More Than a Perioperative Surgical Home: An Opportunity for Anesthesiologists to Advance Public Health.

Public health and the medical specialty of anesthesiology have been closely intertwined throughout history, dating back to the 1800s when Dr. John Snow used contact tracing methods to identify the Broad Street Pump as the source of a cholera outbreak in London. During the COVID-19 pandemic, leaders in anesthesiology and anesthesia patient safety came forward to develop swift recommendations in the face of rapidly changing evidence to help protect patients and healthcare workers. While these high-profile examples may seem like uncommon events, there are many common modern-day public health issues that regularly intersect with anesthesiology and surgery. These include, but are not limited to, smoking; chronic opioid use and opioid use disorder; and obstructive sleep apnea. As an evolving medical specialty that encompasses pre- and postoperative care and acute and chronic pain management, anesthesiologists are uniquely positioned to improve patient care and outcomes and promote long-lasting behavioral changes to improve overall health. In this article, we make the case for advancing the role of the anesthesiologist beyond the original perioperative surgical home model into promoting public health initiatives within the perioperative period.

Acute pain service reduces barriers to buprenorphine/naloxone initiation by using regional anesthesia techniques.

BACKGROUND: Medications for opioid use disorder (MOUD) are a life-saving intervention; thus, it is important to address barriers to successful initiation. Spasticity affects many patients with spinal cord injury and can be painful and physically debilitating. Chronic painful conditions can lead to the illicit use of non-prescribed opioids, but fear of pain is a barrier to the initiation of MOUD. In this case report, we describe the novel use of botulinum toxin A injections to treat abdominal spasticity and facilitate Acute Pain Service-led buprenorphine/naloxone initiation in a patient with opioid use disorder and severe abdominal spasticity due to spinal cord injury. CASE PRESENTATION: A patient with C4 incomplete tetraplegia and opioid use disorder complicated by abdominal spasticity refractory to oral antispasmodics and self-treating with intravenous heroin was referred to the Acute Pain Service for inpatient buprenorphine/naloxone initiation. The patient began to fail initiation of buprenorphine/naloxone secondary to increased pain from abdominal spasms. The patient was offered ultrasound-guided abdominal muscle chemodenervation with botulinum toxin A, which resulted in the resolution of abdominal spasticity and facilitated successful buprenorphine/naloxone initiation. At 6 months post-initiation, the patient remained abstinent from non-prescribed opioids and compliant with buprenorphine/naloxone 8 mg/2 mg three times a day. CONCLUSIONS: This case report demonstrates that inpatient buprenorphine/naloxone initiation by an Acute Pain Service can improve the success of treatment by addressing barriers to initiation. Acute Pain Service clinicians possess unique skills and knowledge, including ultrasound-guided interventions, that enable them to provide innovative and personalized approaches to care in the complex opioid use disorder population.

Changing a clinical pathway to increase spinal anesthesia use for elective hip arthroplasty: a single-centre historical cohort study.

PURPOSE: International consensus recommendations support neuraxial anesthesia as the preferred anesthetic technique for total hip arthroplasty. We hypothesized that an institutional initiative to promote spinal anesthesia within a clinical pathway would result in increased use of this technique. METHODS: We reviewed primary unilateral total hip arthroplasty data between June 2017 and June 2019-one year before vs one year after implementation. The primary outcome was rate of spinal anesthesia use. Secondary outcomes included postoperative pain scores and opioid use, rates of postoperative complications, and unplanned resource use. We built a run chart-tracking rates of spinal anesthesia; compared postoperative outcomes based on anesthetic technique; and developed a mixed model, multivariable logistic regression with margins analysis evaluating the use of spinal anesthesia. RESULTS: The final sample included 172 patients (87 before and 85 after implementation) with no significant differences in baseline characteristics. For the primary outcome, 42/87 (48%) patients received spinal anesthesia before implementation compared with 48/85 (56%) postimplementation (unadjusted difference, 8%; 95% confidence interval, -7 to 23; P = 0.28). There were no differences in secondary outcomes. Factors associated with receipt of spinal anesthesia included American Society of Anesthesiologists Physical Status II (vs III), lower body mass index, and shorter case duration. Using a reduced mixed model, the average marginal effect was 10.7%, with an upper 95% confidence limit of 25.7%. CONCLUSION: Implementation of a clinical pathway change to promote spinal anesthesia for total hip arthroplasty may not have been associated with increased use of spinal anesthesia, but utilization rates can vary widely. Baseline spinal anesthesia usage at our institution was higher than the USA national average, and many factors may influence choice of anesthesia technique. Patients who receive spinal anesthesia have decreased opioid requirements and pain scores postoperatively.

RéSUMé: OBJECTIF: Les recommandations consensuelles internationales soutiennent l'anesthésie neuraxiale comme technique anesthésique à privilégier lors d'une arthroplastie totale de la hanche. Nous avons émis l'hypothèse qu'une initiative institutionnelle visant à promouvoir la rachianesthésie dans le cadre d'une trajectoire clinique entraînerait une utilisation accrue de cette technique. MéTHODE: Nous avons examiné les données sur l'arthroplastie totale unilatérale primaire de la hanche entre juin 2017 et juin 2019, soit un an avant vs un an après la mise en œuvre. Le critère d'évaluation principal était le taux d'utilisation de la rachianesthésie. Les critères d'évaluation secondaires comprenaient les scores de douleur postopératoire et la consommation d'opioïdes, les taux de complications postopératoires et l'utilisation imprévue des ressources. Nous avons construit un graphique de séquence faisant le suivi des taux de rachianesthésie, comparé les résultats postopératoires basés sur la technique anesthésique, et développé un modèle mixte et une régression logistique multivariée avec analyse des marges évaluant l'utilisation de la rachianesthésie. RéSULTATS: L'échantillon final comprenait 172 patients (87 avant et 85 après la mise en œuvre) sans différences significatives dans leurs caractéristiques initiales. Pour le critère d'évaluation principal, 42/87 (48 %) patients ont reçu une rachianesthésie avant la mise en œuvre, contre 48/85 (56 %) après la mise en œuvre de l'initiative (différence non ajustée, 8 %; intervalle de confiance à 95 %, -7 à 23; P = 0,28). Aucune différence significative n'a été observée dans les critères d'évaluation secondaires. Les facteurs associés à l'administrion d'une rachianesthésie comprenaient : l'état physique selon l'American Society of Anesthesiologists (II vs III), un indice de masse corporelle inférieur et une durée de cas plus courte. En utilisant un modèle mixte réduit, l'effet marginal moyen était de 10,7 %, avec une limite supérieure de confiance de 95 % de 25,7 %. CONCLUSION: La mise en œuvre d'un changement de trajectoire clinique pour promouvoir la rachianesthésie pour l'arthroplastie totale de la hanche n'a peut-être pas été associée à une utilisation accrue de la rachianesthésie, mais les taux d'utilisation peuvent varier considérablement. L'utilisation initiale de la rachianesthésie dans notre établissement était supérieure à la moyenne nationale des États-Unis, et de nombreux facteurs peuvent influencer le choix de la technique d'anesthésie. Les patients qui reçoivent une rachianesthésie ont diminué leurs besoins en opioïdes et leurs scores de douleur postopératoires.

Implementing an intravenous ketamine protocol for acute pain in the medical-surgical setting.

ABSTRACT: A subanesthetic intravenous ketamine infusion is a safe and effective acute pain management modality for moderate to severely painful surgical procedures and may be useful in patients who are at increased risk for opioid-related adverse events. Despite its safety profile, intravenous ketamine is often restricted to the intensive care unit, which results in decreased patient access to this effective therapy. For clinicians who wish to implement an intravenous ketamine protocol in the medical-surgical setting, there are few resources available. In this brief report, we present our ketamine infusion protocol for acute pain and the clinical and financial outcomes 1 year after implementation. In our experience, ketamine infusions on the medical-surgical ward are safe and cost-effective when an established acute pain service protocol is followed. Nurse practitioners play an essential role in increasing patient access to intravenous ketamine infusions and leading change by collaborating with stakeholders to develop a protocol, training nurses and interdisciplinary team members, and providing ongoing support to nursing staff.

Automated text messaging follow-up for patients who receive peripheral nerve blocks.

BACKGROUND: Routine follow-up of patients who receive a nerve block for ambulatory surgery typically consists of a phone call from a regional anesthesia clinician. This process can be burdensome for both patients and clinicians but is necessary to assess the efficacy and complication rate of nerve blocks. METHODS: We present our experience developing an automated system for completing follow-up via short message service text messaging and our preliminary results using it at three clinical sites. The system is built on REDCap, a secure online research data capture platform developed by Vanderbilt University and currently available worldwide. RESULTS: Our automated system queried patients who received a variety of nerve block techniques, assessed patient-reported nerve block duration, and surveyed patients for potential complications. Patient response rate to text messaging averaged 91% (higher than our rates of daily phone contact reported previously) for patients aged 18 to 90 years. CONCLUSIONS: Given the wide availability of REDCap, we believe this automated text messaging system can be implemented in a variety of health systems at low cost with minimal technical expertise and will improve both the consistency of patient follow-up and the service efficiency of regional anesthesia practices.

Educating Nurses on Intravenous Lidocaine for Postoperative Pain Management.

As healthcare practitioners continue to search for multimodal analgesic therapies to reduce postoperative opioid requirements, surgical ward nurses need to stay up to date on the status of emerging therapies. One of these is intravenous lidocaine for postoperative pain management. Unfortunately, there is a lack of resources to assist surgical ward nurses who are unfamiliar with lidocaine infusions for pain. This article aims to review the pharmacology of intravenous lidocaine for pain management, describe an experience of a university-affiliated Veterans Affairs hospital with implementation of intravenous lidocaine on the surgical ward, and suggest practical tools that can be used to develop protocols and educational content for nurses managing intravenous lidocaine infusions in the postoperative period.

Replacement of Fascia Iliaca Catheters with Continuous Erector Spinae Plane Blocks Within a Clinical Pathway Facilitates Early Ambulation After Total Hip Arthroplasty.

OBJECTIVE: The optimal continuous peripheral nerve block (CPNB) technique for total hip arthroplasty (THA) that maximizes both analgesia and mobility is unknown. Continuous erector spinae plane (ESP) blocks were implemented at our institution as a replacement for fascia iliaca (FI) catheters to improve our THA clinical pathway. We designed this study to test the hypothesis that this change will increase early postoperative ambulation for elective primary THA patients. METHODS: We identified all consecutive primary unilateral THA cases six months before and six months after the clinical pathway change to ESP catheters. All other aspects of the THA clinical pathway and multimodal analgesic regimen including perineural infusion protocol did not change. The primary outcome was total ambulation distance (meters) on postoperative day 1. Other outcomes included total ambulation on postoperative day 2, combined two-day ambulation distance, pain scores, opioid consumption, inpatient length of stay, and minor and major adverse events. RESULTS: Eighty-eight patients comprised the final sample (43 FI and 45 ESP). Postoperative day 1 total ambulation distance was greater for the ESP group compared with the FI group (median [10th-90th percentiles] = 24.4 [0.0-54.9] vs 9.1 [0.7-45.7] meters, respectively, P = 0.036), and two-day ambulation distance was greater for the ESP group compared with the FI group (median [10th-90th percentiles] = 68.6 [9.0-128.0] vs 46.6 [3.7-104.2] meters, respectively, P = 0.038). There were no differences in pain scores, opioid use, or other outcomes. CONCLUSIONS: Replacing FI catheters with continuous ESP blocks within a clinical pathway results in increased early ambulation by elective primary THA patients.

Complementing Root Cause Analysis With Improvement Strategies to Optimize Venous Thromboembolism Prophylaxis in Patients With Epidural Catheters.

BACKGROUND AND OBJECTIVES: High reliability organizations in health care must identify defects and systematically approach causal factors with subsequent process redesign to achieve goals important to patients, families, and staff. Root cause analysis (RCA) is a commonly leveraged strategy for reviewing adverse events and can yield immense benefits toward patient safety when applied alongside complementary change management strategies such as Lean and Six Sigma. We performed an RCA in response to a hospital-acquired venous thromboembolism (VTE) event in a postoperative patient for which pharmacologic VTE prophylaxis was not appropriately resumed following removal of an epidural catheter. METHODS: A multidisciplinary stakeholder team was assembled to further understand the details of the event. A current process map was created and non-value-added steps were identified. Causal analysis revealed that frequent staff turnover, variable methods of communication between stakeholders, inconsistent responsibilities with respect to ordering and administering pharmacologic VTE prophylaxis, and lack of an established standard work process were key contributors toward the defect of concern. Several countermeasures were introduced to combat these identified root causes, including shifting responsibility for managing VTE prophylaxis orders periepidural catheter removal from the surgical house staff to our regional anesthesia service, and creation of an epidural catheter heparin restart order set, which in one step places an order to resume prophylaxis following catheter removal at a specific time. Recommendations from this session were disseminated to staff through previously established huddles that are a component of our daily management system. RESULTS: Postintervention, review of our updated process demonstrated a reduction in variability through establishment of standard work that is primarily owned by a constant factor in this care pathway (our regional anesthesia team). On review of the subsequent 10 cases of patients with epidural catheters, all patients receiving pharmacologic VTE prophylaxis had a maximum of 1 dose stopped for epidural catheter removal, therefore minimizing time without VTE prophylaxis. CONCLUSIONS: RCA can be utilized in the aftermath of an adverse event to establish causal factors and identify countermeasures to prevent recurrence of such an event. It can be further augmented with additional change management strategies including Lean, Six Sigma, the Model for Improvement, and failure modes and effects analysis. These strategies allowed us to design effective error-reducing strategies to achieve a more reliable process, which yielded reduced VTE prophylaxis administration defects that in turn has prevented recurrence of hospital-acquired VTE in patients with epidural catheters.

Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery.

BACKGROUND AND OBJECTIVES: At our institution, we developed an individualized discharge opioid prescribing and tapering protocol for joint replacement patients and implemented the same protocol for neurosurgical spine patients. We then tested the hypothesis that this protocol will decrease the oral morphine milligram equivalent (MME) dose of opioid prescribed postdischarge after elective primary spine surgery. METHODS: In this retrospective cohort study, we identified all consecutive elective primary spine surgery cases 1 year before and after introduction of the protocol. This protocol used the patient's prior 24-hour inpatient opioid consumption to determine discharge opioid pill count and tapering schedule. The primary outcome was total opioid dose prescribed in oral MME from discharge through 6 weeks. Secondary outcomes included in-hospital opioid consumption in MME, hospital length of stay, MME prescribed at discharge, opioid refills, and rates of minor and major adverse events. RESULTS: Eighty-three cases comprised the final sample (45 preintervention and 38 postintervention). There were no differences in baseline characteristics. The total oral MME (median (IQR)) from discharge through 6 weeks postoperatively was 900 (420-1440) preintervention compared with 300 (112-806) postintervention (p<0.01, Mann-Whitney U test), and opioid refill rates were not different between groups. There were no differences in other outcomes. CONCLUSIONS: This patient-specific prescribing and tapering protocol effectively decreases the total opioid dose prescribed for 6 weeks postdischarge after elective primary spine surgery. Our experience also demonstrates the potential generalizability of this protocol, which was originally designed for joint replacement patients, to other surgical populations.

Five-year follow-up to assess long-term sustainability of changing clinical practice regarding anesthesia and regional analgesia for lower extremity arthroplasty.

Background: Long-term and sustainable clinical practice changes in anesthesia procedures have not previously been reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change favoring spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA), who did not undergo a clinical pathway change, and studied utilization rates of continuous peripheral nerve block (CPNB). METHODS: We identified all primary unilateral TKA and THA cases completed from January 2013 through December 2018, thereby including clinical pathway change data from one-year pre-implementation to 5-years post-implementation. Our primary outcome was the overall application rate of spinal anesthesia. Secondary outcomes included CPNB utilization rate, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions. RESULTS: The sample included 1,859 cases, consisting of 1,250 TKAs and 609 THAs. During the initial year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) cases the year before implementation (P < 0.001). During the following 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (P = 0.532 vs. year 1). The number of THA cases receiving spinal anesthesia the year after implementation was 78/124 (62.9%), compared to 48/116 (41.4%) pre-implementation (P = 0.001); however, the rate decreased over the following 4-year period to 193/369 (52.3%) (P = 0.040 vs. year 1). CPNB use was high in both groups, and there were no differences in 30-day postoperative complications, hospital readmission, emergency department visits, or blood transfusions. CONCLUSIONS: A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.

A Multidisciplinary Patient-Specific Opioid Prescribing and Tapering Protocol Is Associated with a Decrease in Total Opioid Dose Prescribed for Six Weeks After Total Hip Arthroplasty.

OBJECTIVE: This retrospective cohort study tested the hypothesis that implementing a multidisciplinary patient-specific discharge protocol for prescribing and tapering opioids after total hip arthroplasty (THA) will decrease the morphine milligram equivalent (MME) dose of opioids prescribed. METHODS: With institutional review board approval, we analyzed a Perioperative Surgical Home database and prescription data for all primary THA patients three months before (PRE) and three months after (POST) implementation of this new discharge opioid protocol based on patients' prior 24-hour inpatient opioid consumption. The primary outcome was total opioid dosage in MME prescribed and opioid refills for six weeks after surgery. Secondary outcomes included the number of tablets and MME prescribed at discharge, in-hospital opioid consumption, length of stay, and postoperative complications. RESULTS: Forty-nine cases (25 PRE and 24 POST) were included. Total median (10th-90th percentiles) MME for six weeks postoperatively was 900 (57-2082) MME PRE vs 295 (69-741) MME POST (mean difference = 721, 95% confidence interval [CI] = 127-1316, P = 0.007, Mann-Whitney U test). Refill rates did not differ. The median (10th-90th percentiles) initial discharge prescription in MME was 675 (57-1035) PRE vs 180 (18-534) POST (mean difference = 387, 95% CI = 156-618, P = 0.003, Mann-Whitney U test) MME. There were no differences in other outcomes. CONCLUSIONS: Implementation of a patient-specific prescribing and tapering protocol decreases the mean six-week dosage of opioid prescribed by 63% after THA without increasing the refill rate.

Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center.

OBJECTIVE: The feasibility and safety of managing ambulatory continuous peripheral nerve blocks (CPNB) in Veterans Health Administration (VHA) patients are currently unknown. We aimed to characterize the outcomes of a large VHA cohort of ambulatory upper extremity surgery patients discharged with CPNB and identify differences, if any, between catheter types. METHODS: With institutional review board approval, we reviewed data for consecutive patients from a single VHA hospital who had received ambulatory CPNB for upper extremity surgery from March 2011 to May 2017. The composite primary outcome was the occurrence of any catheter-related issue or additional all-cause health care intervention after discharge. Our secondary outcome was the ability to achieve regular daily telephone contact. RESULTS: Five hundred one patients formed the final sample. The incidence of any issue or health care intervention was 104/274 (38%) for infraclavicular, 58/185 (31%) for interscalene, and 14/42 (33%) for supraclavicular; these rates did not differ between groups. Higher ASA status was associated with greater odds of having any issue, whereas increasing age was slightly protective. Distance was associated with an increase in catheter-related issues (P < 0.01) but not additional health care interventions (P = 0.51). Only interscalene catheter patients (3%) reported breathing difficulty. Infraclavicular catheter patients had the most emergency room visits but rarely for CPNB issues. Consistent daily telephone contact was not achieved. CONCLUSIONS: For VHA ambulatory CPNB patients, the combined incidence of a catheter-related issue or additional health care intervention was approximately one in three patients and did not differ by brachial plexus catheter type. Serious adverse events were generally uncommon.

Implementation of the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block into a multimodal analgesic pathway for total knee replacement.

BACKGROUND: The Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block is a new anesthesiologist- administered analgesic technique for controlling posterior knee pain that has not yet been well studied in total knee arthroplasty (TKA) patients. We compared pain outcomes in TKA patients before and after implementation of the IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 than non-IPACK patients. METHODS: With Institutional Review Board approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon 4 months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and peri-operative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and adverse events within 30 days. RESULTS: Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group. On POD 0, the lowest pain score (median [10th-90th percentiles]) was significantly lower for the POST group compared to the PRE group (0 [0-4.3] vs. 2.5 [0-7]; P = 0.003). The highest patient-reported pain scores on any POD were similar between groups with no differences in other outcomes. CONCLUSIONS: Within a multimodal analgesic protocol, addition of IPACK blocks decreased the lowest pain scores on POD 0. Although other outcomes were unchanged, there may be a role for new opioid-sparing analgesic techniques, and changing clinical practice change can occur rapidly.

Care of the Patient With a Peripheral Nerve Block.

Long-acting peripheral nerve blocks provide effective postoperative pain management, but there are risks associated with rendering an extremity insensate. Perianesthesia nurses play a major role in anticipating and mitigating risks and carefully monitoring patients for potential complications. This article presents uncommon but important considerations related to the care of patients with a peripheral nerve block. These include compartment syndrome, local anesthetic systemic toxicity, thermal injuries, falls, and fractures as well as their management and prevention. The nurse's responsibility in discharge education after a peripheral nerve block is also discussed.

Patient education and engagement in postoperative pain management decreases opioid use following knee replacement surgery.

OBJECTIVE: Effects of patient education on perioperative analgesic utilization are not well defined. We designed a simple pain management educational card for total knee arthroplasty (TKA) patients and retrospectively reviewed clinical data before and after implementation to test the hypothesis that more informed patients will use less opioid. METHODS: With IRB approval, we analyzed clinical data collected perioperatively on all TKA patients one month before (PRE) and one month after (POST) card implementation. The card was designed using a modified Delphi method; the front explained all analgesic medications and the Defense and Veterans Pain Rating Scale was on the back. The primary outcome was total opioid dosage in morphine milligram equivalents (MME) for the first two postoperative days. Secondary outcomes included daily opioid usage, pain scores, ambulation distance, hospital length of stay and use of antiemetics. RESULTS: There were 20 patients in each group with no differences in baseline characteristics. Total two-day MME [median (10th-90th percentiles)] was 71 (32-285) for PRE and 38 (1-117) for POST (p = 0.001). There were no other differences. CONCLUSION: Educating TKA patients in multimodal pain management using a simple tool decreases opioid usage. PRACTICE IMPLICATIONS: Empowering TKA patients with education can reduce opioid use perioperatively.