How to set up Regional Anesthesia Service

That improves Theatre Efficiency

Prof. Krishna Boddu MBBS, MD (Anes), DNB, FANZCA, MMEd.

Department of Anesthesiology & Pain Medicine

University of Texas Health Sciences, Houston, Texas

University of Western Australia, Perth, Australia

Director, Regional Anaesthesia, Royal Perth Hospital, Perth, Australia

Phone: +17138559971 (USA), +61416030020 (Australia)

kboddu@yahoo.com

www.nerveblocks.org

OurMission

Zero Suffering for 100% of our patients

Is it possible?

PT, OT, Wound Care RN

PhysiciansSurgeons

Technicians,Theater Nurses,

Ward Nurses,

Patients, Family

Registrars,Fellows

Midlevel Providers

AllPerioperativePhysicians

HospitalManagement

3

Sharing The Same

Goal & Vision By

What is Regional Anesthesia?

• It is one of the several modes of analgesia that might be superior but it is not the only mode of analgesia

• It is an extension of Acute Pain Service• It provides better dynamic pain control,

possibly decreases hospital stay, prevents development of chronic pain

• Generates more income than other modes of analgesia

Setting up Regional Anesthesia Service is a “Project” & Every “Project Needs Planning”

• Any plan is better than no plan

• A reasonable plan is better than just any plan

• But a first rate plan with poor implementation

Is not as good As a reasonable plan with first rate

implementation!

Project management Counseling

Implementation Is “Team Work”

Improves Patients

Satisfaction

Provides Effective

Dynamic Pain Control

Least or NoAdverse Effects

Early Return Of Bowel Function

Decrease DVT/

Pneumonia

Prevents Chronic Pain Syndromes

FacilitatesEarly

Discharge

More Direct & Indirect Incomes 6

Adapt Techniques That……

Regional Anesthesia Provides Effective Pain Control As A

Part of Multimodal Analgesia

Regional Anesthesia Service Models

• RA in separate dedicated area(RA Wing)

• Expensive but Best Results• Best for teaching (Not rushed)• $ Generating Even for Follow Up• Recognition For RA Service

• Moderately Expensive• Needs at least TWO providers• Juggle two cases simultaneously• Facility Fee split?

• Most Expensive with poor results• Million Eyes Watching You &

Surgeon breathing down your neck.

• RA in

Induction Room

(Ante room)

• RA in Theater as a part of Anesthesia

Which Regional Anesthesia model is best for your hospital?

Based on workload & manpower• In Operating Room : Only Specialist or Trainee• In Induction Room : Specialist + Trainee/ CRNA• Dedicated RA area : Dedicated RA team

------------------------------------------------------------------------• Based on number of cases per day• Based on reimbursement structure

Most of the Teaching Hospitals Should Have Dedicated Regional Anesthesia Team

OR/Theater Time Is Very Valuable

If Surgeon & Anesthesiologist Are NotWorking Simultaneously, OR Time Is

Considered As “Non Productive” Time

Anesthesia Time

ProductiveWhen

Surgical Team In Action

Not Productive When Surgeon Is Sitting Doing

Nothing while Paid.Examples: Pre Anesthesia AssessmentIV Line PlacementNerve Blocks

Cost Savings By Conducting Blocks Outside OR

15 Blocks/day Average # surgical cases per day with nerve blocks

20 min/ block Average time taken for conducting nerve block

5 hours/ day # hours OR is in use for nerve blocks per day

250 day/ year Days in year surgeries take place

$80/ min Average cost per minute in OR - Not including Surgeon

$4,800/ hour Average cost in OR per hour - Not including Surgeon

$48,000/ day Total cost per 10 hour day for OR - Not including Surgeon

20 min/ block Time savings per nerve block conducted (in minutes)

300 min/day Minutes saved per day

$24,000/ day Cost savings per day

$ 6,000,000/ year Total cost savings per year to hospital (250 working days/ year)

If Surgeon Is Breathing Down Your Neck,You Tend To Do Single Shot Nerve Block

Single Shot Nerve Block

Patient VeryComfortable

Early Discharge from PACU

Tired Surgical Resident Sleeping

Block Wore Off & in Pain

Frustrated Nurse Calls Primary

Un-happyResident

Anesthesia- Surgery War !!!!

12

Poorly designed Regional Anesthesia leads to poor clinical care, resulting in poor clinical & financial outcomes

Dedicated RA Team ModelMan Power & Billing Equipment & Drugs Documentation &

Follow up

Attending * Regional Anesthesia Cart Procedure Notes

Nurse/ Tech * Ultrasound Machine Follow-up Notes

Resident/ CRNA Nerve Stimulator Audits

Nerve Block Needles Consult Forms

Catheters & PumpsCommunication Devices

Regional Anesthesia Team(Mobile Phones/ Pagers)

Theater/ OR Team

APS Team

Board Runner

Theater/ ORScheduling

Orderlies PACU

Pharmacy PT/OT

Over $650,000 investment by Hospital to save over $10,00,000

Man Power & Interest Survey• Survey Your Department:

For experience /comfort levels with various blocks, local anesthetics and catheter techniques

• How much your team is interested in introducing RA practice

• Their Educational Needs• Identify core group of PARTNERS

Gather Similar Information from Nursing & Technicians

Be Prepared To Answer The Question: Why Regional Anesthesia?

• From the Anesthesia standpoint• From the Patient’s standpoint• From the Surgeon’s standpoint• From the Facilities standpoint• From management standpoint• From PACU standpoint• From Physiotherapy/ Occupational

Therapy standpoint

Challenge YourselfWhy Not Regional Anesthesia?

&What are the limiting factors?

• Forethought / logistic coordination• Proficiency/ thorough knowledge of anatomy/

drugs• Need more manpower• Would it be warranted by more revenues ?

Your “Trump Card” To ConvinceFor Regional Anesthesia Will Be…

Any Method Of Pain Control That Reduces

Adverse Effects/ Events Translates to

Superior Method With Improved Outcomes

Regional Anesthesia BasicallyRemoves Pain

From Surgical Equation

Hadzic et al. ResultsNerve Block GA

Bypass PACU 79% 25%

Pain Scores >3 on Arrival in PACU 3% 48%

Additional Pain Meds Requested in PACU 0% 48%

Time to home readiness 100 min 203 min

Discharge times 121 min 218 min

Adverse Effects Less

Pavlin et al.¹- 90 min. reduction in discharge time in RA vs GA pts.Pavlin et al.² showed max. pain score predicted recovery time, cumulative fentanyl predicted PONVWilliams et al.³ – each nursing intervention assoc. w/ 27 to 45 min delay in discharge 1) Pavlin DJ, et al. Anesth Analg 2002; 95:627-34 2) Pavlin DJ, et al. Anesth Analg 1998; 87:816-26

3) Williams, BA et al. Best Pract Res Clin Anesthes 2002: 16: 175-94

Any equipment you purchase is expected to be money generating

Money CowMoney Office

Why should we invest more money?

Will it improve patient outcome?Will it decrease complications?Will it improve patient satisfaction?Will it improve the OR turn around time?Will it decrease hospital stay for the patient?Will insurance companies reimburse?

Be Prepared For Other common management questions:

The above are equivalents for generation of money

Create The Service

• Formally create a Regional Anesthesia Service

• Appoint leadership of the service• START SLOWLY • Gather all success stories & data for obtaining

further support• Realize success depends on a safe, efficient ,

and well coordinated service

Official inauguration of RA Service

Invitees1. CEO or Health Minister2. Head of the Department3. Other Hospital Executives (CNO. CMO, COO, CFO etc)4. All department heads and all surgical consultants5. All charge nurses of every ward6. All OR/ theater staff (nurses, technicians, orderlies etc)7. Physical Therapy, Occupational Therapy, Pharmacy8. Also invite all key people from other hospitals in your town

Make it a big deal. Make it as a Project for the Hospital

not just yours

23

Our Regional Anesthesia Real Estate

Ask Yourself Where ?

Educate the Masses• Must establish educational programs for

Anesthesiologists, R.N.’s, and Surgeons• Patients need information too

Communicate • Identify block candidates ahead of time and

prepare for them• Know the Surgeon’s needs, likes & dislikes • Close follow-up with patients an absolute

must• Regular meetings / discussions within your

group

25

A SMALL TRUTH TO MAKE SUCCESS 100%

Is Equal to

Hard Work (H+A+R+D+W+O+R+K)8+1+18+4+23+15+18+11 = 98%

Knowledge (K+N+O+W+L+E+D+G+E) 11+14+15+23+12+5+4+7+5 = 96%

Love (L+O+V+E) 12+15+22+5 = 54%

Luck (L+U+C+K) 12+21+3+11 = 47%

26

Then what makes 100% ?Is it Money (M+O+N+E+Y) ? ... NO !

3+15+14+5+25 = 72%

Is it Leadership? NO ! (L+E+A+D+E+R+S+H+I+P)?

12+5+1+4+5+18+19+9+16 = 89%Every problem has a solution, only if we perhaps change our attitude.

ATTITUDE A+T+T+I+T+U+D+E

1+20+20+9+20+21+4+5 = 100%