1
|
An Anesthesia Block Room Is Financially Net Positive for a Hospital Performing Arthroplasty. J Am Acad Orthop Surg 2022; 30:e1058-e1065. [PMID: 35862214 DOI: 10.5435/jaaos-d-21-01217] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/17/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Regional anesthesia is increasingly used in total joint arthroplasty (TJA). It has shown efficiency benefits as it allows parallel processing of patients in a dedicated block room (BR). However, granular quantification of these benefits to hospital operations is lacking. The goal of this study was to determine the financial effect of establishing a BR using comprehensive operational modeling. METHODS A discrete-event simulation model of daily operating room (OR) patient flow for TJA procedures at a mid-sized hospital was developed. Two scenarios were tested: (1) without and (2) with a BR. Scenarios were compared according to staffing requirements, hours/day, and labor costs. The number of ORs and cases varied from 2 to 6 ORs performing 3 to 5 cases. These results were used as the inputs of a discounted cash flow (CF) model. Discounted CF model outputs were CF, net present value, internal rate of return, and return on investment. RESULTS Mean time savings of incorporating a BR were 68 min/d (range: 30 to 80 min/d), reducing the OR closing time by 1 hour. Incremental labor costs/day from nurse overtime pay ranged from $2,025 to $10,125 with no BR and $1,595 to $9,045 with a BR, which resulted in an increase in profit/day from $360 to $1,605. The CF/annum was $54,363, the net present value was $213,082, the internal rate of return was 12%, and the return on investment was 43.61%. DISCUSSION This study demonstrates that under all scenarios, a BR is more profitable than no BR to a hospital performing TJA via a bundled care or private payer remuneration model. A BR was shown to be financially net positive even when considering the necessary financial investment to establish it. In addition, this study demonstrates the potential of combining discrete-event simulation with financial analyses to assess various operational models of care to improve hospital efficiency, such as dedicated trauma rooms and swing rooms. LEVEL OF EVIDENCE Level III.
Collapse
|
2
|
Mazda Y, Peacock S, Wolfstadt J, Matelski J, Chan V, Gleicher YJ. Developing a business case for a regional anesthesia block room: up with efficiency, down with costs. Reg Anesth Pain Med 2021; 46:986-991. [PMID: 33980698 DOI: 10.1136/rapm-2021-102545] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/16/2021] [Accepted: 04/22/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Regional anesthesia techniques offer many benefits for total joint arthroplasty (TJA) patients. However, they require personnel and equipment resources, as well as valuable operating room (OR) time. A block room offers a dedicated environment to perform regional anesthesia procedures while potentially offsetting costs. METHODS The goal of this prospective quality improvement study was to develop a business case for implementation of a regional anesthesia block room and to demonstrate the cost-effectiveness of this program in decreasing OR time for TJA. All elective TJA patients presenting between January 2019 and March 2020 were included in our analysis. RESULTS Our detailed business plan was approved by the hospital leadership. 561 patients in the preintervention group and 432 in the postintervention group were included for data analysis. Mean total OR time per surgical case decreased from 166 to 143 min for a difference of 23 min (95% CI 17 to 29). Similarly, anesthesia controlled OR time decreased from 46 min to 26 min for a difference of 20 min (95% CI 17 to 22). The block room resulted in an additional primary TJA case per daily OR list. The percentage of TJA patients receiving a peripheral nerve block increased from 63.1% to 87.0% (p<0.001). No safety events or block room associated OR delays were observed. CONCLUSION Implementing a regional anesthesia block room required a comprehensive business plan for securing the necessary resources to support the program. The regional anesthesia block room is a cost-effective method to improve patient care and OR efficiency.
Collapse
Affiliation(s)
- Yusuke Mazda
- Division of Obstetric Anesthesia, Department of Anesthesiology, Saitama Medical Center, Kawagoe, Japan
| | - Sharon Peacock
- Anesthesiology and Pain Medicine, Sinai Health, Toronto, Ontario, Canada
| | - Jesse Wolfstadt
- Surgery, Division of Orthopaedics, Sinai Health, Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Vincent Chan
- Department of Anesthsia, University Health Network-, Toronto, Ontario, Canada
| | | |
Collapse
|
3
|
Johnston DF, Turbitt LR. Defining success in regional anaesthesia. Anaesthesia 2021; 76 Suppl 1:40-52. [PMID: 33426663 DOI: 10.1111/anae.15275] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/13/2022]
Abstract
Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.
Collapse
Affiliation(s)
- D F Johnston
- Department of Anaesthesia, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - L R Turbitt
- Department of Anaesthesia, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| |
Collapse
|
4
|
Desmet M, Bindelle S, Breebaart M, Camerlynck H, Casaer S, Fourneau K, Gautier P, Goffin P, Lecoq J, Lenders I, Leunen I, Van Aken D, Van Houwe P, Van Hooreweghe S, Vermeylen K, Sermeus I. Guidelines for the safe clinical practice of peripheral nerve blocks in the adult patient. ACTA ANAESTHESIOLOGICA BELGICA 2020. [DOI: 10.56126/71.3.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Peripheral Nerve Block working group of the Belgian Association for Regional Anesthesia has revised and updated the “Clinical guidelines for the practice of peripheral nerve block in the adult” which were published in 2013.
Collapse
|
5
|
Chitnis SS, Tang R, Mariano ER. The role of regional analgesia in personalized postoperative pain management. Korean J Anesthesiol 2020; 73:363-371. [PMID: 32752602 PMCID: PMC7533178 DOI: 10.4097/kja.20323] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 07/15/2020] [Indexed: 12/29/2022] Open
Abstract
Pain management plays a fundamental role in enhanced recovery after surgery pathways. The concept of multimodal analgesia in providing a balanced and effective approach to perioperative pain management is widely accepted and practiced, with regional anesthesia playing a pivotal role. Nerve block techniques can be utilized to achieve the goals of enhanced recovery, whether it be the resolution of ileus or time to mobilization. However, the recent expansion in the number and types of nerve block approaches can be daunting for general anesthesiologists. Which is the most appropriate regional technique to choose, and what skills and infrastructure are required for its implementation? A multidisciplinary team-based approach for defining the goals is essential, based on each patient's needs, and incorporating patient, surgical, and social factors. This review provides a framework for a personalized approach to postoperative pain management with an emphasis on regional anesthesia techniques.
Collapse
Affiliation(s)
- Shruti S Chitnis
- Department of Anesthesiology and Perioperative Care, University of British Columbia, Vancouver General Hospital, BC, Canada
| | - Raymond Tang
- Department of Anesthesiology and Perioperative Care, University of British Columbia, Vancouver General Hospital, BC, Canada
| | - Edward R Mariano
- Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|
6
|
McCartney CJL, Mariano ER. COVID-19: bringing out the best in anesthesiologists and looking toward the future. Reg Anesth Pain Med 2020; 45:586-588. [DOI: 10.1136/rapm-2020-101629] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 04/27/2020] [Indexed: 11/03/2022]
|
7
|
King R, Mariano ER, Yajnik M, Kou A, Kim TE, Hunter OO, Howard SK, Mudumbai SC. Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center. PAIN MEDICINE 2019; 20:2256-2262. [DOI: 10.1093/pm/pnz023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
The feasibility and safety of managing ambulatory continuous peripheral nerve blocks (CPNB) in Veterans Health Administration (VHA) patients are currently unknown. We aimed to characterize the outcomes of a large VHA cohort of ambulatory upper extremity surgery patients discharged with CPNB and identify differences, if any, between catheter types.
Methods
With institutional review board approval, we reviewed data for consecutive patients from a single VHA hospital who had received ambulatory CPNB for upper extremity surgery from March 2011 to May 2017. The composite primary outcome was the occurrence of any catheter-related issue or additional all-cause health care intervention after discharge. Our secondary outcome was the ability to achieve regular daily telephone contact.
Results
Five hundred one patients formed the final sample. The incidence of any issue or health care intervention was 104/274 (38%) for infraclavicular, 58/185 (31%) for interscalene, and 14/42 (33%) for supraclavicular; these rates did not differ between groups. Higher ASA status was associated with greater odds of having any issue, whereas increasing age was slightly protective. Distance was associated with an increase in catheter-related issues (P < 0.01) but not additional health care interventions (P = 0.51). Only interscalene catheter patients (3%) reported breathing difficulty. Infraclavicular catheter patients had the most emergency room visits but rarely for CPNB issues. Consistent daily telephone contact was not achieved.
Conclusions
For VHA ambulatory CPNB patients, the combined incidence of a catheter-related issue or additional health care intervention was approximately one in three patients and did not differ by brachial plexus catheter type. Serious adverse events were generally uncommon.
Collapse
Affiliation(s)
- Roderick King
- Stanford University School of Medicine, Stanford, California
| | - Edward R Mariano
- Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Meghana Yajnik
- Stanford University School of Medicine, Stanford, California
| | - Alex Kou
- Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - T Edward Kim
- Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Oluwatobi O Hunter
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Steven K Howard
- Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Seshadri C Mudumbai
- Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| |
Collapse
|
8
|
Updates on multimodal analgesia and regional anesthesia for total knee arthroplasty patients. Best Pract Res Clin Anaesthesiol 2019; 33:111-123. [DOI: 10.1016/j.bpa.2019.02.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/23/2019] [Accepted: 02/26/2019] [Indexed: 01/17/2023]
|
9
|
Levene JL, Weinstein EJ, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anesthetics and regional anesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children: A Cochrane systematic review and meta-analysis update. J Clin Anesth 2019; 55:116-127. [PMID: 30640059 DOI: 10.1016/j.jclinane.2018.12.043] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/23/2018] [Accepted: 12/18/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Regional anesthesia may mitigate the risk of persistent postoperative pain (PPP). This Cochrane review, published originally in 2012, was updated in 2017. METHODS We updated our search of Cochrane CENTRAL, PubMed, EMBASE and CINAHL to December 2017. Only RCTs investigating local anesthetics (by any route) or regional anesthesia versus any combination of systemic (opioid or non-opioid) analgesia in adults or children, reporting any pain outcomes beyond three months were included. Data were extracted independently by at least two authors, who also appraised methodological quality with Cochrane 'Risk of bias' assessment and pooled data in surgical subgroups. We pooled studies across different follow-up intervals. As summary statistic, we reported the odds ratio (OR) with 95% confidence intervals and calculated the number needed to benefit (NNTB). We considered classical, Bayesian alternatives to our evidence synthesis. We explored heterogeneity and methodological bias. RESULTS 40 new and seven ongoing studies, identified in this update, brought the total included RCTs to 63. We were only able to synthesize data from 39 studies enrolling 3027 participants in a balanced design. Evidence synthesis favored regional anesthesia for thoracotomy (OR 0.52 [0.32 to 0.84], moderate-quality evidence), breast cancer surgery (OR 0.43 [0.28 to 0.68], low-quality evidence), and cesarean section (OR 0.46, [0.28 to 0.78], moderate-quality evidence). Evidence synthesis favored continuous infusion of local anesthetic after breast cancer surgery (OR 0.24 [0.08 to 0.69], moderate-quality evidence), but was inconclusive after iliac crest bone graft harvesting (OR 0.20, [0.04 to 1.09], low-quality evidence). CONCLUSIONS Regional anesthesia reduces the risk of PPP. Small study size, performance, null, and attrition bias considerably weakened our conclusions. We cannot extrapolate to other interventions or to children.
Collapse
Affiliation(s)
- Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, United States of America
| | - Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, United States of America
| | - Marc S Cohen
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Doerthe A Andreae
- Department of Allergy/Immunology, Milton S Hershey Medical Center, Hershey, PA, United States of America
| | - Jerry Y Chao
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Matthew Johnson
- Human Development, Teachers College, Columbia University, New York, NY, United States of America
| | - Charles B Hall
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Michael H Andreae
- Department of Anesthesiology & Perioperative Medicine, Milton S Hershey Medical Center, Hershey, PA, United States of America.
| |
Collapse
|
10
|
Mudumbai SC, Auyong DB, Memtsoudis SG, Mariano ER. A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine. Pain Manag 2018; 8:475-485. [DOI: 10.2217/pmt-2018-0017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.
Collapse
Affiliation(s)
- Seshadri C Mudumbai
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - David B Auyong
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
- Departments of Anesthesiology and Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
11
|
Webb CAJ, Kim TE. Establishing an Acute Pain Service in Private Practice and Updates on Regional Anesthesia Billing. Anesthesiol Clin 2018; 36:333-344. [PMID: 30092932 DOI: 10.1016/j.anclin.2018.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute pain management is an expanding perioperative specialty and there is a renewed focus on implementing and developing an acute pain service (APS) in nonacademic hospitals (ie, "private practice"). An anesthesiologist-led APS can improve patient care by decreasing perioperative morbidity and potentially reducing the risk of chronic postsurgical pain syndromes. Elements of a successful APS include multidisciplinary collaboration to develop perioperative pain protocols, education of health care providers and patients, and regular evaluation of patient safety and quality of care metrics. Standardization of regional anesthesia procedures and billing practices can promote consistent outcomes and efficiency.
Collapse
Affiliation(s)
- Christopher A J Webb
- Department of Anesthesiology and Perioperative Medicine, Kaiser Permanente South San Francisco Medical Center, 1200 El Camino Real, South San Francisco, CA 94080, USA; Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, 521 Parnassus Avenue, San Francisco, CA 94143, USA
| | - T Edward Kim
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA 94304, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.
| |
Collapse
|
12
|
Kim TE, Ganaway T, Harrison TK, Howard SK, Shum C, Kuo A, Mariano ER. Implementation of clinical practice changes by experienced anesthesiologists after simulation-based ultrasound-guided regional anesthesia training. Korean J Anesthesiol 2017; 70:318-326. [PMID: 28580083 PMCID: PMC5453894 DOI: 10.4097/kjae.2017.70.3.318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/29/2016] [Accepted: 11/29/2016] [Indexed: 11/21/2022] Open
Abstract
Background Anesthesiologists who have finished formal training and want to learn ultrasound-guided regional anesthesia (UGRA) commonly attend 1 day workshops. However, it is unclear whether participation actually changes clinical practice. We assessed change implementation after completion of a 1 day simulation-based UGRA workshop. Methods Practicing anesthesiologists who participated in a 1 day UGRA course from January 2012 through May 2014 were surveyed. The course consisted of clinical observation of UGRA procedures, didactic lectures, ultrasound scanning, hands-on perineural catheter placement, and mannequin simulation. The primary outcome was the average number of UGRA blocks per month reported at follow-up versus baseline. Secondary outcomes included preference for ultrasound as the nerve localization technique, ratings of UGRA teaching methods, and obstacles to performing UGRA. Results Survey data from 46 course participants (60% response rate) were included for analysis. Participants were (median [10th–90th percentile]) 50 (37–63) years old, had been in practice for 17 (5–30) years, and were surveyed 27 (10–34) months after their UGRA training. Participants reported performing 24 (4–90) blocks per month at follow-up compared to 10 (2–24) blocks at baseline (P < 0.001). Compared to baseline, more participants at follow-up preferred ultrasound for nerve localization. The major obstacle to implementing UGRA in clinical practice was time pressure. Conclusions Participation in a 1 day simulation-based UGRA course may increase UGRA procedural volume by practicing anesthesiologists.
Collapse
Affiliation(s)
- T Edward Kim
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Toni Ganaway
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - T Kyle Harrison
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Steven K Howard
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Cynthia Shum
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Alex Kuo
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|
13
|
|
14
|
Kumar G, Howard SK, Kou A, Kim TE, Butwick AJ, Mariano ER. Availability and Readability of Online Patient Education Materials Regarding Regional Anesthesia Techniques for Perioperative Pain Management. PAIN MEDICINE 2016; 18:2027-2032. [DOI: 10.1093/pm/pnw179] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
15
|
Walters TL, Howard SK, Kou A, Bertaccini EJ, Harrison TK, Kim TE, Shafer A, Brun C, Funck N, Siegel LC, Stary E, Mariano ER. Design and Implementation of a Perioperative Surgical Home at a Veterans Affairs Hospital. Semin Cardiothorac Vasc Anesth 2015; 20:133-40. [PMID: 26392388 DOI: 10.1177/1089253215607066] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The innovative Perioperative Surgical Home model aims to optimize the outcomes of surgical patients by leveraging the expertise and leadership of physician anesthesiologists, but there is a paucity of practical examples to follow. Veterans Affairs health care, the largest integrated system in the United States, may be the ideal environment in which to explore this model. We present our experience implementing Perioperative Surgical Home at one tertiary care university-affiliated Veterans Affairs hospital. This process involved initiating consistent postoperative patient follow-up beyond the postanesthesia care unit, a focus on improving in-hospital acute pain management, creation of an accessible database to track outcomes, developing new clinical pathways, and recruiting additional staff. Today, our Perioperative Surgical Home facilitates communication between various services involved in the care of surgical patients, monitoring of patient outcomes, and continuous process improvement.
Collapse
Affiliation(s)
- Tessa L Walters
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - Steven K Howard
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - Alex Kou
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - Edward J Bertaccini
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - T Kyle Harrison
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - T Edward Kim
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - Audrey Shafer
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - Carlos Brun
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - Natasha Funck
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lawrence C Siegel
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - Erica Stary
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| | - Edward R Mariano
- VA Palo Alto Health Care System, Palo Alto, CA, USA Stanford University School of Medicine, Palo Alto, CA, USA
| |
Collapse
|
16
|
Tighe P, Buckenmaier CC, Boezaart AP, Carr DB, Clark LL, Herring AA, Kent M, Mackey S, Mariano ER, Polomano RC, Reisfield GM. Acute Pain Medicine in the United States: A Status Report. PAIN MEDICINE 2015; 16:1806-26. [PMID: 26535424 DOI: 10.1111/pme.12760] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Consensus indicates that a comprehensive,multimodal, holistic approach is foundational to the practice of acute pain medicine (APM),but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service,which is often unavailable or inconsistently applied.This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs. METHODS A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education. RESULTS The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers,hospital administrators, and other key stake holders to convey the importance of APM. CONCLUSION This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.
Collapse
Affiliation(s)
- Patrick Tighe
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Mariano ER, Walters TL, Kim TE, Kain ZN. Why the Perioperative Surgical Home Makes Sense for Veterans Affairs Health Care. Anesth Analg 2015; 120:1163-1166. [DOI: 10.1213/ane.0000000000000712] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
18
|
Long-term Functional Outcomes after Regional Anesthesia: A Summary of the Published Evidence and a Recent Cochrane Review. ACTA ACUST UNITED AC 2015; 43:15-26. [PMID: 26456997 DOI: 10.1097/asa.0000000000000033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
19
|
Abstract
This article presents an overview of how to set up an ambulatory regional anesthesia program for orthopedic surgery. This information is valuable to anesthesiologists who want to expand their regional anesthesia practice and provides a greater understanding of relevant issues and strategies to maximize success.
Collapse
Affiliation(s)
- Danielle B Ludwin
- Division of Regional and Orthopedic Anesthesia, Department of Anesthesiology, Columbia University College of Physicians & Surgeons, 630 West 168th Street, P & S Box 46, New York, NY 10032, USA.
| |
Collapse
|
20
|
A retrospective comparative provider workload analysis for femoral nerve and adductor canal catheters following knee arthroplasty. J Anesth 2014; 29:303-7. [DOI: 10.1007/s00540-014-1910-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 08/23/2014] [Indexed: 10/24/2022]
|
21
|
Mariano ER, Lehr MK, Loland VJ, Bishop ML. Choice of loco-regional anesthetic technique affects operating room efficiency for carpal tunnel release. J Anesth 2013; 27:611-4. [PMID: 23460418 DOI: 10.1007/s00540-013-1578-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 02/11/2013] [Indexed: 11/27/2022]
Abstract
Intravenous regional anesthesia (Bier block) is indicated for minor procedures such as carpal tunnel release but must be performed in the operating room. We hypothesize that preoperative peripheral nerve blocks decrease anesthesia-controlled time compared to Bier block for carpal tunnel release. With IRB approval, we reviewed surgical case data from a tertiary care university hospital outpatient surgery center for 1 year. Unilateral carpal tunnel release cases were grouped by anesthetic technique: (1) preoperative nerve blocks, or (2) Bier block. The primary outcome was anesthesia-controlled time (minutes). Secondary outcomes included surgical time and time for nerve block performance in minutes, when applicable. Eighty-nine cases met criteria for analysis (40 nerve block and 49 Bier block). Anesthesia-controlled time [median (10th-90th percentiles)] was shorter for the nerve block group compared to Bier block [11 (6-18) vs. 13 (9-20) min, respectively; p = 0.02). Surgical time was also shorter for the nerve block group vs. the Bier block group [13 (8-21) and 17 (10-29) min, respectively; p < 0.01), but nerve blocks took 10 (5-28) min to perform. Ultrasound-guided nerve blocks performed preoperatively reduce anesthesia-controlled time compared to Bier block and may be a useful anesthetic modality in some practice environments.
Collapse
Affiliation(s)
- Edward R Mariano
- Department of Anesthesia, Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA 94304, USA.
| | | | | | | |
Collapse
|
22
|
Udani AD, Harrison TK, Howard SK, Kim TE, Brock-Utne JG, Gaba DM, Mariano ER. Preliminary study of ergonomic behavior during simulated ultrasound-guided regional anesthesia using a head-mounted display. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:1277-1280. [PMID: 22837293 DOI: 10.7863/jum.2012.31.8.1277] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
A head-mounted display provides continuous real-time imaging within the practitioner's visual field. We evaluated the feasibility of using head-mounted display technology to improve ergonomics in ultrasound-guided regional anesthesia in a simulated environment. Two anesthesiologists performed an equal number of ultrasound-guided popliteal-sciatic nerve blocks using the head-mounted display on a porcine hindquarter, and an independent observer assessed each practitioner's ergonomics (eg, head turning, arching, eye movements, and needle manipulation) and the overall block quality based on the injectate spread around the target nerve for each procedure. Both practitioners performed their procedures without directly viewing the ultrasound monitor, and neither practitioner showed poor ergonomic behavior. Head-mounted display technology may offer potential advantages during ultrasound-guided regional anesthesia.
Collapse
Affiliation(s)
- Ankeet D Udani
- Department of Anesthesia, VA Palo Alto Health Care System, Palo Alto, California 94304, USA
| | | | | | | | | | | | | |
Collapse
|
23
|
|
24
|
Abstract
The use of local anesthetics in ambulatory surgery offers multiple benefits in line with the goals of modern-day outpatient surgery. A variety of regional techniques can be used for a wide spectrum of procedures; all are shown to reduce postprocedural pain; reduce the short-term need for opiate medications; reduce adverse effects, such as nausea and vomiting; and reduce the time to dismissal compared with patients who do not receive regional techniques. Growth in ambulatory procedures will likely continue to rise with future advances in surgical techniques, changes in reimbursement, and the evolution of clinical pathways that include superior, sustained postoperative analgesia. Anticipating these changes in practice, the role of, and demand for, regional anesthesia in outpatient surgery will continue to grow.
Collapse
Affiliation(s)
- Adam K Jacob
- Department of Anesthesiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | | | | |
Collapse
|