REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas

REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD Ph. D FRCPC May 23 rd, 2009

HOLLAND CENTRE

The Holland Centre Sunnybrook Hospital Orthopedic and Arthritic Hospital AMALGAMATION 1998 Orthopedic and Arthritic Institute SWCHCS Holland Centre 2005

Resources • • • 4 Operating Rooms 5 bay Post Anesthesia Care Unit 10 bay Same Day Admission Area 5 Anesthetists (OR and Pre-assessment) 50 Acute Care Beds 20 Short term Rehab Beds

2004 • • • 3200 cases per year 1500 total joint arthroplasties 100% under General Anesthesia Limited use of femoral nerve blocks Post-op nurse-managed morphine PCA

2004 • Average length of stay 7 days • In-patient rehab 10 days • 20% to long term rehab 16 days

2004 • Average 16/20 lists per month ran overtime • Average overtime 30 hours/month • Average 18 cancellations/month

• How can patient care be improved at the Holland Centre? • Wait Time strategy 2004 • Holland Centre of Excellence Aug 2005 • Anesthesia and Nursing shortages

Regional Anesthesia • 4 -fold reduction in mortality with regional compared to GA (Shamrock et al 1995) • decreased DVT/PE; decreased blood loss and transfusion rate (Mauermann et al 2006) • better pain control and decreased opioid use (Salinas et al 2006) • improved surgical outcomes (Peters et al 2006)

VISION Convert the Holland Centre to Regional Anesthesia

Regional Anesthesia at the Holland Centre • better patient care • decrease overtime and cancellations through increased efficiency • ability to increase volume of cases • increase nursing satisfaction • increase recruitment and retention

• • • prolonged operating room time decreased efficiency unpredictable success rate inferior surgical conditions unacceptable to patients CHANGE!!

Anesthesia Concerns • Regional Anesthesia requires time • Regional Anesthesia requires expertise • Regional Anesthesia requires co-operation • Regional Anesthesia requires a team effort Investment for Improvement

Administration Concerns $$$$$$

Anesthesia Care Team Model • Create a separate but adjacent “Block Area” (4 bays) • “Block RNs” to staff area (2) – check patients, prepare equipment, monitor patients • Anesthesia Assistants (2) – monitor stable patients under regional anesthesia in OR while anesthetist performs regional/blocks for next patient • Anesthesiologists (4) – each anesthesiologist does own blocks in the Block Area

Patient Flow Same Day Admission OR Block Area PACU

2007

Surgeon Education • Approached surgeons individually and as a group • Provided relevant literature (including surgical literature) • Presented rounds

Nursing Education • Involved Pre-Assessment Clinic nursing staff, ward nurses, OR nurses • Provided with literature, in-services • Invited to Block Area and PACU

Allied Health Professionals • educational sessions for Physiotherapy • feedback from Physiotherapy on issues in regards to rehab • revision of practice and protocols to address concerns with hypotension, prolonged motor block, etc. • consultation with Pharmacy re pre-op medications, pre-printed orders

Patient education • by anesthetist at pre-op visit • patient information pamphlets • DVD video sent home with patient • Web-site

Post-operatively • established an Acute Pain Service under the direction of Nurse Practitioner and a dedicated anesthesiologist (Nov 2005) • developed best practices for post-op pain management (epidural analgesia, PCEA, oral analgesia protocols for THR, multi-modal analgesia regimens)

• Developed protocols and standardization for selected procedures initially and introduced new procedures slowly – Spinal Anesthesia for THR and TKR – Femoral Nerve Blocks for TKR – Sciatic Nerve Blocks for TKR – Combined spinal epidural anesthesia for bilateral TKR – Peripheral nerve block catheters

2007 • • 2100 total joint arthroplasties Neuraxial anesthesia in 90% Peripheral nerve blocks used in 90% of TKA Peripheral nerve block catheters for continuous infusions

OR Time 17% decrease in time for patient-in to patient-out from 2004 to 2007 in total knee arthroplasties 18. 6% decrease in time required from patient-in to patient-out for total hip arthroplasties

OR Overtime (* cancellations)

PACU Length of Stay

• • Average LOS 4. 8 days 67% discharged home (day 5) 24% short term in-pt rehab- 5 days (day 3) 9% longer in-pt rehab

Anesthesiologist’s Perspective • Changes in anesthetic practice facilitated improved efficiency and “fast-tracking” • Improvement in global peri-operative care • No incremental risk for patients • Improved outcomes • Benefits for patients, physicians, nurses, allied health care practitioners • No additional Anesthesia resources required

100 TKA PACU Time - Admitted to Discharge PACU Time (mins) 80 60 40 2004 2007 2008 2009

100 TKA PACU Time 80 60 Admitted to ready Admitted to moved 40 2004 2007 2008 2009

100 THA PACU Time 80 60 Admitted to ready Admitted to moved 40 2004 2007 2008 2009

PACU Discharge Criteria Modifications for Spinal Anesthesia • sensory block level at a minimum of T 8 • recession of sensory block by at least one dermatome level • any patient admitted to PACU with a sensory block at T 10 or below and some movement of the lower extremities may be discharged from PACU

The Future Improved patient care • • • Continuous catheters Patient controlled oral analgesia Expanded ultrasound applications Optimization of drugs and dosages Best Practice guidelines Expansion of Anesthesia Care Team model

• Retainment and Recruitment (Anesthesiologists, Block RNs, Anesthesia Assistants) • • Documenting improved outcomes Continuous improvement Expansion of program to Sunnybrook site Maintaining expertise at 2 sites

THANK YOU