1. QI project: Improve the number of nerve blocks APS resident can perform for 7:30 AM start cases
Advisors: Dr. Janik and Dr. Simon
Residents: Tam Nguyen CA-3, Alex Behm CA-2, Nick Stringer CA-1

2. Problem
Frequently, APS residents are limited to 2 (at most 3) nerve blocks for 730 AM start cases. This issue potentially affects residents’ education, surgery team’s satisfaction, and quality of care for patients.

3. Anesthesia attending present in pre- operative area.
Process map
Patient arrives at hospital and checks in at front desk in pre-operative area.
Pre-operative staff admits patient into pre- operative area for pre-op questionnaire, gown changing, vital signs, and IV placement.
Surgical team assesses patient, performs physical exam, obtains consent, marks surgical site and enters History and Physical note.
Anesthesia team (resident, fellow, attending) to assess patient, update clinical history, and obtain consent.
Anesthesia attending present in pre- operative area.
Acute Pain Service performs peripheral/neuraxial nerve blocks for patient.
Patient ready for OR. 1 2 4a 4b 5 3

4. Methods Surveys were created and sent to:
Patients
Pre-op nurses
Surgical residents
Anesthesia residents
Anesthesia APS attending
Surveys focused on opinions of the involved parties regarding changes (most important being earlier start time), potential barriers, and proposed solution for the barriers.

5. Results
Patients (N=27): 81.4% of patients had prior nerve block in the past. 100% supported the changes and agreed to arrive 30 min earlier.
Pre-op nurses (N=14):
2 agree that the changes will not affect their routine activity.
5 out of 14 felt that changes could be made with modifications.
7 out of 14 nurses felt changes should not be implemented at all, citing:
Lack of volunteers to come in early
Lack or coverage for breaks due to work hour restrictions,
Patients do not want to come in any earlier than current schedule.

6. Results (Cont’d) Surgery (Orthopedic) residents (N=12):
7 agree that if patients were ready by 6:15 AM, surgical consent can be done by 6:30 AM. Of the 5 residents who disagree, all of them cite time conflict w/ morning rounding and conference at 6:30 AM being the barrier. However, the majority agree that the problem can be solved by having a PA on the team to assist.
Anesthesia residents: (N=39, w/ 6 excluded that had not done APS before)
All 33 residents agreed that changes would be highly beneficial for both residents’ education and patient care. All of the surveyed residents agreed to come in min earlier to perform more blocks assuming that pre-op work up from other parties will be completed min earlier.
Anesthesia APS attending (N=6):
5/6 agree to come in 30 min earlier and 1 does not. Potential barriers include delays from other parties involved and potential lack of support from compensation committee for the extra time.

7. Conclusions
It is possible to improve the number of nerve block for 7:30 AM start cases by implementing changes to the involved parties including:
Patients: Due to support and positive response from 100% of surveyed patients, implementing these changes would likely require minimal effort and be easily achieved.
Nursing staff: Most of the staff surveyed opposed the changes. Thus, implementing these changes likely will require extensive discussion at the administrative level to clarify the details. This will likely require moderate/extensive amount of effort.
Surgery residents: Thoughts were mixed. The main barrier for surgery residents is conflict with morning report. This can be overcome by possibly having the PA come, consent, and mark the patient. This likely requires minimal effort with high chance of success.
Anesthesia residents: Support from almost all Anesthesia residents to changes. Once agreements to changes from other parties are obtained, schedule changes for anesthesia residents likely can be done with ease.
Anesthesia APS attending: The main issues are delays from other parties and lack of support from the compensation committee. Once agreements to change can be obtained from other parties involved, a discussion with the compensation committee can be conducted.

8. Next steps:
Development of PDSA cycle based on results from surveys and process map findings.