How regional anesthesia increases case volume and improves the healthcare experience — Q&A with NAPA's Dr. Sonia Szlyk

As the era of bundled payments and value-based care dawns, hospitals and patients alike are looking for high-quality healthcare experiences delivered at a lower cost. Newer modalities in anesthesia care, namely regional anesthesia techniques, are helping improve the surgical experience for patients while contributing to lower costs.

Sonia Szlyk, MD, director of regional anesthesia for North American Partners in Anesthesia's Mid-Atlantic division and a practicing anesthesiologist in Virginia weighs in on how the role of regional anesthesia has changed patient care in the last decade as well as the benefits it offers all healthcare industry stakeholders.  

Question: What is regional anesthesia?

Dr. Sonia Szlyk: Regional anesthesia is the injection of local anesthetic or numbing medication around a nerve or group of nerves to create numbness at the site of surgery. Regional anesthesia can be used as the primary anesthetic in the operating room as well as for postoperative pain control. There are different types of regional anesthesia such as neuraxial anesthesia, which is a spinal or epidural, and also ultrasound-guided nerve blocks and catheters used for postoperative pain control. The two major categories of nerve blocks are a single injection block that lasts 12 to 18 hours or a nerve block catheter infusion that provides extended pain control for approximately three days.

Q: How have regional anesthesia protocols changed over the years?

SS: The most relevant change has been the introduction of ultrasound guidance for nerve blocks. It was introduced in the late 1970s, but gained tremendous momentum and widespread use in the anesthesia community over the last 10 years. Ultrasound guidance has had such an impact because it allows us to visualize structures beneath the skin and tailor the nerve block injection to the patient's anatomy. The major benefit is that the injections are more accurate and can be performed in a very safe, efficient manner.
 
Regional anesthesia plays an ever-increasing role in facilitating early recovery after surgery. Especially for lower extremity procedures such as total knee replacement, ultrasound guidance is used to selectively inject local anesthetic around the nerves responsible for pain, while preserving motor function or strength in the leg. This allows patients to be comfortable after surgery without hindering physical therapy, which is a key satisfier for both surgeons and patients.

In the past, pain management protocols for most orthopedic procedures were heavily dependent on patient-controlled analgesia using intravenous narcotics. This opioid-based pain control often led to nausea, vomiting, confusion and an increased risk of respiratory events after surgery. By minimizing or even eliminating the need for narcotics, regional anesthesia has played a significant role in allowing us to avoid the use of patient-controlled analgesia and drastically reduce narcotics in our pain protocols. Initially, regional anesthesia was more focused on total joint replacements, but ultrasound guidance has fueled its applicability to many surgical specialties such as sports medicine, breast, colorectal, thoracic, general and cosmetic surgery to name a few. This is one of the reasons why having a strong regional anesthesia team at your hospital or ASC is such a strategic advantage for everyone involved.

Q: How does regional anesthesia benefit patients, surgeons and hospitals?

SS: Regional anesthesia allows patient to receive fewer narcotics, experience less postoperative nausea and vomiting, provides excellent pain control and leads to high patient satisfaction. Hospitals using regional anesthesia typically have high HCAHPS scores. Also, patients with medical conditions, such as obstructive sleep apnea and/or a larger BMI, are more sensitive to the effects of opioids on their breathing. By minimizing narcotics we can safely provide excellent pain control for a more complex patient population.  

Surgeons are thrilled to have an anesthesia team skilled in regional anesthesia because their patients have improved pain control and ambulate sooner after surgery. Regional anesthesia decreases length of stay, and surgeons can perform more complex procedures on an outpatient basis. Nerve block catheters allow for extended pain control via a small, portable elastomeric pump that infuses local anesthetic. This non-narcotic pain control lets patients go home readily after surgery instead of staying in the hospital. The pump even allows the patient to adjust the infusion at home depending on their level of comfort. Pain management is not a one-size-fits-all and patients appreciate the ability to have customized pain control.

Hospital administrators are very supportive of regional anesthesia programs, as they increase both patient and surgeon satisfaction. Pain management is included in many patient satisfaction surveys. Nerve block patients will typically answer positively to questions about pain management, including whether they would recommend the hospital. Patients have fewer side effects, such as nausea and vomiting, shorter lengths of stay, decreased opioid-related adverse events, and they go home sooner because their pain is controlled more effectively. With the evolving era of bundled payments there is increased awareness about the importance of pain management and its impact on hospital readmission and discharge disposition. Well-executed pain control can allow for patients to receive higher quality care at a lower cost; this gets the attention of hospital administrators.

Of course, you can't really talk about of importance of pain management without addressing the growing opioid epidemic. More than 70 million patients per year are prescribed opioids for postoperative pain and one in 15 will go on to long-term use and abuse. We have a responsibility to our patients and our community to make sure we are providing excellent pain control and using non-narcotic methods to achieve that goal. Regional anesthesia helps us do that.

Q: Can you give examples how regional anesthesia has increased case volume and reduced the need for opioids?

SS: NAPA is an innovator in anesthesia care and their regional anesthesia program development is one reason why. For example, NAPA's regional anesthesia program in Fairfax, Va., was started seven years ago when our group responded to surgeons who were looking for better postoperative pain control for their patients. The program has since blossomed from performing 50 to more than 2,000 nerve blocks a year. The hospital is seen as the leader in the area for regional anesthesia, and surgeons bring their patients to the hospital because they value the high-quality regional anesthesia we provide their patients. Our success is also evidenced by the hospital administration's strong support of the program. They allocated one FTE-equivalent nurse to be a Block Nurse; this contributed to increased safety and maintenance of on-time starts in the operating room, all leading to patient and surgeon satisfaction. Our Fairfax location was recognized and recently received reaccreditation as a Center of Excellence for joint replacement by The Joint Commission, and that is due in part to the regional anesthesia program. The Joint Commission noted that we are ahead in terms of prioritizing pain management for our patients.

A comprehensive regional anesthesia program addresses all stakeholders and educates everyone in the care spectrum, which is a natural fit for the NAPA team. When our hospital administration looks to expand a service line or welcome new surgeons, they have the surgeon speak to a member of our regional anesthesia team to learn about the pain management options we can provide for their surgical patients. Our hospital administration views NAPA as a collaborator and a significant value-add to the hospital. NAPA keeps in mind the overarching strategic goals of the organization looking to provide the best care at a lower cost.  

In terms of a reduced need for postoperative opioids, our hospital previously used patient-controlled anesthesia and IV narcotics for pain control after surgery for total joint replacement. Now, it is rare for patients to receive patient-controlled anesthesia and that's because patients are receiving nerve blocks and so their need for IV narcotics is drastically reduced.

Regional anesthesia has evolved in the operating room as well. A more traditional anesthetic involved inhaled anesthetic gases delivered through an endotracheal tube. More recently, a spinal anesthetic is used. Patients that receive spinal anesthesia are still asleep during surgery, however they receive IV sedation and are not intubated. Studies show that patients receiving spinal anesthesia are more alert after surgery and the fall risk is reduced. This is especially important because a large number of our joint replacement patients are older so their risk for postoperative cognitive decline is increased, especially with exposure to inhaled anesthetics. Anything we can do to eliminate that exposure is beneficial. Patients appreciate feeling more alert and less groggy after surgery. This positively impacts patient satisfaction, as they are more readily able to start physical therapy and return to their lives.

Q: What is on the horizon for RA?

SS: We will continue to see new applications for nerve blocks and further understand the impact our anesthetic has on a patient's early and long-term outcome. Through the use of ultrasound guidance, we are already able to perform more specialized nerve blocks and reduce the use of narcotics. This enables us to perform more complex surgeries on an outpatient basis — even joint replacements. A critical combination of the right patient, surgeon and anesthesia team with the ideal anesthetic plan allows procedures to be performed on an outpatient basis, when in the past it required several days in the hospital. This is why regional anesthesia is the modern "anesthetic of choice" and will remain an integral part of enhanced recovery after surgery protocols.

Within the healthcare marketplace, patients are more informed than ever and anything we can do to make the quality of care more transparent to our patients is well received. Millennials are raising expectations for transparency in healthcare with their ability to compare institutions and make a deliberate decision about where they want to receive their care.

Patients are tasked with spending more of their earnings on healthcare so they are more discerning and we see this as a great opportunity and challenge. Within NAPA, we are prioritizing what is best for our patients. We collected data on our millionth anesthetic last year. We are continually gathering performance data on our team, examining the data and improving. Patients deserve and expect high-quality care and regional anesthesia allows us to deliver that care in a cost-conscious environment.

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