Archive March 2014 XV, No. 3

Regional's Building Blocks

4 keys to improving pain management for orthopedic procedures.

Gregory Hickman, MD

femoral block LOCAL HERO Regional anesthesia expert Gregory Hickman, MD, places a femoral block at the famed Andrews Institute Ambulatory Surgery Center.

When the Andrews Institute Ambulatory Surgery Center opened in 2007, my goal was to minimize to the greatest degree possible the use of opioids to control orthopedic patients' post-op pain. Today, fewer than 10% of our patients end up receiving narcotics in the PACU, which speeds their recoveries and improves our case efficiencies. What's not to like?

1. Grasp the potential
An effective multimodal approach to managing post-op pain is best built with regional anesthesia as the cornerstone but, in my opinion, more facilities should be taking advantage of blocks' many benefits. My sense is there's still some resistance at the front line from facility leaders who erroneously believe placing blocks is an added cost for which they can't get reimbursed. Medicare won't reimburse for block placements, and third-party payors won't pay for individual supplies and medications, but you can bundle those expenses and get paid by private payors by billing the procedure as a separate charge for the sole purpose of preempting post-op pain.

In addition, veteran anesthesia providers who've never incorporated regional into their practices are sometimes hesitant to try a technique they believe increases intraoperative risks without adding a significant financial payoff.

But regional can improve outcomes. For example, because pain is controlled with fewer narcotics, our PONV rate is less than 1%, significantly lower than the reported national average of 37%. That lets us send happy patients home sooner, which has increased surgeon and patient satisfaction.

Regional is primarily most effective in orthopedics, especially with the added use of continuous catheters, which let our surgeons perform more invasive cases such as major knee and shoulder cases in the outpatient setting.

It's no surprise, then, that our regional program has also helped recruit surgeons, including 2 physician-owners of a local surgery center who used to send us patients for placement of continuous catheters. The docs eventually decided to reap the rewards of our regional program on a full-time basis.

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