Front: Dr. Palm, Kara Morningstar DNP, CRNA, Jeremy Anderson CRNA, Eric Swanlund II DNP, CRNA, Jill Lange CRNA, Kristin Doan DNP, CRNA, Dr. Trillos, Dr. Webber, Dr. Apostolidou (Chief Anesthesiologist),
Back: Dr. Tolly, Mr. Kelly Minneapolis Director, Garrett Peterson DNP, CRNA, Dr Waly, Thomas Rubenzer CRNA (Chief CRNA), Dr. Rocha, Dr. Santilli, (Chief of Surgical Services)
The Minneapolis Veterans Affairs Health Care System: Acute Regional Pain Service received Second Place in the 2019 VISN 23 Network Star Award. Pictured above is the Pain team.
The Minneapolis Veterans Affairs Health Care System began an Acute Regional Pain Service in early 2018. The pain service is made up of anesthesiologists and nurse anesthetists. This service currently provides peripheral nerve blocks, epidural and peripheral nerve catheters to almost all surgical patients Over the last year and ½, our service has expanded and since May 2018 until present the pain team has performed over 2400 Peripheral Nerve Blocks, 34 epidurals and 65 peripheral nerve catheters.
Below are the AIMs we choose for the Star Award.
1. To offer regional anesthesia options to every eligible veteran and educate him/her on the variety of options for pain control after surgery as part of the facility’s organizational goal and our commitment to patient-centered care. Specifically, we sought to increase the number of PNBs offered for total knee arthroplasties from 0% in 2017 to 100%.
2. To reduce the use of opioid medications perioperatively and subsequently reduce the incidence of postoperative side effects associated with them including: nausea, constipation, sedation, delirium, substance abuse and death. Specifically, we sought to reduce the intraoperative fentanyl dose in total shoulder and total knee arthroplasties and reduce the hydromorphone dose in total knee arthroplasty.
3. To utilize regional anesthesia as the sole anesthetic technique when appropriate and reduce the use of general anesthesia whenever possible. Specifically, we sought to reduce the percentage of general anesthesia necessary for total shoulder arthroplasty from 53% in 2017.
4. Progressively expand the number and diversity (types) of PNBs offered to veterans.
AIM 1: To offer regional anesthesia options to every eligible veteran as part of the facility’s organizational goal and our commitment to patient-centered care. One specific aim was to increase the number of PNBs offered for total knee arthroplasties from 0% to 100%. The ARPS reviewed the operating room schedule daily and screened every patient having surgery the following day who might benefit from a regional technique. A tentative list of patients was generated and relayed to the team for the following day. The morning of surgery, the regional team met with preoperative nursing and verified appropriateness of the PNB with the surgical team. Patient education and the informed consent process were then initiated for all appropriate patients. Our success in offering regional techniques to every eligible patient is exemplified by our review of total knee arthroplasties prior to and after implementation of the ARPS (green bars in figure 1): in July-Sept 2017, no patients received a PNB (n=0/58); during the initial implementation of the ARPS (Jan-Mar 2018), 42% of patients received a PNB (n=15/36); in July-Sept 2018, 100% of patients received a PNB (n=60/60).
AIM 2: To reduce perioperative opioid use. We compared the dose of opioid medications used intraoperatively before (July-Sept 2017), during (Jan-Mar 2018) and after (July-Sept 2018) implementation of the ARPS. We looked specifically at two types of procedures: total knee arthroplasty and total shoulder arthroplasty.
Total Knee Arthroplasties: none of the patients in July-Sept 2017 received a PNB (n=0/58); 42% of patients in Jan-Mar 2018 received a PNB (n=15/36); and all of the patients in July-Sept 2018 received a PNB (n=60/60). Figure 1 demonstrates the mean amount of intraoperative hydromorphone and fentanyl used for total knee arthroplasties before and after implementation of the ARPS. In 2017 the mean amount of hydromorphone was 0.66 mg per patient and decreased to 0.26 mg per patient in July-Sept 2018 when all patients received a PNB (60% reduction). The mean amount of fentanyl decreased from 262.5 mcg to 190.8 mcg per patient in July-Sept 2018 (27% reduction).
Total Shoulder Arthroplasties: there were 38 patients that underwent total shoulder arthroplasty in July-Sept 2017, 43 patients in Jan-Mar 2018, and 43 patients in July-Sept 2018. All patients in 2017 and 2018 received a PNB (before and after implementation of the ARPS and standardization of the process). However, we see a trend when it comes to the effectiveness of the PNBs: figure 2 demonstrates the mean intraoperative dose of fentanyl for total shoulder arthroplasties decreased from 97 mcg per patient in 2017 to 50 mcg per patient in 2018, representing a 48% reduction (blue line). This suggests that following implementation of the ARPS, PNBs were more effective, leading to reduced opioid requirements.
AIM 3: To utilize regional anesthesia as the sole anesthetic technique when appropriate and reduce the use of general anesthesia whenever possible. One specific aim was to reduce the percentage of general anesthesia necessary for total shoulder arthroplasty from 53% in 2017. The utilization of general anesthesia as the primary anesthetic technique for total shoulder arthroplasty was 53% in July-Sept 2017 (n=20/38), did not change in Jan-Mar 2018 (n=23/43), and decreased to 33% (n=14/44) in July-Sept 2018 (Red bars in Figure 2). This is a 38% reduction in the use of general anesthesia following implementation of the ARPS and reflects an increase in the efficacy of PNBs. In addition to better pain control and reduced opioids, utilizing regional anesthesia as the primary anesthetic saves operating room time by avoiding the time of induction of, and emergence from general anesthesia. For the first 6 months of 2018, we reviewed the intraoperative time from patient arrival to the operating room, until positioning or “anesthesia ready” for total shoulder arthroplasty with general anesthesia versus regional anesthetia: when general anesthesia was used as the primary technique, the time to anesthesia ready was 20.5 minutes, compared to 13.5 minutes when regional anesthesia was the primary technique, resulting in a reduction of operating room time of 7 minutes per patient (on the front end of surgery).
AIM 4: Progressively expand the number and diversity (types) of PNBs offered to veterans. Although we initiated the project in January 2018, we fully implemented the ARPS and began tracking all PNBs performed in May 2018. Between May 2018 and January 2019, 1067 PNBs were placed. Table 1 shows the number and types of blocks performed each month. The two bottom rows indicate the number of blocks per month and the cumulative total to date. Figure 3 displays these data graphically: we increased the number of blocks per month from 61 in May 2018, to 125 in September 2018, and reached 177 in January of 2019 (blue bars in Figure 3); we expanded the diversity (types) of blocks from 11 basic blocks performed in May 2018, to 19 different types of blocks by January 2019 (red line in Figure 3). By increasing the diversity of blocks offered, we are able to minimize opioids in a greater variety of surgeries.