Transcript anesthesia care teams

REGIONAL ANESTHESIA
Anesthesia Care Teams and Block Areas
NAPAN Conference
Sue Belo MD PhD FRCPC
May 23rd, 2009
HOLLAND CENTRE
The Holland Centre
Sunnybrook
Hospital
Orthopedic and
Arthritic Hospital
AMALGAMATION 1998
Orthopedic and Arthritic Institute
SWCHCS
Holland
Centre
2005
Resources
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4 Operating Rooms
5 bay Post Anesthesia Care Unit
10 bay Same Day Admission Area
5 Anesthetists (OR and Pre-assessment)
50 Acute Care Beds
20 Short term Rehab Beds
2004
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3200 cases per year
1500 total joint arthroplasties
100% under General Anesthesia
Limited use of femoral nerve blocks
Post-op nurse-managed morphine PCA
2004
• Average length of stay 7 days
• In-patient rehab 10 days
• 20% to long term rehab 16 days
2004
• Average 16/20 lists per month ran overtime
• Average overtime 30 hours/month
• Average 18 cancellations/month
• How can patient care be improved at the
Holland Centre?
• Wait Time strategy 2004
• Holland Centre of Excellence Aug 2005
• Anesthesia and Nursing shortages
Regional Anesthesia
• 4-fold reduction in mortality with regional
compared to GA (Shamrock et al 1995)
• decreased DVT/PE; decreased blood loss and
transfusion rate (Mauermann et al 2006)
• better pain control and decreased opioid use
(Salinas et al 2006)
• improved surgical outcomes (Peters et al
2006)
VISION
Convert the Holland Centre to
Regional Anesthesia
Regional Anesthesia at the Holland Centre
• better patient care
• decrease overtime and cancellations
through increased efficiency
• ability to increase volume of cases
• increase nursing satisfaction
• increase recruitment and retention
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prolonged operating room time
decreased efficiency
unpredictable success rate
inferior surgical conditions
unacceptable to patients
CHANGE!!
Anesthesia Concerns
•Regional Anesthesia requires time
•Regional Anesthesia requires expertise
•Regional Anesthesia requires co-operation
•Regional Anesthesia requires a team effort
Investment for Improvement
Administration Concerns
$$$$$$
Anesthesia Care Team Model
• Create a separate but adjacent “Block Area” (4 bays)
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“Block RNs” to staff area (2)
– check patients, prepare equipment, monitor patients
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Anesthesia Assistants (2)
– monitor stable patients under regional anesthesia in OR while
anesthetist performs regional/blocks for next patient
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Anesthesiologists (4)
– each anesthesiologist does own blocks in the Block Area
Patient Flow
Same Day Admission
OR
Block Area
PACU
2007
Surgeon Education
• Approached surgeons individually and as a
group
• Provided relevant literature (including
surgical literature)
• Presented rounds
Nursing Education
• Involved Pre-Assessment Clinic nursing staff,
ward nurses, OR nurses
• Provided with literature, in-services
• Invited to Block Area and PACU
Allied Health Professionals
• educational sessions for Physiotherapy
• feedback from Physiotherapy on issues in
regards to rehab
• revision of practice and protocols to address
concerns with hypotension, prolonged motor
block, etc.
• consultation with Pharmacy re pre-op
medications, pre-printed orders
Patient education
• by anesthetist at pre-op visit
• patient information pamphlets
• DVD video sent home with patient
• Web-site
Post-operatively
• established an Acute Pain Service under the
direction of Nurse Practitioner and a
dedicated anesthesiologist (Nov 2005)
• developed best practices for post-op pain
management (epidural analgesia, PCEA, oral
analgesia protocols for THR, multi-modal
analgesia regimens)
• Developed protocols and standardization for
selected procedures initially and introduced new
procedures slowly
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Spinal Anesthesia for THR and TKR
Femoral Nerve Blocks for TKR
Sciatic Nerve Blocks for TKR
Combined spinal epidural anesthesia for bilateral TKR
Peripheral nerve block catheters
2007
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2100 total joint arthroplasties
Neuraxial anesthesia in 90%
Peripheral nerve blocks used in 90% of TKA
Peripheral nerve block catheters for continuous
infusions
OR Time
Year
2004
2007
125
Mean SurgicalTime
100
75
50
25
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Hips
Knees
Type
Error bars: +/- 1 SD
17% decrease in time for patient-in to patient-out from 2004 to 2007 in total knee arthroplasties
18.6% decrease in time required from patient-in to patient-out for total hip arthroplasties
OR Overtime
(* cancellations)
35
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*21
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Overtime (hours)
25
20
*14
2004
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15
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10
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June
July
September
October
2007
PACU Length of Stay
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Average LOS 4.8 days
67% discharged home (day 5)
24% short term in-pt rehab- 5 days (day 3)
9% longer in-pt rehab
Anesthesiologist’s Perspective
• Changes in anesthetic practice facilitated
improved efficiency and “fast-tracking”
• Improvement in global peri-operative care
• No incremental risk for patients
• Improved outcomes
• Benefits for patients, physicians, nurses,
allied health care practitioners
• No additional Anesthesia resources
required
TKA PACU Time - Admitted to Discharge
100
PACU Time (mins)
80
60
40
20
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2004
2007
2008
2009
TKA PACU Time
100
80
60
Admitted to ready
Admitted to moved
40
20
0
2004
2007
2008
2009
THA PACU Time
100
80
60
Admitted to ready
Admitted to moved
40
20
0
2004
2007
2008
2009
PACU Discharge Criteria
Modifications for Spinal Anesthesia
• sensory block level at a minimum of T8
• recession of sensory block by at least one
dermatome level
• any patient admitted to PACU with a sensory
block at T10 or below and some movement of
the lower extremities may be discharged from
PACU
PACU readiness for discharge
70
60
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Time
40
(minutes) 30
20
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64.6
40.9
2009
2007
Year
The Future
Improved patient care
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Continuous catheters
Patient controlled oral analgesia
Expanded ultrasound applications
Optimization of drugs and dosages
Best Practice guidelines
Expansion of Anesthesia Care Team model
• Retainment and Recruitment
(Anesthesiologists, Block RNs, Anesthesia Assistants)
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Documenting improved outcomes
Continuous improvement
Expansion of program to Sunnybrook site
Maintaining expertise at 2 sites
THANK YOU