PROPER PLANNING You must be committed to nerve block success to realize its many benefits.

True, regional anesthesia takes more time pre-operatively than general anesthesia, but blocks can make up that time, and then some, post-operatively. Blocks can shorten recovery times, decrease post-op pain and nausea, and let patients regain awareness and mobility sooner than with general anesthesia. Patients should be ready to move from the OR at least 15 minutes sooner than they would if they'd been under general anesthesia, and may even be able to go straight to Phase II recovery. However, you'll enjoy these back-end benefits only if you run an efficient block program. Here are some simple, sensible strategies to make that happen.

OFF AND RUNNING WITH REGIONAL A well-run nerve block program improves throughput and profitability.

1. Meet with patients pre-operatively. Before surgery, the surgeon or anesthesia provider should meet with the patient to discuss the anesthetic and pain management plan. Patients should understand what pain technique they'll receive, if any. The surgeon or anesthetist should also describe how and when the pain technique, such as a regional block, will be administered. During the pre-operative meeting, encourage an open Q&A dialogue with patients. Patients can ask any questions about the surgical process, including the anesthetic and pain management plans. Educate patients on the pain technique through handouts, videos or websites. This way, when the anesthesia provider walks in the door on the day of surgery, he can do the regional block and move the patient forward rather than spend his first 15 minutes answering questions from the patient and her family.

2. Check tomorrow's charts today. Have your staff review the next day's patient charts for any medical issues that might warrant a switch from regional to general anesthesia. For example, patients who are on blood thinners, such as Plavix (clopidogrel) or Coumadin (warfarin), should stop taking those medications 7 to 10 days before a block is to be performed. Patients with a history of severe chronic obstructive pulmonary disease or those who have undergone major cardiac procedures, such as valve replacements or bypass surgery, may not be good candidates for certain types of blocks. Look for potential bottlenecks in the schedule when you review patient histories. Let's say a dialysis patient slated for a block needs a potassium test done. These lab results can take 30 to 60 minutes to complete and get back. Seeing this the night before rather than being caught by surprise the day of surgery will let you plan accordingly.

3. Ready supplies at the bedside. If you've reviewed the schedule the night before, analyzed the patient's history and looked at the case she's scheduled for, you'll know what supplies will be needed. Why not ready them at the bedside before the case? This includes all medications, supplies and needles, as well as the ultrasound machine or nerve stimulator. This way, you're not running all over the facility in search of medical dressing, gloves or catheter kits. Having supplies at the ready keeps anesthesia providers happy, speeds up cases and lets you perform more regional blocks.

4. Instruct patients to arrive early. Block patients should arrive 15 to 20 minutes before surgery is scheduled to begin. This will let the anesthesia provider provide the regional block in a timely manner without being rushed. Perform blocks concurrently with the surgical procedures and not in a series. While the OR team is in a case, you should be performing a block on the next patient. This way, the block will be completed before the OR team is ready to take the patient to the OR. Remember, a block program that doesn't delay the surgeon sells itself.

5. Never perform blocks in the OR. When you perform blocks for the next case in a separate induction room while the current case proceeds, the effect on turnover time is neutral. Perform blocks outside the OR, either in pre-op bays or in a designated area or room set aside just for blocks. Nothing drains efficiency, impedes patient flow and kinks the schedule more than spending OR time on peripheral nerve blocks or epidurals.

6. Standardize drugs. See if you can stock 2 peripheral block medications in your cart plus 2% lidocaine for local infiltration. Most peripheral nerve blocks will be some combination of 1.5% mepivacaine and 0.5% ropivacaine, typically 15cc each. Most analgesic peripheral nerve blocks are typically 30cc of 0.5% ropivacaine. Limiting the block medications you stock in your cart will cut down on confusion and cost, and increase efficiency because you know the concentrations and doses of the medications.

7. Have a well-stocked block cart. Create a cart especially for your regional anesthesia patients. Your block nurse or anesthesia technician should restock the cart every day with, among other things, needles, sterile prep, drugs, nerve stimulators, ultrasounds and emergency medications. All patients need to have basic monitoring: EKG, pulse oximetry, blood pressure cuff and supplemental oxygen. Be prepared for immediate induction of general anesthesia or airway management needs. Be sure to stock Intralipid, an antidote to vascular collapse/cardiac arrest, which is a complication of inadvertent intravascular administration of local anesthetics.

Having supplies at the ready keeps anesthesia providers happy, speeds up cases and lets you perform more regional blocks.

8. Have patients move the surgical limb immediately after injection. Neural blockade is a frequency- and voltage-dependent phenomenon. Muscle activity opens the sodium channels that the local anesthetic blocks. Ask patients to actively move the surgical limb immediately after injection. You'll hasten block onset by increasing the number and frequency of open sodium channels available to the local anesthetic.

9. Don't overly sedate. It's common to sedate regional anesthesia patients to help them relax and sleep, but you might want to reserve pre-operative midazolam to sedate only your extremely anxious patients. Having patients alert and oriented facilitates flow — and keeps the block team moving. Plus, an anesthesia provider will have to remain at the overly sedated patient's side until she is fully aware.

10. Follow-up is priceless. Anesthesia providers should make an effort to follow up with patients post-operatively to make sure they're comfortable and don't have any serious side effects, such as neurological damage from regional blocks. Not only is following up a patient safety measure, but it also highlights the care and concern of the surgical facility, and aids post-operative data collection.

11. Appoint a dedicated block nurse. In addition to lightening the load for the rest of the anesthesia team, the presence of an experienced, educated block nurse who is familiar with correct injection pressure, ultrasound and nerve stimulation, and the ideal-sized syringes for local anesthetic to be injected can reduce the risk of nerve injuries and can also improve patient flow. Developing standard practices for regional blocks ultimately makes them faster and more efficient. The block nurse leads the time out with anesthesia before initiation of the block, goes through consents and site marking in the same way each time, organizes a block board that lists block rooms and patients for the day, and updates physician preference cards so you know what to have ready for each surgeon and anesthesia provider in each case. For example, a block nurse will know that the ankle surgeon always wants popliteal catheters and saphenous blocks with teaching done for the family before surgery. The block nurse will know what supplies to have and what needs to be complete before the procedure.