Cite as: Colaizzo D, Gurrieri C. Advancing regional anesthesia utilization in rural and community hospitals. ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra080126.009.

During the past several decades, the opioid crisis has intensified the need for effective alternatives for perioperative pain management.¹ In response, enhanced recovery and fast-track perioperative protocols have increasingly emphasized opioid-sparing strategies that promote faster recovery and earlier discharge. Regional anesthesia (RA) has become a cornerstone of modern perioperative care because of its ability to reduce opioid consumption and opioid-related adverse effects, including postoperative nausea and vomiting and respiratory complications. In addition, RA may reduce airway manipulation and provide a safer anesthetic option for elderly and high-risk patients.²

While tertiary and academic centers have widely embraced RA techniques, adoption in community and rural hospitals has lagged. Multiple factors contribute to this disparity, with workforce shortages representing one of the most significant barriers. Staffing shortages affect all areas of medicine but are particularly severe in anesthesiology. The American Society of Anesthesiologists recently reported that the percentage of facilities experiencing anesthesia staffing shortages increased from 35% in early 2020 to 78% by late 2022.³ These shortages are especially pronounced in rural settings. A 2021 study evaluating the surgical and anesthesia workforce in rural communities found that 55.1% of rural counties had no surgeon, 81.2% had no anesthesiologist, and 58.1% had no certified registered nurse anesthetist.⁴ Recruitment is difficult for rural hospitals because of geographic isolation, limited clinical variety, and fewer institutional resources. As a result, providers in these settings often face heavy clinical workloads with limited protected time for teaching, continuing education, or learning newer RA techniques.

Another major barrier is limited access to formal RA training. Providers in community hospitals may have less exposure to ultrasound-guided regional anesthesia during residency or early practice, leading to lower confidence and decreased utilization. The rapid evolution of novel fascial plane and peripheral nerve block techniques has further widened this gap. In addition, training limitations are often compounded by restricted access to equipment. Rural hospitals may lack sufficient ultrasound machines, specialized block needles, or supplies for peripheral nerve catheters. Peterman et al, for example, reported that point-of-care ultrasound access was available in only 38.84% of rural counties compared with 88.56% of metropolitan counties.⁵

Institutional culture and awareness also play important roles. In some hospitals, general anesthesia remains the default approach due to familiarity, established workflow patterns, or limited awareness of the broader benefits of RA among clinicians and administrators. Financial constraints may further impede implementation. The upfront costs of ultrasound equipment, disposables, and staff training may appear prohibitive for hospitals operating under narrow margins. Reimbursement challenges also contribute to underutilization. Depending on the payer structure, nerve blocks may be bundled into global surgical payments, potentially resulting in RA services not being reimbursed. These concerns are amplified in rural healthcare systems, where inflation-adjusted Medicare reimbursement for interventional pain procedures declined by an average of 3.63% annually between 2014 and 2023, with the largest decreases occurring in rural states.⁶

Providers in community hospitals may have less exposure to ultrasound-guided regional anesthesia during residency or early practice, leading to lower confidence and decreased utilization.

Despite these barriers, expanding RA utilization in rural and community hospitals is feasible. Successful implementation requires a combination of education, multidisciplinary collaboration, and system-level support. Structured educational initiatives are particularly important. Workshops, simulation-based learning, tele-mentoring, and mentorship partnerships with tertiary centers can help improve provider confidence and procedural competency.⁷ Practical models may include periodic “bread-and-butter” block workshops, visiting faculty block days, or remote ultrasound-guided teaching sessions. For example, VanEenenaam et al⁷ reported a high rate of successful blocks performed by general anesthesiologists at a rural hospital after implementing their RA practice. Specifically, fellowship-trained anesthesiologists mentored generalists in RA techniques, including “simple” blocks, such as adductor canal, interscalene, and femoral nerve blocks. They also developed a safety protocol for nurses regarding sedation, monitoring, and fundamentals of RA techniques. Introducing RA gradually, beginning with high-yield, low-complexity, and highly reproducible blocks, can facilitate adoption while minimizing workflow disruption.⁸

Moreover, tracking measurable outcomes, such as postoperative pain scores, opioid consumption, post-anesthesia care unit length of stay, and patient satisfaction, can help demonstrate the clinical and economic value of RA programs. Evidence of reduced complications and shorter hospital stays may justify continued investment in training and equipment. Also, technological advances may further support broader adoption. The increasing availability of portable and lower-cost ultrasound systems has made ultrasound-guided RA more accessible in community settings. Reusable equipment and standardized protocols may also help reduce long-term costs.

Finally, a multidisciplinary approach is essential for sustainable success. Engagement from surgeons, nursing staff, hospital leadership, and perioperative teams is critical to fostering institutional support. Education directed toward both clinicians and patients can improve acceptance of RA techniques. Counseling patients on the benefits of RA—including improved pain control, reduced opioid exposure, and faster recovery—while offering combined approaches such as RA with sedation may help alleviate concerns about being awake during surgery.

In conclusion, implementation of regional anesthesia programs in rural and community hospitals is challenged by workforce shortages, training limitations, workflow barriers, and financial constraints. Nevertheless, targeted interventions focused on education, infrastructure, collaboration, and institutional support can substantially expand the use of RA in community settings. Increased adoption has the potential to improve patient outcomes, reduce opioid reliance, and optimize perioperative care delivery in underserved populations.

References

1. Marino J. Regional anesthesia in community practice: Admir Hadzic, ed. NYSORA Textbook of Regional Anesthesia and Acute Pain Management. New York, NY: McGraw Hill; 2017.
2. Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surg 2017;152(7):691-7. https://doi.org/10.1001/jamasurg.2017.0898
3. American Society of Anesthesiologists. Anesthesia workforce shortage poses threat to health care. https://www.asahq.org/about-asa/newsroom/news-releases/2024/06/anesthesia-workforce-shortage-poses-threat-to-health-care. Published June 17, 2024. Accessed April 1, 2026.
4. Cohen C, Baird M, Koirola N, et al. The surgical and anesthesia workforce and provision of surgical services in rural communities: a mixed-methods examination. J Rural Health 2021;37(1):45-54. https://doi.org/10.1111/jrh.12417
5. Peterman NJ, Yeo E, Kaptur B, et al. Analysis of rural disparities in ultrasound access. Cureus 2022;14(5):e25425. https://doi.org/10.7759/cureus.25425
6. Wiest G, Dorius A, Bateman C, et al. National and geographic trends in medicare reimbursement for pain management 2014-2023. Pain Physician 2024;27(7):E687-93.
7. VanEenenaam DP, Johnson KN, Harris HM, et al. Development and implementation of a regional anesthetic service by general anesthesiologists for total joint arthroplasty patients in a small community hospital in the United States. Anaesthesia, Pain & Intensive Care 2019;250-5. https://doi.org/10.35975/apic.v23i3.1131
8. Turbitt LR, Mariano ED, El-Boghdadly K. Plan A blocks in regional anaesthesia: a narrative review. Anaesthesia 2026;81(7):985-94. https://doi.org/10.1111/anae.70182