Relying on Regional Anesthesia

A successful block program is an essential element of effective multimodal pain management strategies.

Necessity is the mother of invention, which is something anesthesiologist Brian Kashin, MD, FRCPC, and his colleagues experienced firsthand while launching a regional anesthesia program at North York General Hospital in Toronto.

“It came about because of a clinical need,” he says. “We wanted to improve the perioperative flow and pain management of our patients.”

Foundation of a block program

The program they created was built on a foundation of core elements that contribute to increased efficiencies, satisfied surgeons and improved patient care.

• A dedicated space. Regional blocks should be placed in a procedure area before cases begin to maximize use of valuable OR minutes. Dr. Kashin and his colleagues first focused on placing blocks in hip and knee replacement patients and started the process after patients had been brought into the OR. The practice grinded surgical efficiencies to a halt as block teams had to wait until rooms were cleaned between cases before getting to work. It was an inefficient use of time that wasted about 45 minutes and resulted in nearly four hours of lost operative time each day. Dr. Kashin and his team therefore decided there was a business case to be made for creating and staffing a dedicated block room. The area sits adjacent to the ORs and contains four bays, where patients are wheeled after being prepped in pre-op.

Blocks need time to take effect, which must be factored into the day’s schedule. For example, patients undergoing knee procedures at North York General receive spinal anesthesia and adductor canal and iPACK blocks, which require 20 to 30 minutes to place and numb the joint. Hernia surgery requires peripheral truck blocks, which need about 40 minutes of soak time. “We’re now able to place these blocks as the ORs are being turned over,” explains Dr. Kashin. “That between-case efficiency saves a significant amount of time and allows us to perform more surgeries.”

• Consistent approach. Successful regional anesthesia programs eliminate decision-making when it comes to setting up the equipment and supplies needed to place blocks, says anesthesiologist Tom Durick, MD, an assistant professor at The Ohio State University Wexner Medical Center in Columbus. “A standardized set-up is key,” he explains. “The needles, local anesthetics and probes should be kept in a centralized location, so providers don’t go hunting for them when they’re needed. A lot of attention is paid to how quickly blocks are placed, but the time needed to set up for the procedure is an often-overlooked aspect. Your team shouldn’t spend 15 minutes preparing for a block that takes five minutes to place.”

Dr. Durick creates kits the day before planned procedures that include the essential items — syringes, needles, local anesthetics, ultrasound probes, probe covers and gel — he needs to place blocks. He’s also worked in surgery centers that kept block supplies in a well-organized storage room, where providers could grab what they need in minutes. At Ohio State, he helped to standardize supplies in dedicated block carts that are now set up the same way across the health system’s surgery centers and HOPDs. “Providers know in which drawer specific items are located,” says Dr. Durick. “That has taken the guesswork out of preparing for blocks and expedited the process.”

Your team shouldn’t spend 15 minutes preparing for a block that takes five minutes to place.
— Tom Durick, MD

• Frontline facilitators. Assign an anesthesia provider to facilitate the placement of blocks, improve patient flow and serve as champions of the program, suggests Dr. Kashin. They can supervise less experienced practitioners and help them improve their techniques. “That builds a core set of knowledge that’s passed on to providers, so they gain greater confidence in their techniques, achieve a higher block success rate and have fewer complications,” says Dr. Kashin.

Creating the role of a block nurse can help keep a program on track, according to Dr. Durick. The block nurse at Ohio State Medical Center sets up procedure areas for block placement and acts as an air traffic controller of sorts, coordinating the schedules of physicians and the movement of patients to ensure candidates for blocks are identified before the day of surgery and the care team is alerted. The nurse reviews the surgical schedule a day or two in advance to flag potential block patients based on the procedure they’re scheduled to undergo and contacts the surgeon to confirm that a block should be placed. The nurse also populates a regional anesthesia field in the health system’s EMR, so providers know blocks are needed in advance of procedures and can refer to the records for documentation that they occurred.

Block room nurses and anesthesia assistants help to prepare the block room each morning. The anesthetist who is assigned to serve as the block room physician arrives by 7:30 a.m. to place blocks for the first cases and is on hand to assist colleagues throughout the day.

• Advanced techniques. Anesthesia professionals should never stop developing their block-placement skills in order to keep pace with developments in the field. In 2019, providers at North York Hospital placed about 1,700 blocks, one of the highest volumes among Canadian facilities, according to Dr. Kashin. At that time, the hospital employed 28 anesthetists, 17 of whom were comfortable placing blocks. The others, according to Dr. Kashin, continued to develop their skills and became more comfortable with the techniques. “Providers who have been hired subsequently have completed a regional anesthesia fellowship or have a great deal of expertise in the field,” he says.

MORNING ROUTINE Standardizing the supplies and set-ups used to place blocks increases overall efficiencies and improves outcomes.

Dr. Kashin is a senior clinician and the regional anesthesia and ultrasound guidance techniques he developed over time were the result of his completion of continuing education courses and mentorship by colleagues in practice. The standardized way blocks are placed at the hospital creates a unified block team and allows experienced providers to share their knowledge and skills more easily with colleagues. Dr. Durick is involved in teaching experienced providers how to effectively place a wide variety of blocks, including pectoralis and TAP blocks. “Don’t be stingy with knowledge,” he says. “Any provider who wants to learn how to place blocks should be taught.”

Ultrasound guidance is the standard of care in block placement and there’s no excuse for facilities failing to have enough units on hand to ensure providers can keep pace with case volumes, according to Dr. Durick. “The cost of the technology is dropping significantly, and newer handheld units offer a less expensive option,” he says. He points out that facilities and physicians can bill Medicare and private insurers for use of the ultrasound guidance using CPT code 76942 (with different modifiers for the facility and physician fees).

• Digitized records. On peak days, providers in the block room at North York General care for about 25 patients, a significant volume that demands a coordinated effort among dedicated providers. Patients who are scheduled to receive blocks are entered into the hospital’s EMR and block room nurses assign the patients to one of the four bays in the block room. On the day of the procedures, the block room physician enters the patients into the hospital’s EMR, which is populated with the procedures patients are scheduled to undergo. The system automatically generates anesthesia digital order sets for each block to be placed, including specific concentrations and volumes of the local anesthetic that will be used.

• Surgeon buy-in. Achieving success in regional anesthesia demands constant communication with surgeons to keep them informed about the importance and advantage of a regional block program. “The placement of blocks should not slow down patient flow,” says Dr. Durick. “Blocks need to be placed efficiently and they need to be effective. Otherwise, your surgeons will push back against the program within its first week.”

Consistency in how blocks are placed — in method and quality — gives surgeons confidence in the program, according to Dr. Kashin. “They’ll be impressed by how comfortable their patients were after surgery, how few pain medications they required and how much throughput increased,” he says. OSM