION OF BLOCK PROGRAMS
1. On occasion, a few of the MD‟s/CRNA‟s may do a SS block (1-3 blocks)
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Very little organization needed at all, and no real follow-up on pts needed
Need the CART & HORSE basics to be developed
2. All MD/CRNA‟s do a few SS block types for same basic situation/case X
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Some organization will help, especially for a busier practice and need CART basics help
Better Paperwork/Block Cart will help!
Goal is to get 1 thing added only, nothing big. (“Hey, that wasn‟t a big deal.”)
3. All or „Block Team‟ do lots of SS blocks/many types & rare CPNB is done
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Very likely can improve the efficiency, address follow-up to allow them to do more cases
May just need : better communication, A plan for Pt follow-up/better efficiency
Again, what is limiting them? HORSE and CART help

5. EVOLUTION OF BLOCK PROGRAMS
4. Regularly doing CPNB for limited type of case/block types (except Dr. Y…)
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Some things „on the menu‟ and Dr. Y runs „Chef Specials‟
Tremendous potential to expand and likely need help organizing system/follow-up
Need data gathered to prove point and to improve current outcomes
Is there severe opposition? Where? Why? CART and HORSE
Introducing Ultrasound, plan for patient follow-up strategy (inpt & outpt), > Efficiency
5. Regularly doing CPNB for expanding types of cases, many levels of skill
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Lots you can do here in organizing, planning, facilitating, help avoid mistakes.
They may know what they need, but just can‟t logistically get it done
Learning US, expanding to outpatients, Learning New Blocks/Need Insight (fine points)
It‟s on fire already. Don‟t screw it up during the expansion of the program!
6. Mature CPNB program, organized f/up, teach others/research, „up to date‟
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Many processes delegated to RN‟s or Nurse Practitioners with developed protocols
Have optimized P.T. schedule/plan, block bolus protocols, Multimodal Therapy

6. EVOLUTION OF BLOCK PROGRAMS
Single Shot
Continuous in-patient
Continuous outpatient
with disposable pumps

7. MMC BEFORE
MY GROUP
CRNAS, floor & P.T.
½ agreed to „allow‟ me to train them
½ neutral or tried to sabotage all of it
Thrown off by it
An added annoyance
ADMINISTRATION
O.R. STAFF
Very suspicious of adding cost
I had to beg for a 6 month „trial‟ with On-Q
Ambivalent/unaware/tolerant of it
PHARMACISTS
SURGEONS
A few agreeable/tolerated an attempt
A few really excited to get it
“MY patients don‟t need „all that‟/they don‟t
hurt/don‟t mess with the system”
Willing to try something new, but concerned
PATIENTS
„Worth a try‟ „Whatever you say‟
„I don‟t like needles‟
PAT/PHA/PACU
OTHERS
„Just being nice‟ vs acted ignorant
Most wanted it to die on the vine
Completely unaware…
Except when I talked to them about it

8. MMC EXPERIENCE IN BRIEF
Asked partners if they would help me
(Block Training for ½ of group on 1 block only)
(„Chef Specials‟ only at this point for Nerve Blocks)
Started working on the PROCESS more
(PT EDUCATION, LOGISTICS, PREPRINTED PAPERWORK)
(Started Outpatients then since I‟d done inpatients for months already)
Saw where/how it impacted other services
(INSERVICE OTHER DEPTS, CREATE PROTOCOLS, COMMUNICATING)

9. MMC EXPERIENCE IN BRIEF
Trained enough MD‟s to put CISB „On the Menu‟
(I did outpatient follow-up myself at first, delegated after patterns noted)
(Displayed Positive Results to the surgeons; Created a „Presence‟)
Started training „1st wave‟ on next block or 2 &
Slowly trained „2nd wave‟ on CISB
Improved PHA organization/Infrastructure
(STANDARDIZING PROCESSES, PROACTIVE ATTITUDE, EXPECTATIONS)
Developed same in SDS, PACU, 3East, O.R.

10. MMC EXPERIENCE IN BRIEF
Gathered Data/Surgeon „Perspective‟ for Admin
Fixed problems, modified protocols, got feedback
(ADDRESSED OBJECTIONS, FOUND SOLUTIONS, EMPOWERED PEOPLE)
Made incremental changes to the system
Planning for next processes/new blocks/facilities
(1 SURGEON, 1 CASE, 1 ANESTHESIOLOGIST & MADE MODIFICATIONS)

11. MMC AFTER
MY GROUP
CRNAS, floor & P.T.
ALL knew that it is a good thing & it works
„Haters‟ know there were no reasonable excuses to
hide behind anymore & started learning
„Proud‟ of program/absence of opioids & Goals met
Want to know more/learn.
Many have had cpnb‟s & are sworn believers!
ADMINISTRATION
O.R. STAFF
Big change in attitude (more facilitating)
Requested commercial & did even more advertising
Significant assistance, proactive.
Add own ideas to the system
Convince own family/friends to choose block if offered.
SURGEONS
More & more requests –even outside Orthopedics
Didn‟t need to remind them to „request‟ blocks.
„Hey, what can you do for this guy?...‟
VERY Appreciative.
PHARMACISTS
The „rest of the main staff‟ on board
„Hate‟ to see me though
PATIENTS
PAT/PHA/PACU
Some of most ardent advocates now that they have
SEEN the difference for self/pts/family members.
RN Directors took „ownership‟
SDS/PACU particularly appreciative
I don‟t have enough room here
OTHERS
I would lecture on daily basis just going to restroom or trying
to leave work!!
Thank me for „bringing‟ CPNB to MMC b/c their friend or
family had a great experience with one.

12. PROGRAM: ESSENTIAL ELEMENTS
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This is a „TEAM‟ sport
Reliable Results in Limited Scope  Expand
„On the Menu‟ vs „Chef Special‟
Poor Block Evaluation = Block Failure
Track your Results
Problems WILL come
All are UNIQUE; not all are GREAT!

13. PROGRESS IS PROCESS
Point A  Point Z
There are Points in between
Need Appropriate Support/Skill/Organization to Initiate Next Step
Work toward Reliable Results in Limited Scope
Get a „Feel‟ for Block/Process, Intraop & Postop mgmt (Inpts 1st)
Recognize Processes to improve Patient Care/Outcomes
Organize to Improve the efficiency of these processes
Address Issues, Problems along the way
Streamline Processes, make it user-friendly, greater uniformity
Train additional providers once „bugs‟ are out
Expand to more surgeons, then „Put block 1 on the Menu‟
Incrementally alter processes to optimize Patient Care/Outcomes
Plan ahead for tomorrow‟s cases today. How can we Streamline?

14. ONGOING PROGRESS
Start „building‟ Infrastructure
Look at System from Surgeon‟s Office to Going Home
 Communication lines in place? Getting RN feedback?
 Are Pts coming in early enough?
 Anesthesia have enough training?
 Are Pts going to PAT?
 Is Patient Education adequate?
 Do we need to change the order of procedures?
Is Block Paperwork in place, user-friendly?
 Are Block Assistants Organized, Educated, Proficient?
 OR/PACU management adequate, optimized?
 Are Orders adequate? What do Ortho RN‟s say?
 How long does Rounding/Pt Calls take? Problems?
 Make each „next step‟ Concrete

15. THINKING AHEAD
Reevaluate & Plan Ahead
What problems are we running into?
What block should we tackle next? What surgery? Which surgeon?
Are we getting compensated for new charges?
Are the catheters coming out, leaking, getting pulled out?
Do we need to modify our starting infusion rates?
What problems and advantages are we seeing on the floor?
Does it still make sense to train 75% of group before we introduce?
What can we do to deal with that problem with PAT?
Who should we talk to about the issue with PT?
Do we need to re-inservice the ortho floor now?
Are we efficient enough to begin tracking data?
Do everything, then delegate, then delegate further

16. SUCCESS
Sustainable at the „next‟ level
Initial „push-back‟ has ceased
Hearing ideas to continue to the „next‟ level
Seeing and hearing positive comments
Concrete difference in Patient Care
Seeing people satisfied with their work
Still have problems, but still  solutions
Enough „evidence‟ seen to continue
Efficient, Effective, Safe Process in place

17. MONITORING DATA -ONGOING VS HISTORICAL DATA
P.T. Goals met/exceeded
PACU times
PACU interventions
Cost of opioids/anti-emetics/monitoring/PCA
Length of Stay (LOS) inpatient & outpatient
Pt Satisfaction Scores
RN interventions on floor
Readmissions
O.R. time/Turnover time
Charges & Reimbursement
ICU/Step-Down stays and Complications (& costs)
PACU bypass (later)