Comparison of migration rates between traditional and tunneled adductor canal block catheters: a randomized controlled trial.

INTRODUCTION: Total knee arthroplasty is associated with significant postoperative pain. Continuous adductor canal blocks via an inserted adductor canal catheter are effective analgesia interventions with the advantage of decreasing quadriceps weakness and the potential of extending the analgesic effect. The classical adductor canal catheter insertion technique may have a high likelihood of catheter dislodgement out of the canal. The interfascial plane between the sartorius muscle and femoral artery (ISAFE) approach has the potential of decreasing the adductor canal catheter migration. The purpose of this study was to evaluate the incidence of catheter dislodgment to outside the adductor canal, for ISAFE and classical approaches. We hypothesized that ISAFE approach would result in a lower dislodgment rate. METHODS: Ninety-seven patients for unilateral total knee arthroplasty were included and randomized to either ISAFE intervention group or conventional group. The primary outcome was the incidence of adductor canal catheter dislodged to outside the adductor canal, on ultrasound evaluation, 24 hours after the surgery. Secondary outcomes were pain scores, opioid consumption and continuous adductor canal block related complications for the first 48 hours after surgery. RESULTS: The catheters placed using ISAFE approach had a lower rate of dislodgement in comparison to the control group (18.6% vs 44.9%, respectively, p=0.01), at 24 hours after surgery; and lower pain scores for rest, on the first two postoperative days. CONCLUSIONS: ISAFE group had a significantly lower rate of dislodgement at 24 hours. The continuous adductor canal block analgesic benefit for knee arthroplasty depends on the position of the tip of the catheter inside the adductor canal.

Effectiveness of preoperative thoracic epidural testing strategies: a retrospective comparison of three commonly used testing methods.

PURPOSE: Thoracic epidural analgesia (TEA) is a well stablished technique for pain management in major thoracic and abdominal surgeries; however, it has considerable failure rates. Local anesthetic (LA) administration and subsequent assessment of sensory block through physical examination (e.g., decreased temperature perception determined via an LA temperature dissociation test [LATDT]) has been the historical standard for evaluation of thoracic epidural placement. Nevertheless, newer methods to objectively evaluate successful placement have recently been developed, e.g., the epidural electrical stimulation test (EEST) and epidural pressure waveform analysis (EWA). The purpose of this study was to evaluate the effectiveness of preoperative TEA catheter testing (LATDT, EEST, and EWA) on reducing TEA failure. METHODS: After obtaining an institutional research ethics board approval for a retrospective study, we conducted a single-institution retrospective review on all TEAs performed between January 2016 and December 2021. Patients were assigned to one of four groups based on the performed test method to verify the placement of the TEA catheter: no test, LATDT, EEST, and EWA. A TEA was deemed successful if it provided bilateral dermatomal sensory block to ice test in the postoperative period, and was used for patient analgesia for at least 24 hr. RESULTS: One thousand two hundred and forty-one patients submitted to preoperative TEA were included. Twenty-eight patients were excluded. Tested and untested epidurals had failure rates of 3.8% (95% confidence interval [CI], 1.8 to 6.2) and 11.5% (95% CI, 5.2 to 17.1), respectively (P < 0.001). CONCLUSION: Objective preoperative testing after placement of thoracic epidurals was associated with a reduction in failure rates.

RéSUMé: OBJECTIF: L'analgésie péridurale thoracique (APT) est une technique bien établie pour la prise en charge de la douleur dans les chirurgies thoraciques et abdominales majeures; cette modalité entraîne cependant des taux d'échec considérables. L'administration d'anesthésique local (AL) et l'évaluation subséquente du bloc sensitif par un examen physique (p. ex. diminution de la perception de la température déterminée par un test de dissociation de la température après l'AL [LATDT]) ont constitué la norme historique pour l'évaluation du positionnement de la péridurale thoracique. Néanmoins, de nouvelles méthodes permettant d'évaluer objectivement le positionnement réussi ont récemment été mises au point, par exemple le test de stimulation électrique péridurale (EEST) et l'analyse de la forme d'onde de pression péridurale (EWA). L'objectif de cette étude était d'évaluer l'efficacité des tests préopératoires de cathéters d'APT (LATDT, EEST et EWA) sur la réduction des échecs d'APT. MéTHODE: Après avoir obtenu l'approbation d'un comité d'éthique de la recherche de l'établissement pour une étude rétrospective, nous avons réalisé un examen rétrospectif monocentrique de toutes les APT réalisées entre janvier 2016 et décembre 2021. Les patient·es ont été assigné·es à l'un des quatre groupes en fonction de la méthode de test utilisée pour vérifier l'emplacement du cathéter d'APT, soit : aucun test, LATDT, EEST et EWA. Une APT a été jugée efficace si elle a fourni un bloc sensitif dermatomal bilatéral au test de glace en postopératoire et a été utilisée pour l'analgésie pendant au moins 24 heures. RéSULTATS: Mille deux cent quarante et un·e patient·es soumis·es à une APT préopératoire ont été inclus·es. Vingt-huit personnes ont été exclues. Les péridurales testées et non testées présentaient des taux d'échec de 3,8 % (intervalle de confiance [IC] à 95 %, 1,8 à 6,2) et de 11,5 % (IC 95 %, 5,2 à 17,1), respectivement (P < 0,001). CONCLUSION: Les tests préopératoires objectifs après la mise en place de péridurales thoraciques ont été associés à une réduction des taux d'échec.

The Impact of Peripheral Nerve Block on the Quality of Care After Ankle Fracture Surgery: A Quality Improvement Study.

OBJECTIVES: To increase peripheral nerve block (PNB) administration for ankle fracture surgeries (AFSs) at our institution to above 50% by January 1st, 2021. DESIGN: Longitudinal, single-center quality improvement study conducted at a high-volume tertiary care center. PATIENTS: All patients undergoing isolated AFS for unimalleolar, bimalleolar, or trimalleolar ankle fracture from July 2017 to April 2021 were included in this study. INTERVENTION: Interventions implemented to minimize barriers for PNB administration included recruitment and training of expert anesthesiologists in regional anesthesia, procurement of ultrasound machines, implementation of a dedicated block room, and creation of a pamphlet for patients describing multimodal analgesia. MAIN OUTCOME MEASUREMENT: The primary outcome was the percentage of patients receiving PNB for AFS. Secondary outcomes included hospital length-of-stay, postanesthesia care unit (PACU) and 24-hour postoperative opioid consumption (mean oral morphine equivalent [OME]), proportion of patients not requiring opioid analgesic in PACU, and PACU and 24-hour postoperative nausea/vomiting requiring antiemetic. RESULTS: The PNB and non-PNB groups included 78 and 157 patients, respectively. PNB administration increased from <5% to 53% after implementation of the improvement bundle. Mean PACU and 24-hour opioid analgesic consumption was lower in the PNB group (PACU OME 38.96 mg vs. 55.42 mg, P = 0.001; 24-hour OME 50.83 mg vs. 65.69 mg, P = 0.008). A greater proportion of patients in the PNB group did not require PACU opioids (62.8% vs. 27.4%, P < 0.001). CONCLUSIONS: By performing a root cause analysis and implementing a multidisciplinary, patient-centered improvement bundle, we increased PNB administration for AFSs, resulting in reduced postoperative opioid analgesia consumption. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Color flow Doppler in spinal ultrasound: a novel technique for assessment of catheter position in labor epidurals.

BACKGROUND: Ultrasound is commonly used to facilitate epidural catheter placement. However, data are lacking regarding its potential to confirm its position in the epidural space. Our aim was to visualize flow in the epidural space of patients receiving epidural analgesia for labor using color flow Doppler ultrasound. METHODS: We conducted a prospective observational cohort study that included patients who had delivered vaginally under epidural analgesia. We used a 5-2 mHz curvilinear probe in a left and right paramedian longitudinal oblique view to visualize the anterior and posterior complex at the interspace of epidural catheter insertion, one and two interspaces above and below. At each window, the color flow Doppler function was used to visualize flow within the epidural space on injection of normal saline (1 mL). If no flow was visualized at any interspace, one assessment at the level of insertion was repeated with a 1 mL air/saline mixture. We studied a convenience sample size of 40 patients. RESULTS: We visualized flow in the epidural space in all 40 patients. Flow was visualized on injection of 1 mL of saline in 37/40 patients (93%). In the remaining 3/40 patients (7%), flow was visualized with an air/saline mixture. Flow on injection of saline was visualized only at the interspace of insertion in 26/37 patients (70%), at the interspace of insertion and one interspace above in 10/37 (27%), or only at one interspace above in 1/37 (3%). Flow was visualized only on the left or on the right paramedian view in 19/37 patients (51%), despite a symmetrical sensory block in all patients. CONCLUSION: Color flow Doppler ultrasound is a feasible and fast way to determine flow in the epidural space in the obstetric population. Its potential clinical uses are confirmation of the epidural catheter position after placement, as well as troubleshooting of unsatisfactory epidural analgesia. Interestingly, our results suggest that epidural catheters predominantly remain at the interspace of insertion. TRIAL REGISTRATION NUMBER: NCT05126745.

Rapid implementation of an outpatient arthroplasty care pathway: a COVID-19-driven quality improvement initiative.

BACKGROUND: Hip and knee total joint arthroplasty (TJA) procedures are two of the most common inpatient surgical procedures worldwide. Outpatient TJA has emerged as a feasible option. COVID-19 caused significant constraints on inpatient surgical resources and contributed to a growing surgical backlog. We present a quality improvement (QI) initiative aimed at adding an outpatient TJA pathway to our pre-existing inpatient TJA programme, with the target of performing 25% of our primary TJA as outpatients. METHODS: This was a QI study at a tertiary level arthroplasty centre. To achieve our aim, a patient-centred needs analysis revealed the need to develop patient selection criteria, perform a specific and tailored anaesthetic, provide patient education and conduct virtual care follow-up. Based on these findings, an outpatient TJA intervention bundle was developed and implemented. RESULTS: After implementing the outpatient pathway, 65 patients were scheduled for outpatient TJA. Fifty-five (84.6%) patients were successfully discharged home on the day of surgery. Successful outpatient TJA accounted for 33.3% of all primary TJAs performed at our intuition throughout the study period. There was excellent adherence to the intervention protocols, with the success hinging on multidisciplinary team and supported QI culture. Thirty-day emergency department visits for inpatient and outpatient TJAs were 8.93% and 6.15%, respectively. No outpatient TJA patients required hospital readmission within 30 days. CONCLUSION: Our study demonstrates that implementation of an outpatient TJA pathway in response to inpatient resource constraints during the COVID-19 pandemic is feasible. The findings of this report will be of interest to surgical centres facing surgical backlog and constraints on inpatient resources during and after the pandemic.

Developing a business case for a regional anesthesia block room: up with efficiency, down with costs.

BACKGROUND: Regional anesthesia techniques offer many benefits for total joint arthroplasty (TJA) patients. However, they require personnel and equipment resources, as well as valuable operating room (OR) time. A block room offers a dedicated environment to perform regional anesthesia procedures while potentially offsetting costs. METHODS: The goal of this prospective quality improvement study was to develop a business case for implementation of a regional anesthesia block room and to demonstrate the cost-effectiveness of this program in decreasing OR time for TJA. All elective TJA patients presenting between January 2019 and March 2020 were included in our analysis. RESULTS: Our detailed business plan was approved by the hospital leadership. 561 patients in the preintervention group and 432 in the postintervention group were included for data analysis. Mean total OR time per surgical case decreased from 166 to 143 min for a difference of 23 min (95% CI 17 to 29). Similarly, anesthesia controlled OR time decreased from 46 min to 26 min for a difference of 20 min (95% CI 17 to 22). The block room resulted in an additional primary TJA case per daily OR list. The percentage of TJA patients receiving a peripheral nerve block increased from 63.1% to 87.0% (p<0.001). No safety events or block room associated OR delays were observed. CONCLUSION: Implementing a regional anesthesia block room required a comprehensive business plan for securing the necessary resources to support the program. The regional anesthesia block room is a cost-effective method to improve patient care and OR efficiency.

Reducing Acute Hospitalization Length of Stay After Total Knee Arthroplasty: A Quality Improvement Study.

BACKGROUND: The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve quality of care while minimizing costs. The aim of our quality improvement project is to reduce the acute hospitalization length of stay to less than 2 days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery bundle. METHODS: This study used a before-and-after design. The pre-intervention period was January to December 2017 and the post-intervention period was January 2018 to August 2019. A root cause analysis was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: (1) perioperative peripheral nerve block; (2) prophylactic antiemetic medication; (3) avoidance of routine preoperative urinary catheterization; and (4) preoperative patient education. RESULTS: The pre-intervention and post-intervention groups included 232 and 383 patients, respectively. Mean length of stay decreased from 2.82 to 2.13 days (P < .001). The need for inpatient rehabilitation decreased from 20.2% to 10.7% (P = .002). Mean 24-hour oral morphine consumption decreased from 60 to 38 mg (P < .001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24 hours decreased by 25% and 15%, respectively (P < .001). Thirty-day emergency department visits following discharge decreased from 12.9% to 7.3% (P = .030). CONCLUSION: Significant improvements in the recovery of patients after TKA were achieved by performing a root cause analysis and implementing a multidisciplinary, patient-centered enhanced recovery after surgery bundle. LEVEL OF EVIDENCE: Level III.

Developing Capacity to Do Improvement Science Work.

Developing capacity to do improvement science starts with prioritizing quality improvement training in all health professions curricula so that a common knowledge base and understanding are created. Educational programs should include opportunities for colearning with patients, health professionals, and leaders. In this way, knowledge translation (also called implementation) is more effective and better coordinated when applied across organizations. Key factors that enable and drive behavior change are reviewed, as is the importance of influence and leadership. A comprehensive approach that accounts for these factors hardwires quality improvement into the health care systems and creates a culture that enables its ongoing development.

Thoracic Epidural Catheter Placement in a Preoperative Block Area Improves Operating Room Efficiency and Decreases Epidural Failure Rate.

BACKGROUND AND OBJECTIVES: The primary aim of this study was to review the impact of inserting thoracic epidural catheters in a preoperative block room setting on operating room efficiency. METHODS: We conducted a retrospective preintervention/postintervention review of thoracic epidurals inserted over a 12-month period. The review included 6 months of data prior to implementation of the regional anesthesia block room and 6 months of data following implementation. The primary outcome measure was anesthesia-controlled operating room time, defined as time from patient arrival to the operating room to time of surgical site sterile preparation. Secondary measures included operating room waiting time for the patient arrival, thoracic epidural failure rate, and number of epidural insertion attempts. RESULTS: Data from thoracic epidurals for 112 patients of preblock room and 142 patients of postblock room implementation were collected. Anesthesia-controlled operating room time was reduced by an average of 22.9 minutes per patient (95% confidence interval, 19.3-26.3 minutes; P < 0.01). Average operating room waiting time for patient arrival increased by 3.8 minutes (95% confidence interval, 1.0-6.5 minutes; P < 0.01), resulting in net operating room time savings of 19.1 minutes per epidural. The epidural failure rate decreased from 16.0% to 5.6% (P < 0.01). There was no difference in the number of epidural insertion attempts made per patient. CONCLUSIONS: Insertion of thoracic epidural analgesia in a preoperative block room setting can significantly reduce anesthesia-controlled operating room time and epidural failure rates.

Improving cardiac operating room to intensive care unit handover using a standardised handover process.

Handovers from the cardiovascular operating room (CVOR) to the cardiovascular intensive care unit (CVICU) are complex processes involving the transfer of information, equipment and responsibility, at a time when the patient is most vulnerable. This transfer is typically variable in structure, content and execution. This variability can lead to the omission and miscommunication of critical information leading to patient harm. We set out to improve the quality of patient handover from the CVOR to the CVICU by introducing a standardised handover protocol. This study is an interventional time-series study over a 4-month period at an adult cardiac surgery centre. A standardised handover protocol was developed using quality improvement methodologies. The protocol included a handover content checklist and introduction of a formal 'sterile cockpit' timeout. Implementation of the protocol was refined using monthly iterative Plan-Do-Study-Act. The primary outcome was the quality of handovers, measured by a Handover Score, comprising handover content, teamwork and patient care planning indicators. Secondary outcomes included handover duration, adherence to the standardised handover protocol and handover team satisfaction surveys. 37 handovers were observed (6 pre intervention and 31 post intervention). The mean handover score increased from 6.5 to 14.0 (maximum 18 points). Specific improvements included fewer handover interruptions and more frequent postoperative patient care planning. Average handover duration increased slightly from 2:40 to 2:57 min. Caregivers noted improvements in teamwork, content received and patient care planning. The majority (>95%) agreed that the intervention was a valuable addition to the CVOR to CVICU handover process. Implementation of a standardised handover protocol for postcardiac surgery patients was associated with fewer interruptions during handover, more reliable transfer of critical content and improved patient care planning.

A prospective study of mental health care for comorbid depressed mood in older adults with painful osteoarthritis.

BACKGROUND: Comorbid depression is common among adults with painful osteoarthritis (OA). We evaluated the relationship between depressed mood and receipt of mental health (MH) care services. METHODS: In a cohort with OA, annual interviews assessed comorbidity, arthritis severity, and MH (SF-36 mental health score). Surveys were linked to administrative health databases to identify mental health-related visits to physicians in the two years following the baseline interview (1996-98). Prescriptions for anti-depressants were ascertained for participants aged 65+ years (eligible for drug benefits). The relationship between MH scores and MH-related physician visits was assessed using zero-inflated negative binomial regression, adjusting for confounders. For those aged 65+ years, logistic regression examined the probability of receiving any MH-related care (physician visit or anti-depressant prescription). RESULTS: Analyses were based on 2,005 (90.1%) individuals (mean age 70.8 years). Of 576 (28.7%) with probable depression (MH score < 60/100), 42.5% experienced one or more MH-related physician visits during follow-up. The likelihood of a physician visit was associated with sex (adjusted OR women vs. men = 5.87, p = 0.005) and MH score (adjusted OR per 10-point decrease in MH score = 1.63, p = 0.003). Among those aged 65+, 56.7% with probable depression received any MH care. The likelihood of receiving any MH care exhibited a significant interaction between MH score and self-reported health status (p = 0.0009); with good general health, worsening MH was associated with increased likelihood of MH care; as general health declined, this effect was attenuated. CONCLUSIONS: Among older adults with painful OA, more than one-quarter had depressed mood, but almost half received no mental health care, suggesting a care gap.