How we developed a regional service

[seinfeld]

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I posted this in another thread but thought it may as well deserve its own

They guy who "invented" our protocol for TKA and elective THA's had to do it slowly over a course of a year. The first principal he started out with was dont delay the surgeon, stupid i know but real world . Our surgeons run 2 rooms and go back and forth while the PA's close. So he started out by securing a "block" room. THis way he could be starting the blocks while the room was being cleaned and turned over by the nurses. Started by just doing spinals to show the surgeons how the flow would work. Then as the surgeons felt no delays he added in a femoral nerve block. Then when timing was working out he added in a sciatic block. It took over a year to accomplish but when i arrived it was pretty well cemented in place. The surgeons and nurses (both PACU and floor) noticed improved pt comfort and therapy. We had a lot of discussions with Physical Therapy. We decreased our concentrations of ropivicaine to 0.4% for lumbar plexus/femoral and 0.2% for sciatic to balance pain control versus need for therapy. I did a couple of regional lectures to the PT people and everything has really taken off. Since my arrival pretty much all the ortho surgeons request blocks without hesitation.

I feel the key was to start by showing them that most of the time there would be no delay in case flow. Now that they know that in general their day wont be screwed with they accept the rare 5-10 minute delay to ensure a block. Also remember that what you do with regional is not isolated to the OR and PACU. If you dont take into account the concerns on the floor with nursing and PT education and the team concept you may end up having a surgeon tell you no because of too much complaint/concern from people you never thought of.

The general flow of our process is as follows
I start patient interview and blocks in the block room 30-40 minutes prior to scheduled case start time. Blocks go in as my 2 rooms are up and going ( we checked with our insurers and as the block are procedures we could "run away from" if needed it was ok to do them with rooms running) spinal goes in when CRNA drops off previous pt in PACU (cant start this without CRNA available as this is an anesthetic ) , Foley is placed in block room. Room turn over is 20 minutes and in most cases i have pt blocked and spinal'd before room is ready, when room is ready pt taken by CRNA to room and i go and start seeing next patient. Most of the time i can do both a lumbar plexus block and sciatic along with a spinal in less time than it take for room turnover. The spinal is generally the hardest part which i bag if it takes too long. During the case we run a semi deep propfol infusion for pt comfort as most dont want to remember the surgery

 

[sevoflurane]

For those of you who don’t work with CRNA’s this is another option which works very well for us.

1. See as many of your patients before 1st case of the day
2. Call holding and let them know you are 20 minutes from blocking your patient. They should then:
   • Make sure they are marked
   • Monitors on
   • Stimulator on and ready to go along with appropriate stim catheter
   • Sonosite with patient info entered
   • Sterile prep and sonosite probe with condom placed
   • Sedation in the form of versed/fentanyl before you arrive.
3. Drop off patient in pacu. Hopefully you've drawn up your LA before dropping off your current patient in pacu. Bring it with you.
4. Go to holding and everything should be ready to go for you to do a <1 minute block. Say hello to your patient for the 2nd time and proceede.
5. If you are doing combined fem/sciatic, have them prep for anterior approach to the sciatic which is an extension of your femoral prep. Both blocks can be done in the supine position very fast.
6. Make sure nursing freeze and save your blocks as well as writing vitals, sedation, times, and max/min mAmps on block sheet.
7. See your next patient before you head back to your room.

It takes a little bit of training, but once there.... smooth sailing with no delays.

 

[pgg]

For those of you who don’t work with CRNA’s this is another option which works very well for us.

1. See as many of your patients before 1st case of the day
2. Call holding and let them know you are 20 minutes from blocking your patient. They should then:
   • Make sure they are marked
   • Monitors on
   • Stimulator on and ready to go along with appropriate stim catheter
   • Sonosite with patient info entered
   • Sterile prep and sonosite probe with condom placed
   • Sedation in the form of versed/fentanyl before you arrive.
3. Drop off patient in pacu. Hopefully you've drawn up your LA before dropping off your current patient in pacu. Bring it with you.
4. Go to holding and everything should be ready to go for you to do a <1 minute block. Say hello to your patient for the 2nd time and proceede.
5. If you are doing combined fem/sciatic, have them prep for anterior approach to the sciatic which is an extension of your femoral prep. Both blocks can be done in the supine position very fast.
6. Make sure nursing freeze and save your blocks as well as writing vitals, sedation, times, and max/min mAmps on block sheet.
7. See your next patient before you head back to your room.

It takes a little bit of training, but once there.... smooth sailing with no delays.

That sounds great.

Here's the polar opposite:

The preop holding area is the hallway outside the OR, with a portable screen that rolls around so the next patient can't watch the current patient's surgery through the window. I could do blocks in the admissions area where they have monitors, but that's on the opposite side of the hospital ... and I don't like to leave patients TOO far from doctors after a block (because of the sedation, risk of delayed LA uptake). So the only practical place to do the blocks is in the OR before induction, making at least some delay totally unavoidable. The crusty old surgeons are good and fast, but they show their crotchety old age if anything runs late.

Worse, I have zero political pull when it comes to this sort of thing. I'm a regular locums guy there, moonlighting away from my Navy day job, usually 5-10 days per month. Any structural changes I make to help blocks go smoother is GONE by the time I come back in a week or two. I've been there a year now so the surgeons know my name and trust me not to kill their patients. I consider that a minor victory in itself. 🙂 But there's no interest from either them or the anesthesia group's side to offering routine blocks, setting up a pain service, following catheters on inpatients for a couple days. There's no money in regional because the insurance mix is poor (lots of self-pay and MediCal) and the group's hospital subsidy doesn't change if any of us do more work. Plus ... lots of these cases are done by the independent-practice CRNA side of the group, and none of them know how to do blocks. The best I've been able to do is squeeze in some single shot blocks on the days when the ortho guys are flipping rooms and aren't tapping their feet while we roll into the room.

We're moving into a new hospital in October though, so I'm hoping the improved floorplan/logistics will make it easier.

 

[urge]

Here is another option:

Go to the office and wait to be paged when the regional team is done.

 

[Dejavu]

"Go to holding and everything should be ready to go for you to do a <1 minute block. Say hello to your patient for the 2nd time and proceed."

Wow, I've been doing blocks for 34 yrs now. Apparently I am doing something wrong and need to watch your technique. There is no way I can verify site and side with procedural pause, open kit, delineate anatomy, prep, drape, draw up drugs, run the nerve stim or U/S and inject the drug, assess for complications and chart all in "<1 minute".

I am truly impressed if you can do it.

 

[Gern Blansten]

Here is another option:

Go to the office and wait to be paged when the regional team is done.

I think I know you.🙄

 

[sevoflurane]

"Go to holding and everything should be ready to go for you to do a <1 minute block. Say hello to your patient for the 2nd time and proceed."

Wow, I've been doing blocks for 34 yrs now. Apparently I am doing something wrong and need to watch your technique. There is no way I can verify site and side with procedural pause, open kit, delineate anatomy, prep, drape, draw up drugs, run the nerve stim or U/S and inject the drug, assess for complications and chart all in "<1 minute".

I am truly impressed if you can do it.

I think you read my post incorrectly. But in case you didn't:

It's not that hard. You just need experienced nurses to help out.

Drugs are drawn up and in my pocket when I get to my patients room. Why would you wait to draw up drugs until you are ready to place the block...? I do it during my previous case. If you wait until you are ready to block that will slow you down for sure.

For single shots, there isn't much of a "kit" to deal with. Stimuplex + stimulator. The stimulator is already on my patient when I enter the room. My stimuplex cath is opened up on a sterile mayo stand, right next to my sterile 7.5 gloves. If I'm doing a fem/sciatic I use a 4 3/4" stimuplex and use the same needle for both blocks.

Nurses prep and drape before I get there. Of course, I help out if my nurses are running behind, but this is infrequent. They are very good.

Verifying correct extremity takes seconds....

I don't run my stimulator. My nurses do. They also chart and take images on the sonosite.

USD is easy compared to traditional approaches. It's like doing a central line with USD. One stick. This is what takes about a minute for a single shot. No need to search.

Assessing for complications is an ongoing phenomena, but with USD you can see exactly what is going on. Total time is certainly less than 5 minutes. More like 3-4 minutes.

This is very doable. Now... if you are doing all this on your own... it will definitely take longer and as such will increases your risk of delaying a case.

 

[pgg]

"Go to holding and everything should be ready to go for you to do a <1 minute block. Say hello to your patient for the 2nd time and proceed."

Wow, I've been doing blocks for 34 yrs now. Apparently I am doing something wrong and need to watch your technique. There is no way I can verify site and side with procedural pause, open kit, delineate anatomy, prep, drape, draw up drugs, run the nerve stim or U/S and inject the drug, assess for complications and chart all in "<1 minute".

I am truly impressed if you can do it.

He said the patient is prepped, draped, monitored, sedated, with the u/s sleeved up ready to go, LA drawn up ahead of time. I'm not as fast as I'd like to be but given that head start I bet I could do the needle driving in under a minute. Then straight to the OR for induction ... charting can wait.

 

[proman]

Here's what HSS does:

Everything in the room.

For lower extremity, having the block set up doesn't matter since they all get spinals or CSEs. For upper extremity, they use mostly mepivacaine so it's set up by the time the arm is prepped etc.

 

[SleepIsGood]

For those of you who don’t work with CRNA’s this is another option which works very well for us.

1. See as many of your patients before 1st case of the day
2. Call holding and let them know you are 20 minutes from blocking your patient. They should then:
   • Make sure they are marked
   • Monitors on
   • Stimulator on and ready to go along with appropriate stim catheter
   • Sonosite with patient info entered
   • Sterile prep and sonosite probe with condom placed
   • Sedation in the form of versed/fentanyl before you arrive.
3. Drop off patient in pacu. Hopefully you've drawn up your LA before dropping off your current patient in pacu. Bring it with you.
4. Go to holding and everything should be ready to go for you to do a <1 minute block. Say hello to your patient for the 2nd time and proceede.
5. If you are doing combined fem/sciatic, have them prep for anterior approach to the sciatic which is an extension of your femoral prep. Both blocks can be done in the supine position very fast.
6. Make sure nursing freeze and save your blocks as well as writing vitals, sedation, times, and max/min mAmps on block sheet.
7. See your next patient before you head back to your room.

It takes a little bit of training, but once there.... smooth sailing with no delays.

wow. If you have RNs at your place doing this. You are the man.

 

[dhb]

Sevo your nurses are fantastic if they do what you described.
👍 good for you. Do you have a pack of doughnuts and a coffee machine sitting on the Sonosite? 😉

 

[seinfeld]

For those of you who don’t work with CRNA’s this is another option which works very well for us.

1. See as many of your patients before 1st case of the day
2. Call holding and let them know you are 20 minutes from blocking your patient. They should then:
   • Make sure they are marked
   • Monitors on
   • Stimulator on and ready to go along with appropriate stim catheter
   • Sonosite with patient info entered
   • Sterile prep and sonosite probe with condom placed
   • Sedation in the form of versed/fentanyl before you arrive.
3. Drop off patient in pacu. Hopefully you've drawn up your LA before dropping off your current patient in pacu. Bring it with you.
4. Go to holding and everything should be ready to go for you to do a <1 minute block. Say hello to your patient for the 2nd time and proceede.
5. If you are doing combined fem/sciatic, have them prep for anterior approach to the sciatic which is an extension of your femoral prep. Both blocks can be done in the supine position very fast.
6. Make sure nursing freeze and save your blocks as well as writing vitals, sedation, times, and max/min mAmps on block sheet.
7. See your next patient before you head back to your room.

It takes a little bit of training, but once there.... smooth sailing with no delays.

Nice work. If i ever get left without a CRNA then you gave me a good approach.

 

[sevoflurane]

Yes. Our nurses are pretty sweet. Midwest baby. No attitude. Eager to get the job done and eager to learn.
In actuality though... is it too much to ask? 😕
I don't think so. You just need to give them enough time to perform these very BASIC tasks. A little teaching and plenty of smiles goes a LONG way around here. Real team players.
Complete opposite from residency where you did it all.
The cardiac rooms are the same. Like a recipe book. Steps 1-15 are done everyday the same way and in the same order. Efficiency makes for some pretty smooth sailing.
I'm lucky that this environment was here before I arrived.

 

[bostonblaz]

1) easiest way to get it started it make sure all of the blocks getting done work. Before I started where I am now it was pathetic. No surgeon wanted any regional because the guys that were here did a horrible job. It took me well over a month before I could even get surgeons to to 1st say a block was a good idea then start asking for it. It then took another two months to sell them on inpatient and then out pateint catheters. It was a lot of long days for me but at this point now we have a booming regional service with two ultrassound mechines and two block rooms with two block nurses that also do the follow up phone calls. I think the most important thing to remember is that once it gets going you have to train all of the others in the group to be as effective or you will find youerself in my situation where you are requested by multiple surgeons and you end up running your assigned rooms but doing all of the regional in the other rooms as well. gets kinda old fast.

 

[sevoflurane]

outpateint catheters

Nice. We are not there yet. Only done a couple. Mainly for triple arthrodesis. From a reimbursent point of view is it worth it? Probably not. I think you get something like $500 for the pump + catheter units. Is this correct?
But... to get your name out in the community... this is HUGE and will give you an edge over competing hospitals/surgery centers.
And of course your patients are more satisfied.

 

[pgg]

Nice. We are not there yet. Only done a couple. Mainly for triple arthrodesis. From a reimbursent point of view is it worth it? Probably not. I think you get something like $500 for the pump + catheter units. Is this correct?
But... to get your name out in the community... this is HUGE and will give you an edge over competing hospitals/surgery centers.
And of course your patients are more satisfied.

Our disposable pumps for outpatient catheters are about $400. It's the military though so economic viability isn't a concern. Mostly we do them for big shoulder and ankle cases. The patients love them.

 

[sbmed100]

What local anesthetic solutions do you guys use for your femoral nerve catheter and sciatic block for TKA's? We use 30cc's of 0.5% bupiv plus epi for the the femoral (and run 0.2% ropivicaine in the pump) and 20cc's of 0.25% bupiv plain for the sciatic.

 

[SleepIsGood]

Yes. Our nurses are pretty sweet. Midwest baby. No attitude. Eager to get the job done and eager to learn.
In actuality though... is it too much to ask? 😕
I don't think so. You just need to give them enough time to perform these very BASIC tasks. A little teaching and plenty of smiles goes a LONG way around here. Real team players.
Complete opposite from residency where you did it all.
The cardiac rooms are the same. Like a recipe book. Steps 1-15 are done everyday the same way and in the same order. Efficiency makes for some pretty smooth sailing.
I'm lucky that this environment was here before I arrived.

Do you have LPNs doing these things? I guess you really on need a RN for this stuff (setting up stuff, calling people at home,etc).

Even a nurse assistant.

Just thinking outload. Since if one wanted to do this they would have to have the adminstration approve for an extra nurse, which has to be 'cost efficient'.

 

[Dejavu]

I think you read my post incorrectly. But in case you didn't:

It's not that hard. You just need experienced nurses to help out.

Drugs are drawn up and in my pocket when I get to my patients room. Why would you wait to draw up drugs until you are ready to place the block...? I do it during my previous case. If you wait until you are ready to block that will slow you down for sure.

For single shots, there isn't much of a "kit" to deal with. Stimuplex + stimulator. The stimulator is already on my patient when I enter the room. My stimuplex cath is opened up on a sterile mayo stand, right next to my sterile 7.5 gloves. If I’m doing a fem/sciatic I use a 4 3/4” stimuplex and use the same needle for both blocks.

Nurses prep and drape before I get there. Of course, I help out if my nurses are running behind, but this is infrequent. They are very good.

Verifying correct extremity takes seconds....

I don't run my stimulator. My nurses do. They also chart and take images on the sonosite.

USD is easy compared to traditional approaches. It's like doing a central line with USD. One stick. This is what takes about a minute for a single shot. No need to search.

Assessing for complications is an ongoing phenomena, but with USD you can see exactly what is going on. Total time is certainly less than 5 minutes. More like 3-4 minutes.

This is very doable. Now... if you are doing all this on your own... it will definitely take longer and as such will increases your risk of delaying a case.

I apologize for not understanding how you have the pt so nicely tee'd up. That is sweet. I thought we had it good here. Rock on.