December, 2006

Four years ago, we performed all our orthopedic procedures under general anesthesia with only the occasional single-shot peripheral nerve block. As a result, our nursing team battled daily with prolonged patient agony and nausea and vomiting. Each day, we collectively walked nearly a mile—three trips per patient—to and from the medication center to retrieve narcotics and anti-emetics. All too frequently, the drugs failed to provide relief, resulting in miserable patients and an unhappy, unfulfilled nursing staff.

What a difference four years has made! Today, nearly all of our patients receive some form of regional anesthesia combined with “light general” or monitored anesthesia care, and nearly 60 percent go home with continuous infusions in place that last up to 72 hours. This has meant the world to me and my PACU nurses. Today, even patients who undergo our most invasive surgeries, including total knee and shoulder procedures, wake up much faster and can converse and drink immediately with virtually no pain. Patients who used to stay in recovery for 1.5 hours now leave our PACU in 30 minutes or less.

The change was a challenge for our nursing team. Our nurses were cautious about regional anesthesia because they didn't know what to expect. To ease the transition, we instituted a two-part regional anesthesia training program.

Part 1 is an anethesiologist-led in-service for all new nurses, covering basic anatomy, nerve block technique, recovery expectations, signs and symptoms of toxicity and block failure, block-specific complications, and patient education concepts like insensate limb protection. Our nurses learn that Horner's syndrome may result after interscalene blocks, enabling them to assuage patients who experience its effects. They learn that sciatic blocks are more prone than others to mechanical and pressure injury, and that frequent repositioning helps avoid stretching and prolonged ischemia of the anesthetized sciatic nerve. They know that medial knee pain in a TKR patient is cause to alert the anesthesiologist, who can then administer a post-op obturator nerve block to improve the patient's comfort.

Part 2 is our nurse-anesthesiologist rotation program. On any day, at least one anesthesiologist focuses solely on peripheral nerve blocks. All new nurses team up with the anesthesiologist for up to two days. During this rotation, the nurse assists with blocks, observes their performance in the OR, and follows patients through to recovery.

This program created a major change in our PACU, and we are now considering bypassing PACU altogether for some patients. Our nurses became happier because our patients were happier. They realized they were helping improve patient outcomes. Research shows that nurse satisfaction is a direct result of a nurse's ability to successfully address problems and contribute to quality of care — not to mention having the time they need to properly care for patients. Our continuous infusion nerve block program has meant miles of difference for our PACU nurses.

Mr. Smith is Team Leader/Unit Manager with the OrthoIndy & Indiana Orthopaedic Hospital in Indianapolis, Indiana.