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REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas. NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009. HOLLAND CENTRE. The Holland Centre. AMALGAMATION 1998. Orthopedic and Arthritic Hospital. Sunnybrook Hospital. Orthopedic and Arthritic Institute SWCHCS.

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regional anesthesia anesthesia care teams and block areas
REGIONAL ANESTHESIAAnesthesia Care Teams and Block Areas

NAPAN Conference

Sue Belo MD PhD FRCPC

May 23rd, 2009

the holland centre
The Holland Centre

AMALGAMATION 1998

Orthopedic and

Arthritic Hospital

Sunnybrook

Hospital

Orthopedic and Arthritic Institute

SWCHCS

Holland Centre 2005

resources
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
slide5
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
slide6
2004
  • Average length of stay 7 days
  • In-patient rehab 10 days
  • 20% to long term rehab 16 days
slide7
2004
  • Average 16/20 lists per month ran overtime
  • Average overtime 30 hours/month
  • Average 18 cancellations/month
slide8

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
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

VISION

Convert the Holland Centre to Regional Anesthesia

regional anesthesia at the holland centre
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
surgical concerns
Surgical Concerns
  • prolonged operating room time
  • decreased efficiency
  • unpredictable success rate
  • inferior surgical conditions
  • unacceptable to patients

CHANGE!!

anesthesia concerns

Anesthesia Concerns

Regional Anesthesia requires time

Regional Anesthesia requires expertise

Regional Anesthesia requires co-operation

Regional Anesthesia requires a team effort

Investment for Improvement

anesthesia care team model
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
Patient Flow

OR

Same Day Admission

Block Area

PACU

slide19

Surgeon Education

Approached surgeons individually and as a group

Provided relevant literature (including surgical literature)

Presented rounds

slide20

Nursing Education

Involved Pre-Assessment Clinic nursing staff, ward nurses, OR nurses

Provided with literature, in-services

Invited to Block Area and PACU

slide21

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

slide22

Patient education

  • by anesthetist at pre-op visit
  • patient information pamphlets
  • DVD video sent home with patient
  • Web-site
slide23

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)

slide24

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
slide25
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
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

clinical outcomes
Clinical Outcomes

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
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
pacu discharge criteria modifications for spinal anesthesia
PACU Discharge CriteriaModifications for Spinal Anesthesia
  • sensory block level at a minimum of T8
  • recession of sensory block by at least one dermatome level
  • any patient admitted to PACU with a sensory block at T10 or below and some movement of the lower extremities may be discharged from PACU
the future
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
challenges
Challenges

Retainment and Recruitment

(Anesthesiologists, Block RNs, Anesthesia Assistants)

Documenting improved outcomes

Continuous improvement

Expansion of program to Sunnybrook site

Maintaining expertise at 2 sites