This introductory presentation outlines the importance of initiating a successful Acute Pain Service (APS) in order to optimize Patient Satisfaction as well as Clinical & Financial Outcomes. The cornerstone of an APS Program that translates into significant outcome differences is a Continuous Peripheral Nerve Block (CPNB). You will not translate your efforts into improved safety or financial gain by taking the 'easy road', by exponentially increasing patient monitoring or by working in a poorly-organized system. If you continue to ignore the consequences of hanging on to the ineffective, costly and dangerous practice of using IV opioids as your primary analgesic agent, you will continue to hemorrhage money from your facility and deliver inferior patient care. There are other important reasons both for Hospital Administrators and Anesthesiologists 'team up' to improve health care in your community. If you are interested in hearing more about how to change your Anesthesia Department from a cost center to a revenue center and provide cutting-edge patient care in your community, contact Dr Jerry Jones at 731-616-8540 or visit our website at CPNBconsulting.com. "Smart Business. Better Care."

1. A NEW ERA IN ACUTE
PAIN CONTROL
CREATING A NERVE BLOCK PROGRAM
Jerry Jones M.D.

2. OBJECTIVES
1.
2.
3.
4.
Is Pain THAT big of a Problem?
What is a Nerve Block „Program’?
How to develop a successful Program
Answer you Questions

3. WHO AM I?






Private Practice for 11 years
Got interested in CPNB in 2007
Developed two CPNB Programs „from scratch‟
Affiliate Faculty at Union University
Speaker & Consultant to: B Braun, I-Flow, Ambu, others
CPNB CONSULTING LLC
Treatment
Total Healing
for
David Stanley, MD
For many patients with cancer, radiation therapy is a lifesaving treatment—but
killing cancer cells frequently doesn’t come without adversely affecting healthy tissue.
Fortunately, Methodist Medical Center of Oak Ridge’s Wound Treatment Center offers
hyperbaric oxygen therapy that can help many patients make a total recovery.
According to David Stanley, MD,
board-certified vascular surgeon
and medical director of the MMC
Wound Treatment Center, patients
undergoing radiation therapy
may suffer symptoms related to
radiation fibrosis—in which tissue
become scarred.
“Symptoms of radiation fibrosis
include cystitis or proctitis, which is
a condition characterized by pain
and bleeding following radiation
for prostate, colorectal, and other
pelvic cancers,” says Dr. Stanley. “As
time goes by, the fibrosis becomes
progressively worse, and even a mild
injury to the area can develop into a
hard-to-heal wound.”
Portable Pain Block
How We Can Help
Dr. Stanley encourages any patient
who has undergone radiation therapy
and anticipates surgery in that same area
of the body to ask their physician for a
referral to the Wound Treatment Center
for a consultation. Team members
can take a transcutaneous oxygen
measurement to determine whether
healing will occur following surgery.
“Failure to take this precaution before
even just a minor procedure can cause
serious complications,” Dr. Stanley says.
“We want to ensure the health and
safety of each of our patients.”
Visit us at www.mmcoakridge.com and click on the
“What Our Patients Say” tab to see how others have
benefited from care at the Wound Treatment Center.
Prolongs Relief
Many patients who undergo certain surgical procedures at Methodist experience extended pain relief without
depending on as much traditional pain medication.
Known as the continuous peripheral
Jerry Jones, MD
nerve block, this new treatment uses
nerve-numbing medication that extends
the traditional 12- to 15-hour window of pain relief coverage of
a “single injection” nerve block to more than two days. The new
pain block is not appropriate for every patient that undergoes
surgery. However, it can significantly reduce the need for
traditional pain medication when it is appropriately used.
“We administer the treatment through thin catheters attached
to balloon-like pumps,” explains Jerry Jones, MD, board-certified
anesthesiologist at Methodist Medical Center of Oak Ridge.
“Those pumps are concealed within a fanny pack and drip the
medication through the catheter to a nerve bundle just under the
skin for two to three days.”
10
MMCO AK RIDG E.CO M FALL/WINTER 2010
.C
Providing Exclusive Service
According to Dr. Jones, patients can remove the bandage
at home and dispose of the entire unit once the treatment is
complete. As the only local healthcare provider that makes the
continuous peripheral nerve block service available, Dr. Jones says
patient satisfaction at Methodist is our highest priority.
“Our facility optimizes patient treatment by providing
superior analgesia pain control through a multimodal regimen,”
says Dr. Jones. “We work to offer our patients the most effective
pain control with the least side effects.”
To read more about this pain block option through the experiences of
actual patients, visit www.mmcoakridge.com and click on the “What Our
Patients Say” tab.

4. QUESTIONS?
JJONESMD@CPNBconsulting.com

5. PAIN
Management

6. WHY PAIN CONTROL IS IMPORTANT

Patient satisfaction has always been important, but with
Medicare reimbursement being partially dependent on
HCAHPS scores, failure to address pain management could
literally be detrimental to a hospital‟s bottom line.

Clear correlations between satisfaction with pain control
and overall patient satisfaction are abundant in the
literature.

Hospitals with the top 15% of HCAHPS scores had 26%
more patients reporting pain well controlled than the bottom
15% (Healthgrades Press Release, 6-2-09).

7. HOW ARE WE DOING?
Acute Pain Management: Programs in U.S.
Hospitals and Experiences and Attitudes
among U.S. Adults
Warfield, Kahn Anesthesiology 1995;83:5:1019-94
500 Adults interviewed 1 year after AHCPR guidelines issued
77% believed it is necessary to experience pain after surgery
57% cited pain after surgery as primary fear (51% whether surgery improve condition)
77% reported pain with 80% of those reporting moderate to extreme!
Despite this, pts often reported satisfaction since they expected pain

8. HOW ARE WE DOING?
Postoperative Pain Experience: Results from
a National survey Suggest Postoperative Pain
Continues to Be Undermanaged
Apfelbaum et al Anesthesia & Analgesia 2003;97:534-40
250 adults who had surgery within 5 years „representative of U.S.‟
80% had acute pain after surgery, 58% before & 75% after D/C home*
86% was moderate, severe, extreme, 39% severe (same if >1 yr ago<)*
59% were most concerned about pain (whether surgery would help 51%)
8% delayed surgery due to fear of pain
23% had pain medication side effects
75% believed it was necessary to experience some pain
90% were satisfied with pain & pain medication

9. HOW ARE WE DOING?
30% of Patients have Moderate to
Severe pain 24 hours after Ambulatory
Surgery: a survey of 5,703 patients.
B McGrath et al Canadian Journal Anaesthesia 2004;51:9: 886-91
Most painful: Microdiscectomy, Lap Chole, Shoulder, Elbow/Hand,
Ankle, Inguinal Hernia & Knee surgery
88% pts indicated analgesic instructions were absolutely clear.
Here‟s our plan:
Do surgery
Send you home
You hurt like %!# for 3-5 days. Got it?
“Yes, Absolutely clear….. I guess that’s normal ”

10. IMPACT OF ACUTE PAIN
Chronic PainNerve Injury 
 Spontaneous
Transcriptional changes, Changes in neighboring neuron
Pain
Barrage of nociceptive input & Loss of growth factors,
At Particular Risk: Thoracotomy, Breast Surgery, Inguinal Hernia, Amputation
The more intense and prolonged acute pain is, the more likely it is to develop.
Morbidity & MortalityMyocardial Ischemia, DVT, Pulmonary Complications, Ileus,
Emesis, Oliguria, Increased Infection, Muscle Atrophy, Bone loss,
Tumor Spread or Recurrence, Impaired Nutritional Intake
F Perkins, H Kehlet Chronic Pain as an Outcome of Surgery A Review of Predictive Factors Anesthesiology 2000;93:1123-33
G Joshi et al Consequences of Inadequate Postoperative Pain Relief & Chronic Persistent Postoperative Pain Anesthesiology Clinics North Americ2005;23:21-36
R Ritchey Optimizing Postoperative Pain Management Cleveland Clinic Journal of Medicine 2006;73:1: S72-6

11. IMPACT OF ACUTE PAIN
Increased Use of Health Care Resources
-
Unplanned Admissions, Readmissions
Longer Stay
More Co$tly Stay
More Follow-up Visits & Care
Anxiety- Increases Pain Perception
Patient Dissatisfaction
#1 Driver of Patient Satisfaction: PAIN CONTROL
F Perkins, H Kehlet Chronic Pain as an Outcome of Surgery A Review of Predictive Factors Anesthesiology 2000;93:1123-33
G Joshi et al Consequences of Inadequate Postoperative Pain Relief & Chronic Persistent Postoperative Pain Anesthesiology Clinics North Americ2005;23:21-36
R Ritchey Optimizing Postoperative Pain Management Cleveland Clinic Journal of Medicine 2006;73:1: S72-6

12. IMPACT OF ACUTE PAIN
Delayed Discharge: PACU & Hospital
- > use of supplies, medications
- > manpower (time & interventions)
Prolonged Recovery/Return to ADL
- Greater bone/muscle loss
- Opportunity for ‘secondary complications’
F Perkins, H Kehlet Chronic Pain as an Outcome of Surgery A Review of Predictive Factors Anesthesiology 2000;93:1123-33
G Joshi et al Consequences of Inadequate Postoperative Pain Relief & Chronic Persistent Postoperative Pain Anesthesiology Clinics North Americ2005;23:21-36
R Ritchey Optimizing Postoperative Pain Management Cleveland Clinic Journal of Medicine 2006;73:1: S72-6

13. IMPACT OF ACUTE PAIN
Delays in Wound Healing
- Catabolic state, Vasoconstriction, Collagen Deposition,
Immobilization, Low- O2 Tension
L McGuire et al Pain & Wound Healing in Surgical Patients. Ann Behavioral Medicine 2006;31:165-72
K Woo; R Sibbald The Improvement of Wound-Associated Pain and Healing Trajectory With a Comprehensive Foot and
Leg Ulcer Care Model. Journal of Wound, Ostomy & Continence Nursing 2009; 36:2: 184-91
Nimmo WS, Duthie DJ. Pain relief after surgery. Anaesth Intensive Care 1987; 15(1): 68-71.
Disrupted Sleep & Worsened Pain
- Opioids Disrupt Sleep Further, Worsening Pain
Moore & Kelz Opiates, Sleep, and Pain: The Adenosinergic Link Anesthesiology 2009;111:6:1175-6
Nelson et al Opioid-induced Decreases in Rat Brain Adenosine Levels Are Reversed by Inhibiting
Adenosine Deaminase Anesthesiology 2009;111:6:1327-33

14. NEUROENDOCRINE ‘STRESS’ RESPONSE
CARDIOVASCULAR*
(>BP, HR, SVR, CVA & ischemia risk)
RESPIRATORY*
(> work of breathing)
GASTROINTESTINAL
(ileus, nausea)
URINARY
(retention)
HEMATOLOGIC
(hypercoagulable, > DVT/PE risk)
IMMUNE*
(depressed, > cancer spread/recurrence)
ENDOCRINE
(> Cortisol, ADH, Epi = catabolic state, negative N balance & nutrition status)
WELL-BEING
(anxiety, poor sleep, worsened pain perception, immobility)
AROUSAL & ENDOGENOUS OPIOIDS
B-blockers good, but limited in scope (too late & affects too few areas)

15. CHALLENGE OF PAIN MANAGEMENT

BALANCE: the pain problems & the pain treatment problems





No objective monitor for pain!
Want to minimize Negative Side-Effects of Opioids
Avoid ADE & Safety Issues
Inter-patient response to Opioids is very variable
As well, Avoid Side-Effects of Adjunct therapies



GI, Renal, Coagulation, Fracture-Healing, Sedation
Epidural: immobility, coagulants, infection, hypotension, foley
GOAL: Optimize recovery economically & D/C early

16. COST OF HOSPITAL COMPLICATIONS






Acute mental health changes - $3,206
In-hospital trauma & fractures (fall)- $5,370
Renal failure without dialysis - $9,934
Venous thrombosis - $15,976
Pneumonia - $16,901
Decubitis ulcer - $28,272

(Healthcare Financing Review, Summer 2009, Vol. 30, #4, 17-32)

17. CHALLENGE OF USING OPIOIDS


Central effect, so helpful for pain anywhere
Central effect, so side-effects are everywhere

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


Hypotension, Respiratory, Ileus, PONV, Confusion, Sedation, Itching
Easier to titrate for static conditions (like convalescing)
Difficult for dynamic pain (cough, OOB, ambulating, active P.T.)
Enough to tolerate P.T. = Too sedated to do P.T.
Higher doses lead to > Monitoring & > Cost

18. ECONOMICS OF USING OPIOIDS
Opioid-Related Adverse Drug Events in Surgical
Hospitalizations: Impact on Costs and Length of
Stay. Ann Pharmacother, 2007, Odera, G.M. et.al.
RESULTS:
Patients experiencing opioid-related ADEs had significantly increased
median total hospital costs (7.4% increase; 95% CI 3.83 to 10.96; p <
0.001) and increased median LOS (10.3% increase; 95% CI 6.5 to 14.2;
p < 0.001) compared with matched non-ADE controls. Higher doses of
opioids were associated with increased risk of experiencing ADEs (OR
1.3; 95% CI 1.07 to 1.60; p = 0.01)
CONCLUSIONS:
These ADEs occurred more frequently in patients
receiving higher doses of opioids.

19. CHALLENGE OF USING OPIOIDS
Recognizing opioid prescribing risks:
Addiction: In a study of 28,000 patients who had minor surgery who
received opioids for <7 days, 10% were identified as long term opioid
users at 1 year*
Side effects: nausea and vomiting, over-sedation & respiratory
depression**, leading to other complications and increased LOS
Enormous implications for OSA & other at risk patients


Prolonged & Increased Inpatient monitoring as Inpatient
Discharging as an Outpatient
** The Joint Commission Sentinel Event Alert Issue 49, August 8, 2012
*Source: outpatientsurgery.net/news/2012/03/16-Study-Opioids-After-Minor-Surgery-Can-Lead-to-Addiction

20. AT RISK FOR RESPIRATORY DEPRESSION
1.
2.
3.
4.
Obstructive Sleep Apnea
Morbid Obesity with high OSA Risk
Snoring
Older Age



5.
6.
7.
8.
9.
10.
11.
12.
61-70 yo  2.8x higher risk
71-80 yo  5.4x higher risk
>80 yo  8.7x higher risk
No recent Opioid use
Post-Surgery, especially upper abdomen or thoracic
Increased Opioid dose requirement or habituation
Longer time under General Anesthesia
Using other sedating drugs
Preexisting Cardiac or Pulmonary disease
Other Major Organ disease or dysfunction
Smoker
The Joint Commission Sentinel Event Alert Issue 49, August 8, 2012

21. NEED FOR AN OPIOID ALTERNATIVE

Relying on Opioids as the primary
analgesic, especially for moderate to severe
pain is inadequate, unsafe & costly

Multimodal Regimens:


Opioid-sparing
Minimize side-effect profiles of individual therapies

22. ‘EFFECTIVE’ PAIN STRATEGY
Depth- intensely block nociception
(NSAIDS are inadequate for major surgery)
Width- to block entire surgical area
(incisional Ropivicaine for ORIF inadequate)
Length- to last long enough into postoperative period
(s.s. interscalene block inadequate for total shoulder replacement)
I Kissin Preemptive Analgesia
Anesthesiology 2000;93:1138-43

23. EXAMPLES OF OUTCOME SUCCESS
A continuous infusion fascia iliaca compartment block in hip
fracture patients: A pilot study Dulaney-Cripe et al Journal of Clinical Medicine Research, 4(1): 45-8; 2012



Algorithmic plan: early aggressive pain management and <24 hours door to OR
Aggressive post-operative pain management with a focus on opioid reduction
and continuous regional block infusion
First year after implementation: saved average of $2350 per patient
Continuous intercostal nerve blockade for rib fractures: ready for
primetime? Truitt, M.S. & Murry, J. et.al., Journal of Trauma, 71(6): p. 1548-1552; 2011



Comparison study of epidural to continuous nerve block infusion
Numeric pain score at rest dropped from 7.5 to 2.6
Average LOS dropped 3 days (2.9 days from 5.9 days from historical control)

24. BOTTOM LINE…

Poor control of acute pain has negative
physiologic and financial consequences.

Optimizing acute pain control can lead to
improvement in patient outcomes and to
increase revenue.

25. WHAT IS A NERVE BLOCK
‘PROGRAM’ ?

26. 2 PARTS TO DEVELOPING A PROGRAM
Thanks for
Noticing!
Infrastructure
Guy with Needle

27. SINGLE SHOT NERVE BLOCK
Minimize opioids & other medications
Less Side-effects (nausea, confusion, somnolence)
Fewer „slow‟ emergences (shorter turnover time)
Quicker Discharge home
RN‟s work decreased (more efficient system)
„Avoid‟ General anesthetic
Avoid Airway concerns (bad AW, full stomach, sore throat, dental damage)
No Volatiles/Ventilator effects (nausea, atelectasis, hypotension)
Minimize/avoid hemodynamic changes of intubation
Less Work, Maintenance & Cost than CPNB Program
Faster than CPNB, minimal pt/staff education, usually no pt follow-up, no pump cost & < materials cost
May have to „Guess‟ right dose of local anesthetic/avoid completely
Shoulder/arm surgery with COPD
Possible Compartment Syndrome
Inadequate length of analgesia  less translation into (+) outcomes
Often wear off in the middle of the night
Worse on outpatients
Better than incisional local anesthetics or not doing anything at all!

28. CPNB OVERVIEW
Continuous: 2 days – > week
vs 12 – 15 hrs with single injection
vs 4-6 hrs with infiltration
Can titrate initial dose
Adjust rate of infusion to effect
Add bolus intermittently
Catheter is Perineural
NOT intraarticular (permanent injury)
NOT subcutaneous (soft tissue spread)
Local anesthetics only
OK to add pain pills/IV pain meds
OK to take it home/disposable
No abuse potential & No tolerance
No inter-variable patient response

29. BASIC TECHNIQUES
Nerve Stimulation
Stimulating Needle Tip+/- Stim Catheter
Stimulator shows nerve proximity (??)
Does not indicate orientation to nerve
Once injection starts, it is no longer reliable
Ultrasound
Visualize tissues, needle, & spread of local
Only a 2D view; may not visualize needle tip
Bigger learning curve:
Anatomy, Artifacts, Hand-eye, „Knobology‟
Both
(Dual Approach)
Good when learning or for deep blocks
N.S. or USG as primary modality &
the other as „alarm‟ or „confirmation‟
Slower than either N.S. or USG alone
NOT „double safe‟, maybe < either alone

30. LAYERED ANALGESIC STRATEGY
MULTI-MODAL & OPIOID-SPARING!!
IV Opioids (unless NPO)
CLINICIAN BOLUS
Oral Opioids PRN (then add scheduled long-acting*)
CPNB BOLUS
SCHEDULED Non-Opioid Rx
Oral & IV Tylenol, Ibuprofen, Toradol, Celecoxib (vs Inflammation), Neurontin, Ketamine
CPNB

31. HOW MUCH BENEFIT?
Patient Selection
Surgical Procedure
„Stoic‟ 60 yom, bad airway
40 yom pt
40 yom pt, severe PONV
101 yof pt, mild Alzheimer‟s
60 yom pt, 380 lb, severe OSA
70 yom pt, MI 8/2013 EF 20%
75 yof pt, 6 mo POCD after
L1-L5 lami in 2012 (No GA please!)
80 yof home O2, COPD exac &
just extubated, has M.H.
60 yom in CHF, home O2, OSA
non-operable CAD, Plavix
Second CTR with MAC/local
Rotator cuff repair
Rotator cuff repair
Bimalleolar ORIF Ankle
Total shoulder repair (1,200 EBL)
ORIF radius/ulna
Endo AAA repair
Proximal humerus nail
BKA for gangrenous foot, signs
of sepsis

32. CPNB COMMONLY USED:
Post-operative Pain Control
1.

‘Moderate’ or ‘Severe’ Pain
‘Problems’ with Traditional Therapy
Usually Orthopedic Surgeries
2.
3.
4.

Chest/Breast, Abdominal, Vascular, Hernia
Within a Multimodal Therapy Plan
5.

6.
or as the primary anesthetic (Avoid G.A.?)
P.O. Opioids, NSAIDS, Ice (vs INFLAMMATION)
Inpatients & Outpatients

33. EVIDENCE FOR BENEFIT
1. Best Analgesia
vs IV PCA, intraarticular, incisional,
selective or single nerve blocks
Singelyn Anesth Analg 1999;89:1216-20
Chelly J Arthroplasty 2001;16(4):436-45
Eledjam Reg Anesth Pain Med 2002;27(6):604-11
White Anesth Analg 2003;97:1303-9
Salinas Anesth Analg 2006;102:1234-9
Richman Anesth Analg 2006;102:248-57
T Winkler Journal of Shoulder & Ebow Surgery 2009;18:4:566-72
2. Less Opioids/Side Effects
Ilfeld Anesthesiology 2002;96(6):1297-1304
Horlocker Reg Anesth Pain Medv2002;27(1):105-8
Capdevila Anesthesiology 1999;(1):8-15
De Ruyter J Arthroplasty 2006;21(8):111-7
Singelyn Reg Anesth Pain Med 2005;30(5)452-57
Barrington Anesth Analg 2005;101:1824-9
3. Improved Sleep
Ilfeld Anesthesiology 2002;96(6):1297-1304
Ilfeld Anesthesiology 2002;97(4):959-65
Zaric Acta Anaesth Scand 2004;48:337-41
Nelson Anesthesiology 2009;111:6:1327-33
vs IV PCA, Epidural

34. EVIDENCE FOR BENEFIT
4. Outpatient instead of Inpatient
ABUNDANTLY CLEAR for multiple procedures sited in the literature
Ilfeld et al Reg Anesth and Pain Med 2006;31:172-76 (Total Elbow)
ILfeld et al Reg Anesth Pain Med 2005;101:1319-22 (Total Shoulder)
5. Patient Satisfaction
I‟ve never seen a study ranking any other modality higher than CPNB
Buckenmaier Best Practice and Clin Anesth 2002;16(2):255-70
Singelyn Reg Anesth Pain Med 2005;30(5):452-57
Singelyn Anesth Analg 2001;92:455-9
Ilfeld Anesthesiology 2002;97(4):959-65
6. Outcomes – ROM/Rehabilitation
Ilfeld Reg Anesth and Pain Med 2005;30(5):429-33
De Ruyter J Arthroplasty 2006;21(8):1111-7
X Capdevila Anesthesiology 2006;105:566-73
L Kadic et al Acta Anaesthesioogica Scandanavica 2009;7:914-20
N Cohen et al Journal Shoulder and Elbow Surgery 2000;9:268-74
B Williams et al Anesthesiology 2000;93:2:529-38
J Apfelbaum et al Anesthesiology 2002;97:1:66-74

35. EVIDENCE FOR BENEFIT
7. Outcome
-Vascular surgery/Thrombosis AVF/Reimplantation
P Inberg et al Acta Anaesthesiol Scand 1995;39:518-22
V Loland et al Pediatric Anesthesia 2009;19:9:905-7
E Malinzak Analgesia & Anesthesia 2009;109:3:976-80
$600 million/yr for interventions to MAINTAIN access (1/4 fail – stenosis, low flow)
I Laskowski et al Ann Vasc Surgery 2007;21:730-3
30% changed from AVG to AVF or proximal to distal with Plexus Block
V Yildirim et al Scand Cardiovasc Journal 2006;40:380-4
Stellate block: Increased flow, peak velocity, Successful Access P<0.001
Prevented radial artery spasm due to arterial dilation
Maturation 41 days (vs 77) P=0.001
D Shemesh et al Ultrasound Med Biol 2006;32:817-22
Pulsitility Index still low 5 hrs after surgery (vs end surgery with GA)
D Shemesh et al Cardiovasc Surgery 2003;11:35-41
AVF lower immediate & early failure rate: 0%, 6.8%
AVF lower 1 yr primary & 2 yr secondary patency rate: 81.8%, 98.6% with BPB

36. EVIDENCE FOR BENEFIT
8. Outcome -Cancer Recurrence & Immune Modulation
A Exadaktylos Anesthesiology 2006;105:4:660-4
C Deegan British J Anesthesia 2009;103:5:685-90
C Deegan et al Regional Anesthesia and Pain Medicine 2010;35:6:490-5
Y Tsuchiya et al Surgery 2003;133:5:547-555
D Sessler European Journal Cancer Prevention 2008;17:3: 269-72
D Sessler et al Contemporary Clinical Trials 2008;29:4:517-26***
(5 year, multi-center randomized trial, 1,100 pts underway)
Retrospective 129 pts, continuous PVB vs GETA
Recurrence- & Metastasis free Survival Rate:
24 months: 94% vs 82%
36 months: 94% vs 77% (P=0.012)
IL-10 (at)
MMP-3 (t)
MMP-9 (t)
IL-1B (t)
GA
-15%
29%
74%
-4.2%
Paravertebral
10.2 %
2.5%
26%
-26%
P
0.001
0.011
0.020
0.003
In vitro study of serum from breast cancer patients who underwent PVB for surgery reduces proliferation
of breast cancer cells significantly when compared with GA/opioid serum. Rate proliferation: -24% vs
73% (P=0.01) “Alters cellular milieu”

37. EVIDENCE FOR BENEFIT
9. Outcome - Chronic Pain
J Katz et al Clinical Journal of Pain 1996;12:1:50-55
“Early post-op pain is the only factor that significantly predicts
long-term pain after thoracotomy.”
P Kairaluoma et al Anesthesia & Analgesia 2006; 103:3: 703-8 (ss* PVB)
G Iohom et al Anesthesia & Analgesia 2006;103:4:995-1000 (Cont. PVB)
No pts (0/14) with CPNB had Chronic pain vs 80% (12/15) standard therapy
“Post-operative analgesia is an important determinant of CPSP
after breast surgery”
J Eisenach Regional Anesthesia & Pain Medicine 2006;2:146-51
J Dahl & S Moiniche British Medical Bulletin 2004;71:13-27
G Strichartz IARS Review Course Lectures 2009;14-21
S Ganapathy Regional Anesthesia & Analgesia 2002;1:27-32
S Reuben Anesthesiology 2004;101:5:1215-24

38. EVIDENCE FOR BENEFIT
10. Fast-Tracking Patients
B Williams et al Anesthesiology 2000;93:2:529-38
D Wilmore, H Kehlet British Medical Journal 2001;322:473
J Apfelbaum et al Anesthesiology 2002;97:1:66-74
B Williams et al Anesthesiology 2002;97:4:981-88
B Williams et al Anesthesiology 2004;100:3:697-706*
B Ilfeld et al Anesthesiology 2008;105:5:999-1007
E Mariano et al Journal Clinical Anesth 2009;21:4:253-57
P White IARS Review Course Lectures 2009
948 ACL patients over 4 years (5 anesthetic types)
Reduced PACU admissions TO 18% for nerve block (to 98% w GA)
Reduced unplanned admissions from 17% to 3 or 4% (with block)
Only 3 pts with nerve blocks admitted for pain (block wore off)
PACU Bypass & < admissions reduced costs by 12% ($98,600/yr)
(P=0.0001)

39. HEALTH CARE CHANGES
Must find ways to accomplish more daily:
1.





< Costs
> Patient Satisfaction
Minimize Complications
Eliminate Patient Care „Outliers‟
Accomplish more & in less time
Maintain business & Attract more business:
2.


Stand out from the competition
Continue (+) outcomes with new increased volumes

40. 2 PARTS TO DEVELOPING A PROGRAM
Infrastructure

41. ‘EFFECTIVE’ PAIN CONTROL
These improved outcomes and reduced morbidities
are much more likely to manifest when used in a
system-wide recovery strategy.
“Importantly, there is a critical need for collaborations between the various healthcare
providers involved in perioperative patient care (e.g., anesthesiologists, surgeons, nurses, &
physiotherapists) to integrate improved perioperative pain management with the recently described
fast-track recovery paradigms. This type of combined approach is well documented to improve the
quality of the recovery process and reduce the hospital stay and postoperative morbidity, leading to
a shorter period of convalescence after surgery.
P White, H Kehlet Improving Postoperative Pain Management Anesthesiology 2010;112:1:220-5

42. BASIC SURGERY DIAGRAM
OPERATING
ROOM
SURGEON‟S
OFFICE
RECOVERY
ROOM (PACU)
BLOCK ROOM or
HOLDING ROOM
FLOOR or
SAME DAY
SERVICES
(SDS)
PRE-TESTING
CLINIC (PAT)
PREP AREA
(SDS)
REGISTRATION
HOME

43. NERVE BLOCK PROGRAM
Patient Satisfaction


Better experience with effective analgesia (& tell their friends)
I would argue this alone is an adequate reason to pursue
Improve Safety



Respiratory Depression/Airway Issues (OSA, COPD, full stomach)
Secondary Injuries (MI, CVA, blood clots, pneumonia)
Confusion/POCD (Elderly)
Affect Outcomes






Decrease Length of Hospital Stay (Faster Day Surgery, Fewer days)
Improve Early Range of Motion
Improve Mobility & Hasten Recovery
Minimize Inactivity-induced Muscle and Bone Loss
Decreased Persistent Pain
Decreased Cancer Spread and Recurrence

44. NERVE BLOCK PROGRAM
Decreased Length of Stay


Hospital $$ Savings
Avoid Inpatient Events (nosocomial pneumonia)
Faster O.R. Turnover



Fewer „slow‟ wake ups
Less Overtime
Surgeons like this, too
Faster Outpatient Discharge



Can Skip PACU completely & drops SDS time to D/C as well
Shorter PACU times & less O.R. Bottle-necking
Decreased Staffing Needs for Hospital/Surgery Center
Outpatient instead of Inpatient Case

45. NERVE BLOCK PROGRAM
Decreased RN Workload


R.N.‟s can perform job more effectively & more safely
Less interventions
Our Hospital’s Image


New Surgeons Attracted
Public more cases!
Job Satisfaction



YOU
Your O.R. staff
Your Hospital Staff

46. ANESTHESIA SERVICE




Seeing a big difference in patient outcomes by
your effort is very satisfying
Less „problems‟ to tend to in the PACU & floor
Perioperative role of anesthesia service
recognized by hospital & public
Appreciation from surgeon colleagues, nursing
staff and administration*

47. Program
Development

48. 3 WAYS TO EXPAND A BLOCK PROGRAM:
1.
2.
3.
Increase Costs, Cause Delays, Unreliable
System, Stressful Environment, Little Change in
Quality of Patient Care
„Break Even‟ (but Patients are doing better)
VERY Satisfied Patients, Decrease
Costs, Increase Efficiency, Greater
Safety, Enjoyable Process, Everyone is Proud
to be part of the Program

49. IMPLEMENTING A PROGRAM
1.
2.
3.
4.
5.
CLEAR PLAN
CLEAR ROLES
CLEAR ENDPOINTS
CONSERVATIVE PACE
WITH SUPPORT

50. CLEAR PLAN
Individualized Course
1.



Established Formula
2.


Literature Review
Clinical Experience
Comprehensive Approach
3.



4.
Current Resources
Opportunities for Growth
Highest Impact Populations First (High Risk, Case Volume)
Infrastructure
Patient & Staff Education
Maintenance & Growth
Adjustments as Needed

51. CLEAR ROLES
Multidisciplinary TEAM Approach
1.


Leadership
2.



3.
4.
Input Requested („Our Program‟)
Communication
„One Trains the Many‟ Approach (Champions)
Expand Education in Waves
Organizing toward future processes
Success in Limited Scope, then Expand
Cross-Train staff, not hiring more staff

52. CLEAR ENDPOINTS
Goals defined after Initial Evaluation
1.
Ex: FNB for TKA Initial Goals











Check Box to Surgeon Orders: “[ ] Request Nerve Block”
2 RN trained to assist with blocks
1 RN Champion for every shift on Orthopedics Floor
< PACU time by 75%
Eliminate PCA use & ICU transfers due to ADE‟s
< PONV treatments by 75%
100% pts to 90 degree ROM on DOS
< LOS by 1 day
90% Pt Satisfaction rating of „Excellent‟ this population
All returning TKA pts asked to do 3 Q survey to compare stay
Monitor Progress
2.


Validate
Keep on Track

53. CONSERVATIVE PACE
One Phase at a time
1.



In order to Maintain Safety
Have to challenge yourself & learn something new, but…
Still stay within your comfort zone (Anesthesia & Staff)
Discrete changes in Service Lines („Start Dates‟)
2.


Though we are already planning next steps to change…
No one is caught off guard or is unprepared
Your Resources  Pace of Changes
3.


Too fast  ERRORS
Too slow Forget Processes, Lose Skills & Interest

54. WITH SUPPORT
Hospital-wide Process
1.



Anesthesia Department is only the Start!
Meetings, Inservicing & Educational Materials
Coordination & Communication
GOOD NEWS
2.



It CAN be done!
In fact, I‟ve even done this where it was “IMPOSSIBLE”
This process is NOT Theoretical:

Built „from scratch‟ twice, influenced Programs nationally

„REAL WORLD‟ Private Practice Methods & Results

Model being requested by B Braun nationally

55. YOU SHOULD FEEL GOOD ABOUT THIS!!
Patient WIN
- analgesia, side-effects, home faster, better rehab & sleep,
complications, other
fewer
Nurses WIN
- happier patients, less issues to fix, easier to get job done
Hospital WIN
- patient satisfaction, length of stay, staffing cost, more pts, staff
satisfaction, compliance, supply cost
Surgeons WIN
- Happier patients, more referrals, less ‘issues’ to address, less rounds
Anesthesia WIN
- image with admin/surgeons, satisfaction, safety, new revenue
Healthcare WIN
- resource utilization, avoid complications, less cost

56. FINAL THOUGHTS…
Beyond the humanitarian interest in patient
comfort, PATIENT SAFETY & IMPROVED
OUTCOMES have an important impact on
health care utilization and cost.
This is one more cog in the wheel to improve
patient care, satisfaction and safety!