Peripheral regional anesthesia has become a popular adjunct to general
or intravenous anesthesia for surgeries such as knee, foot/ankle and
upper extremity procedures. Regional anesthesia targets anesthesia to a
particular part of the body such as a limb, through a single-shot
injection near a nerve supplying the operative site, or by use of a
nerve block catheter, which allows for the infusion of a dilute local
anesthetic over an extended period of time.
Peripheral regional anesthesia has become a popular adjunct to general or intravenous anesthesia for surgeries such as knee, foot/ankle and upper extremity procedures. Regional anesthesia targets anesthesia to a particular part of the body such as a limb, through a single-shot injection near a nerve supplying the operative site, or by use of a nerve block catheter, which allows for the infusion of a dilute local anesthetic over an extended period of time.
The popularity of this method of anesthesia is likely to continue growing in the near future because regional anesthesia not only offers many patient benefits, but its use can also benefit surgeons and facilities.
Patient benefits
Here are three key benefits for patients.
• Less postoperative pain. The use of regional anesthesia will often allow patients to wake up either pain-free or at a significantly reduced level of pain compared to the postoperative pain that remains after use of general anesthesia, says Marc E. Koch, MD, MBA, president and CEO of Somnia, a national provider of turn-key anesthesia services based in New Rochelle, N.Y.
“If they’re pain-free, IV narcotics may be used less frequently and in smaller doses in the recovery room and, as a result, lead to fewer recovery room adverse events and a more expeditious discharge,” he says.
• Fewer side-effects. Since patients are exposed to fewer inhaled and intravenous anesthetic agents, they often wake up more clearheaded with fewer side-effects, such as nausea, vomiting and lethargy, says Dr. Koch.
• Extended pain relief. Some of the newest therapies in pain management allow patients to return home with a catheter placed near the nerves supplying the surgical site. An infusion of a local anesthetic is administered by a pump through the catheter. Patients can return home with a few days of complete or partial pain relief using this system.
“By the time 72 hours goes by, a significant amount of the acute pain is often starting to subside, so patients need fewer pain medications at that point compared to one or two days out,” says Dr. Koch.
Surgeon benefits
Surgeons may find the use of regional anesthesia preferable to general anesthesia because of the
following benefits.
• Less-stressed patients. If a patient has excessive pain after surgery, their first instinct is often to believe that the surgery didn’t go as well as it should have, says Brian A. Williams, MD, MBA, associate professor of anesthesiology and director of outpatient regional anesthesia service at the University of Pittsburgh (Pa.)
Medical Center South Side Hospital. The lower level of pain associated with the use of regional anesthesia can help alleviate their concerns.
“If the patient leaves the hospital pain-free and confident that their pain is initially well-managed, then they’re able to preemptively offset the prejudice that surgery might not have gone well because it hurt so much,” says Dr. Williams. This will reduce the
likelihood of patients calling the organizations where they had their surgery, their surgeon’s office or even 9-1-1 because of fears of possible complications.
• Greater patient satisfaction. If patients have a less-painful postoperative experience, they are more likely to reflect positively on their overall peri-operative experience. Besides the professional resonance this provides surgeons, the virtues of good attitude often play a role in an expeditious and full recovery, says Dr. Koch.
• More referrals. Because many patients are referred to a surgeon or a facility based on friendships or acquaintanceships, excellent service can lead to further referrals; further referrals can lead to fuller schedules; and fuller schedules lead to more revenue generated, says Dr. Williams.
Organization benefits
The organization as a whole can also see benefits by providing regional anesthesia.
• More cases. Since surgeons may capture more referrals from highly satisfied patients, organizations can also expect to see more cases. The
reputation of the organization may also improve as patients speak positively of their surgical
experiences.
• Less recovery time. Since patients wake up faster and may not require additional drugs in the recovery room, there is potential for more
expeditious patient discharge, say both Dr. Koch and Dr. Williams. ASCs may even find that, as a result, they can reduce the amount of staff required for the recovery room.
• Greater appeal to surgeons. If an organization can offer and provide the latest in anesthesia services and technology, prospective surgeons may find this an appealing characteristic when they are choosing where to practice. Organizations can also use their commitment to offering cutting-edge anesthesia as a marketing technique to recruit both surgeons and anesthesiologists.
Making regional anesthesia
work for you
Despite all these benefits, if your ASC doesn’t offer regional anesthesia, you shouldn’t simply start next week. As with any new service, you should perform thorough due diligence before investing in this opportunity. So how do you determine if regional anesthesia is a fit for your ASC? Follow these steps (and tips) from the experts to assess whether regional anesthesia is right for your organization and then how to integrate this new service into your operations.
1. Confirm surgeon interest. Before you can seriously consider adding regional anesthesia, you have to make sure surgeons whose procedures are appropriately amenable to regional anesthesia would be willing to have it provided to their patients, says Dr. Williams.
“Identify surgeons who would be agreeable to the routine use of regional anesthesia if all conditions were right,” he says. A good test for this is to ask your surgeons whether they would allow it to be used on themselves or on their families.
Some surgeons may be firmly opposed to the idea, and you should probably not count on their changing their minds. But if you encounter any surgeons who are not entirely against the idea, you may find that they could eventually come around over time (see step eight).
2. Calculate potential volume. If you have at least a few surgeons who will allow (or, hopefully, embrace) regional anesthesia for their patients, you should determine whether those surgeons’ volumes will warrant your taking a more serious look at investing in the service and seeking out an anesthesiologist who can perform the technique.
“If you have an anesthesiologist who specializes in regional anesthesia, but only one-fifteenth of their time is spent doing regional anesthesia once everything is up and running, you may not get a documentable benefit, whether it be cost, revenues or otherwise, just because the case proportion is too small to make it economically beneficial,” says Dr. Williams.
3. Determine anesthesiologist availability. Not all anesthesiologists will feel comfortable providing regional anesthesia; some simply may not want to provide regional anesthesia because it is typically more labor-intensive than general
anesthesia, says Dr. Williams.
“In my personal and professional experience, to perform a general anesthetic versus something involving regional, the regional probably involves twice the workload for the anesthesiologist/anesthesia care team,” he says. “For a continuous regional anesthetic technique such as the nerve block catheter(s), it can take up to five times as much workload.”
Some anesthesiologists may also feel they lack
the training necessary to provide regional anesthesia comfortably, says Dr. Williams: “Anesthesiologists may feel compelled to not do routine regional anesthesia unless they’ve completed a fellowship.”
It is important then that you identify whether there are anesthesiologists available for your ASC who can provide regional anesthesia. Ask the anesthesiologists your practice currently uses or identify whether anesthesiologists are potentially available in your community for contracting.
4. Weigh financial risks and benefits. There are many financial factors you must consider before adding regional anesthesia, says Dr. Koch. There are the obvious technology costs — purchasing needles, pumps, catheters and nerve stimulators, and some more expensive technology such as ultrasound machines — but there are also several other costs to weigh, including
• development of policies and procedures,
• patient education materials,
• more staffing for the pre-op area (if you
perform nerve blocks before surgery),
and
• additional training for surgeons and nurses.
Another important factor to consider is that surgery centers usually can’t bill a facility fee for most “acute pain management” (synonymous with regional anesthesia) efforts such as blocks and catheter placement, says Dr. Koch.
“The surgery centers need to say there are some patient satisfaction benefits, some staffing benefits, some surgeon satisfaction benefits,” says Dr. Koch. “But the one thing you’re not necessarily going to see across the board in all facilities is a direct one-for-one pecuniary benefit. It’s an indirect financial gain that can sometimes be hard to measure with a high degree of precision in most private practice settings.”
However, facility fees and professional billing are routine for ambulatory surgery units within hospitals, says Dr. Williams, once the learning curves are achieved between both the billing service and the third-party payors.
Significant facility-cost savings, however, has been clearly demonstrated. Dr. Williams and colleagues conducted a study in 2004 showing that the University of Pittsburgh Medical Center saved nearly $1.2 million per year by using nerve blocks for acute pain management (while avoiding general anesthetics) rather than using traditional general anesthesia care for 3,000 patients undergoing moderately painful orthopedic surgery such as anterior cruciate ligament reconstruction. The savings were found because patients reliably bypassed the PACU and achieved same-day discharge, compared with
routine PACU stays and a high (about 20 percent) chance of unplanned hospital admission after general anesthesia.
“Back in the late 1990s, our physicians did not collect additional revenues for the use of nerve blocks,” says Dr. Williams. “However, we felt it was the right plan for the patients to get them safely and comfortably out of the hospital for what was defined as same-day surgery.”
5. Assess space availability. Adding regional anesthesia may require you to allocate space for this service. For example, you may need monitored pre-operative beds in a recovery room, which will permit patients to have appropriate monitoring during the placement of regional anesthetic techniques, says Dr. Williams.
If you lack the space to accommodate these beds, construction is one option. But if you’re willing to think outside of the box, expanding your current space may not be necessary, says Dr. Williams. For example, anesthesiologists can perform blocks in the OR while the OR nursing team is cleaning and setting up the room for the next case.
“OR nurses, in their appropriate diligence and pride in their work, sometimes consider their unready OR as the equivalent of coming out of the shower with a towel on for public view, and I think that most folks could potentially work around that with creative management,” says Dr. Williams. “You could position two poles suspending a really long towel that could just separate the patients’ view from the OR setup.”
6. Develop and provide necessary training and
education. You will need to provide a comprehensive regional anesthesia education program for your surgeons to get them comfortable with the process if they are not already. You will also need to train the nursing staff who will be asked to teach their patients a new set of postoperative instructions, says Dr. Williams. Patients must now be instructed about the potential dangers of a numb limb, such as not bearing weight on a numb leg or cooking with a numb wrist, says
Dr. Koch.
Patients will also need to receive pre-operative education, such as a pamphlet provided by the ASC or surgeons’ offices, so they are not uncomfortable when the anesthesiologist starts to administer this likely unfamiliar method of pain management.
“The patient (should be) educated well in advance so they’re not blindsided on the morning of surgery when they are being told that they are not going to get a breathing tube or breathing machine anesthetic plan that they’ve come to expect based on ‘traditional care,’” says Dr. Williams.
Whenever you talk to your patients, you will also want to indicate that there’s always a risk of nerve injury or other complications — as with any procedure — notes Dr. Koch.
“You will also need to provide a fair amount of education during the pre-operative period to review the potential signs and symptoms of anesthesia toxicity and other complications,” he says. “It is just as important to establish reasonable pain management expectations and ensure patients know when to seek medical attention.”
You should incorporate this patient education into your educational routine as you have with postoperative nausea and vomiting and medication education.
7. Prepare for possible complications. Since it is unlikely that every use of regional anesthesia will go flawlessly, you must prepare your staff to respond to possible complications.
“The patients need to be carefully monitored with the latest monitors including EKG, pulse oximeters and blood pressure as well as have the personnel and pharmacologic support to treat adverse events,” says Dr. Koch.
8. Grow the service. Once you start offering regional anesthesia and, hopefully, begin to see the rewards of your investment, encourage the
surgeons using the service to discuss the benefits of regional anesthesia with those colleagues who were hesitant to consider the service.
“In this situation, once the other surgeons within the facility start hearing from surgeons who start describing their positive patient outcomes and increased referrals, then those surgeons with the previous negative biases may indeed revisit those biases,” says Dr. Williams.
Those surgeons who are opposed to regional
anesthesia may initially take this stance because they have a belief that surgeons have always historically performed their procedures with patients intubated and under deep general anesthesia (and they have received training to support this belief), says Dr. Williams. With some education, a little peer pressure and demonstrations of regional anesthesia’s benefits, these hesitant surgeons may be more apt to reconsider their outlook.
Contact Rob Kurtz at rob@beckersasc.com.
The popularity of this method of anesthesia is likely to continue growing in the near future because regional anesthesia not only offers many patient benefits, but its use can also benefit surgeons and facilities.
Patient benefits
Here are three key benefits for patients.
• Less postoperative pain. The use of regional anesthesia will often allow patients to wake up either pain-free or at a significantly reduced level of pain compared to the postoperative pain that remains after use of general anesthesia, says Marc E. Koch, MD, MBA, president and CEO of Somnia, a national provider of turn-key anesthesia services based in New Rochelle, N.Y.
“If they’re pain-free, IV narcotics may be used less frequently and in smaller doses in the recovery room and, as a result, lead to fewer recovery room adverse events and a more expeditious discharge,” he says.
• Fewer side-effects. Since patients are exposed to fewer inhaled and intravenous anesthetic agents, they often wake up more clearheaded with fewer side-effects, such as nausea, vomiting and lethargy, says Dr. Koch.
• Extended pain relief. Some of the newest therapies in pain management allow patients to return home with a catheter placed near the nerves supplying the surgical site. An infusion of a local anesthetic is administered by a pump through the catheter. Patients can return home with a few days of complete or partial pain relief using this system.
“By the time 72 hours goes by, a significant amount of the acute pain is often starting to subside, so patients need fewer pain medications at that point compared to one or two days out,” says Dr. Koch.
Surgeon benefits
Surgeons may find the use of regional anesthesia preferable to general anesthesia because of the
following benefits.
• Less-stressed patients. If a patient has excessive pain after surgery, their first instinct is often to believe that the surgery didn’t go as well as it should have, says Brian A. Williams, MD, MBA, associate professor of anesthesiology and director of outpatient regional anesthesia service at the University of Pittsburgh (Pa.)
Medical Center South Side Hospital. The lower level of pain associated with the use of regional anesthesia can help alleviate their concerns.
“If the patient leaves the hospital pain-free and confident that their pain is initially well-managed, then they’re able to preemptively offset the prejudice that surgery might not have gone well because it hurt so much,” says Dr. Williams. This will reduce the
likelihood of patients calling the organizations where they had their surgery, their surgeon’s office or even 9-1-1 because of fears of possible complications.
• Greater patient satisfaction. If patients have a less-painful postoperative experience, they are more likely to reflect positively on their overall peri-operative experience. Besides the professional resonance this provides surgeons, the virtues of good attitude often play a role in an expeditious and full recovery, says Dr. Koch.
• More referrals. Because many patients are referred to a surgeon or a facility based on friendships or acquaintanceships, excellent service can lead to further referrals; further referrals can lead to fuller schedules; and fuller schedules lead to more revenue generated, says Dr. Williams.
Organization benefits
The organization as a whole can also see benefits by providing regional anesthesia.
• More cases. Since surgeons may capture more referrals from highly satisfied patients, organizations can also expect to see more cases. The
reputation of the organization may also improve as patients speak positively of their surgical
experiences.
• Less recovery time. Since patients wake up faster and may not require additional drugs in the recovery room, there is potential for more
expeditious patient discharge, say both Dr. Koch and Dr. Williams. ASCs may even find that, as a result, they can reduce the amount of staff required for the recovery room.
• Greater appeal to surgeons. If an organization can offer and provide the latest in anesthesia services and technology, prospective surgeons may find this an appealing characteristic when they are choosing where to practice. Organizations can also use their commitment to offering cutting-edge anesthesia as a marketing technique to recruit both surgeons and anesthesiologists.
Making regional anesthesia
work for you
Despite all these benefits, if your ASC doesn’t offer regional anesthesia, you shouldn’t simply start next week. As with any new service, you should perform thorough due diligence before investing in this opportunity. So how do you determine if regional anesthesia is a fit for your ASC? Follow these steps (and tips) from the experts to assess whether regional anesthesia is right for your organization and then how to integrate this new service into your operations.
1. Confirm surgeon interest. Before you can seriously consider adding regional anesthesia, you have to make sure surgeons whose procedures are appropriately amenable to regional anesthesia would be willing to have it provided to their patients, says Dr. Williams.
“Identify surgeons who would be agreeable to the routine use of regional anesthesia if all conditions were right,” he says. A good test for this is to ask your surgeons whether they would allow it to be used on themselves or on their families.
Some surgeons may be firmly opposed to the idea, and you should probably not count on their changing their minds. But if you encounter any surgeons who are not entirely against the idea, you may find that they could eventually come around over time (see step eight).
2. Calculate potential volume. If you have at least a few surgeons who will allow (or, hopefully, embrace) regional anesthesia for their patients, you should determine whether those surgeons’ volumes will warrant your taking a more serious look at investing in the service and seeking out an anesthesiologist who can perform the technique.
“If you have an anesthesiologist who specializes in regional anesthesia, but only one-fifteenth of their time is spent doing regional anesthesia once everything is up and running, you may not get a documentable benefit, whether it be cost, revenues or otherwise, just because the case proportion is too small to make it economically beneficial,” says Dr. Williams.
3. Determine anesthesiologist availability. Not all anesthesiologists will feel comfortable providing regional anesthesia; some simply may not want to provide regional anesthesia because it is typically more labor-intensive than general
anesthesia, says Dr. Williams.
“In my personal and professional experience, to perform a general anesthetic versus something involving regional, the regional probably involves twice the workload for the anesthesiologist/anesthesia care team,” he says. “For a continuous regional anesthetic technique such as the nerve block catheter(s), it can take up to five times as much workload.”
Some anesthesiologists may also feel they lack
the training necessary to provide regional anesthesia comfortably, says Dr. Williams: “Anesthesiologists may feel compelled to not do routine regional anesthesia unless they’ve completed a fellowship.”
It is important then that you identify whether there are anesthesiologists available for your ASC who can provide regional anesthesia. Ask the anesthesiologists your practice currently uses or identify whether anesthesiologists are potentially available in your community for contracting.
4. Weigh financial risks and benefits. There are many financial factors you must consider before adding regional anesthesia, says Dr. Koch. There are the obvious technology costs — purchasing needles, pumps, catheters and nerve stimulators, and some more expensive technology such as ultrasound machines — but there are also several other costs to weigh, including
• development of policies and procedures,
• patient education materials,
• more staffing for the pre-op area (if you
perform nerve blocks before surgery),
and
• additional training for surgeons and nurses.
Another important factor to consider is that surgery centers usually can’t bill a facility fee for most “acute pain management” (synonymous with regional anesthesia) efforts such as blocks and catheter placement, says Dr. Koch.
“The surgery centers need to say there are some patient satisfaction benefits, some staffing benefits, some surgeon satisfaction benefits,” says Dr. Koch. “But the one thing you’re not necessarily going to see across the board in all facilities is a direct one-for-one pecuniary benefit. It’s an indirect financial gain that can sometimes be hard to measure with a high degree of precision in most private practice settings.”
However, facility fees and professional billing are routine for ambulatory surgery units within hospitals, says Dr. Williams, once the learning curves are achieved between both the billing service and the third-party payors.
Significant facility-cost savings, however, has been clearly demonstrated. Dr. Williams and colleagues conducted a study in 2004 showing that the University of Pittsburgh Medical Center saved nearly $1.2 million per year by using nerve blocks for acute pain management (while avoiding general anesthetics) rather than using traditional general anesthesia care for 3,000 patients undergoing moderately painful orthopedic surgery such as anterior cruciate ligament reconstruction. The savings were found because patients reliably bypassed the PACU and achieved same-day discharge, compared with
routine PACU stays and a high (about 20 percent) chance of unplanned hospital admission after general anesthesia.
“Back in the late 1990s, our physicians did not collect additional revenues for the use of nerve blocks,” says Dr. Williams. “However, we felt it was the right plan for the patients to get them safely and comfortably out of the hospital for what was defined as same-day surgery.”
5. Assess space availability. Adding regional anesthesia may require you to allocate space for this service. For example, you may need monitored pre-operative beds in a recovery room, which will permit patients to have appropriate monitoring during the placement of regional anesthetic techniques, says Dr. Williams.
If you lack the space to accommodate these beds, construction is one option. But if you’re willing to think outside of the box, expanding your current space may not be necessary, says Dr. Williams. For example, anesthesiologists can perform blocks in the OR while the OR nursing team is cleaning and setting up the room for the next case.
“OR nurses, in their appropriate diligence and pride in their work, sometimes consider their unready OR as the equivalent of coming out of the shower with a towel on for public view, and I think that most folks could potentially work around that with creative management,” says Dr. Williams. “You could position two poles suspending a really long towel that could just separate the patients’ view from the OR setup.”
6. Develop and provide necessary training and
education. You will need to provide a comprehensive regional anesthesia education program for your surgeons to get them comfortable with the process if they are not already. You will also need to train the nursing staff who will be asked to teach their patients a new set of postoperative instructions, says Dr. Williams. Patients must now be instructed about the potential dangers of a numb limb, such as not bearing weight on a numb leg or cooking with a numb wrist, says
Dr. Koch.
Patients will also need to receive pre-operative education, such as a pamphlet provided by the ASC or surgeons’ offices, so they are not uncomfortable when the anesthesiologist starts to administer this likely unfamiliar method of pain management.
“The patient (should be) educated well in advance so they’re not blindsided on the morning of surgery when they are being told that they are not going to get a breathing tube or breathing machine anesthetic plan that they’ve come to expect based on ‘traditional care,’” says Dr. Williams.
Whenever you talk to your patients, you will also want to indicate that there’s always a risk of nerve injury or other complications — as with any procedure — notes Dr. Koch.
“You will also need to provide a fair amount of education during the pre-operative period to review the potential signs and symptoms of anesthesia toxicity and other complications,” he says. “It is just as important to establish reasonable pain management expectations and ensure patients know when to seek medical attention.”
You should incorporate this patient education into your educational routine as you have with postoperative nausea and vomiting and medication education.
7. Prepare for possible complications. Since it is unlikely that every use of regional anesthesia will go flawlessly, you must prepare your staff to respond to possible complications.
“The patients need to be carefully monitored with the latest monitors including EKG, pulse oximeters and blood pressure as well as have the personnel and pharmacologic support to treat adverse events,” says Dr. Koch.
8. Grow the service. Once you start offering regional anesthesia and, hopefully, begin to see the rewards of your investment, encourage the
surgeons using the service to discuss the benefits of regional anesthesia with those colleagues who were hesitant to consider the service.
“In this situation, once the other surgeons within the facility start hearing from surgeons who start describing their positive patient outcomes and increased referrals, then those surgeons with the previous negative biases may indeed revisit those biases,” says Dr. Williams.
Those surgeons who are opposed to regional
anesthesia may initially take this stance because they have a belief that surgeons have always historically performed their procedures with patients intubated and under deep general anesthesia (and they have received training to support this belief), says Dr. Williams. With some education, a little peer pressure and demonstrations of regional anesthesia’s benefits, these hesitant surgeons may be more apt to reconsider their outlook.
Contact Rob Kurtz at rob@beckersasc.com.