ASRA Pain Medicine Update

The health care industry in the United States is facing many challenges. As health care systems grow, individual providers are often expected to provide extensive and complex care with decreasing returns. Finding ways to improve patient outcomes and satisfaction while maintaining positive revenue is becoming increasingly important.

Interest in regional anesthesia has come and gone over the years. Recently, evidence has been increasing regarding the benefits of a well-run comprehensive pain management program that contains a strong regional anesthesia component. Benefits include improved patient outcomes (decreased pain levels, improved mobility, decreased incidence of complications) as well as financial savings (reduced length of stay and improved patient satisfaction).^[1–5] To accomplish those goals, providers must build a program that can meet the specific institutional needs.

Benefits include improved patient outcomes (decreased pain levels, improved mobility, decreased incidence of complications) as well as financial savings (reduced length of stay and improved patient satisfaction).

Needs Analysis

The first step in building a regional anesthesia program is to determine what types of surgeries or procedures would benefit from a regional block at your institution. Then, analyze the data, including length of stay, pain levels during admission, patient satisfaction scores, and cost per case, depending on how data are collected at your institution.

Compare the current length of stay at your institution with local or national averages to determine how aggressive the changes need to be to meet service expectations. Once a cost per day for a case or diagnosis is established, multiply it by the projected decrease in length of stay to find the approximate cost savings that could be accomplished by implementing a standardized approach to patient care involving regional anesthesia.

As pain control improves, patient satisfaction is also expected to improve. Quality metrics often have reimbursement components attached, hence the financial incentive for a comprehensive approach to pain management.

Establishing a baseline of financial and quality metrics is critical to future program evaluation to garner support and measure the success after implementation.

Putting the Pieces Together

Several moving parts must be coordinated to bring a regional anesthesia program to life. An administrative sponsor is needed to make decisions regarding financial support for a regional anesthesia program and to assist with completing the financial and quality analysis to guide the initial phases of program development.

Key clinical and administrative stakeholders—including leaders from anesthesia, surgery, perioperative, and nursing departments—should be identified and brought together to determine the desired outcomes and what it will take to achieve them. Individual surgical service line leaders may also be needed once a framework has been established so they can see the impact on their patients and provide input regarding any concerns they may have.

Clinical Background

The anesthesiology group is the obvious first stop on the path to creating a regional anesthesia service. Know what services your anesthesia group can provide, and review the contract for provision of services to see if it specifically includes an expectation to perform regional blocks when appropriate or needed. If anesthesiologists currently on staff are not comfortable with performing the necessary blocks, provide additional training and ensure that new providers have a level of comfort with regional anesthesia as part of the job requirement.

Evaluate the work environment in terms of space to do blocks in the preoperative holding or postanesthesia care unit. Additional support staff may be needed to assist with performing the blocks. Identify necessary equipment for the blocks and ensure it is made available.

Clinical coverage for follow-up care will depend on patient volumes and clinical complexity. Certified registered nurse anesthetists can assist with postoperative regional anesthesia management. If nonregional anesthesia pain management services are needed at your institution, creating a more comprehensive acute pain service may be in the best interest of patients and the institution. When the program is ready to launch, provide training for nursing staff on units where patients will be sent. This training should include the basics of anatomy and pathophysiology of the regional blocks, pharmacology of the medications used for the blocks, and use of equipment for continuous infusions (eg, pumps).

Barriers to Consider

Several groups must come together to establish specific protocols for a regional anesthesia program. For example, a hip fracture protocol may include a femoral or fascia iliaca block or catheter for pain control and involve emergency department physicians, hospitalists, orthopedic surgeons, anesthesiologists, and perioperative services. Consider each service’s budget, staff, and site of service constraints. Setting up timelines and communication strategies will ensure that all services are provided in a timely manner.

The balance of clinical needs and expense will require extensive discussions with hospital administration, because the initial need can be a significant investment. Convincing an institution that the cost of the program is worthwhile may be difficult because the initial revenue may not offset the cost. Thus, highlight the improvement in patient outcomes and cost savings from reductions in hospital length of stay because those will more than cover any initial expenses related to establishing and maintaining the program. The process can take several months, so prepare as much of the background work in advance to demonstrate the overall long-term benefits of a strong regional anesthesia program before initial meetings with stakeholders.

Conclusion

Significant amounts of work will go into data collection and calculations to create a case for developing a regional anesthesia program. All involved parties need to commit to collaborate and develop a program that runs smoothly. Ensure that the health care system understands that without appropriate incentives (eg, call pay, stipends), maintaining the level of quality to achieve the desired benefits may not be possible. Focus on providing patients with the best possible care to reach all of the benefits of a strong regional anesthesia program.

References

1. McIsaac DI, McCartney CJ, Walraven CV. Peripheral nerve blockade for primary total knee arthroplasty: a population-based cohort study of outcomes and resource utilization. Anesthesiology 2017;126:213–320.
2. Parikh RP, Sharma K, Guffey R, Myckatyn TM. Preoperative paravertebral block improves postoperative pain control and reduces hospital length of stay in patients undergoing autologous breast reconstruction after mastectomy for breast cancer. Ann Surg Oncol 2016;23:4262–4269.
3. Morrison RS, Dickman E, Hwang U, et al. Regional nerve blocks improve pain and functional outcomes in hip fracture: a randomized controlled trial. J Am Geriatric Soc 2016;64:2433–2439.
4. Mistry JB, Chughtai M, Elmallah RK, et al. What influences how patients rate their hospital after total hip arthroplasty? J Arthroplasty 2016;31:2422–2425.
5. Etier BE Jr, Orr SP, Antonetti J, Thomas SB, Theiss SM. Factors impacting Press Ganey patient satisfaction scores in orthopedic surgery spine clinic. Spine J 2016;16:1285–1289.