March, 2008

BY NOW, MOST OF US KNOW that peripheral nerve blocks are far superior to other methods for controlling post-op pain in many types of surgery. But did you know that this pain reduction translates into tangible economic benefits for surgical facilities? Here at the Duke Ambulatory Surgery Center, the pain control provided by nerve blocks has helped us gain control over the surgical schedule, increase case volume, reduce drug costs, keep our staff happier, and keep our allimportant patient satisfaction ratings sky high.

We administer a combination of blocks and sedation to about 60 percent of our patients. To accomplish this, we have had to change our protocols and invest extra time, space, and nursing hours into the front end of our process.

First, we ask patients who will be blocked to arrive about 30 minutes earlier than general anesthesia patients. Once the preliminaries are finished, the nerve block is placed by the anesthesiologist in the preoperative holding area. By adjusting the patient's arrival time accordingly, we are able to ensure that the block has taken effect prior to transporting the patient to the OR suite. When the block is successful, as nearly all of them are, the entire process takes about 15 minutes. Occasionally, a block takes longer because the patient has an anatomic abnormality, or because patients are nervous and have difficulty remaining still.

In addition to the extra time and space this requires, we've found that we need to add staff on the front end to effectively administer blocks. Our pre-op nursing staff has to be 25-30 percent larger than it would be if we were using general anesthesia only, in order to manage the process.

This investment of time, space and personnel has really paid off:

• Blocked patients recover from sedation much more quickly than patients who have been under general anesthesia, allowing us to schedule patients more efficiently.
• Patients' pain is contained, and there is a decreased instance of PONV.
• PACU backups are decreased. The days of frustrated PACU nurses staying late trying to get patients' pain under control without making them too groggy and nauseous to go home are long gone, making for a happier staff.
• Because the PACU flow is smooth, we are much more comfortable with scheduling cases later in the day, because we can all but ensure our PACU nurses that they'll be heading home on time. In effect, this has increased our capacity.
• Although I haven't yet quantified it, our drug costs are significantly lower, since regional anesthetics are less expensive than general anesthetics, and we use far fewer postop opioids.
• Most importantly, patients are ecstatic about our care. They tell their doctors, and that makes doctors want to bring more cases to our facility.

In fact, Press-Ganey benchmarks our patient satisfaction scores against other surgical centers across the country, and the latest rating puts us in the 94th percentile. We ascribe this success in large part to our peripheral nerve block program.

Ms. Mattson is Clinical Operations Director with the Duke Ambulatory Surgery Center in Durham, NC.