1. How to set up Regional Anesthesia Service That improves Theatre Efficiency Prof. Krishna Boddu MBBS, MD (Anes), DNB, FANZCA, MMEd. Department of Anesthesiology & Pain Medicine University of Texas Health Sciences, Houston, Texas University of Western Australia, Perth, Australia Director, Regional Anaesthesia, Royal Perth Hospital, Perth, Australia Phone: +17138559971 (USA), +61416030020 (Australia) kboddu@yahoo.com www.nerveblocks.org

2. Our Mission Zero Suffering for 100% of our patients Is it possible?

3. PT, OT, Wound Care RN Physicians Surgeons Technicians, Theater Nurses, Ward Nurses, Patients, Family Registrars, Fellows Midlevel Providers All Perioperative Physicians Hospital Management 3 Sharing The Same Goal & Vision By Sharing The Same Goal & Vision By

4. What is Regional Anesthesia? It is one of the several modes of analgesia that might be superior but it is not the only mode of analgesia It is an extension of Acute Pain Service It provides better dynamic pain control, possibly decreases hospital stay, prevents development of chronic pain Generates more income than other modes of analgesia

5. Setting up Regional Anesthesia Service is a “Project” & Every “Project Needs Planning” Any plan is better than no plan A reasonable plan is better than just any plan But a first rate plan with poor implementation Is not as good As a reasonable plan with first rate implementation! Project management Counseling Implementation Is “Team Work”

6. Improves Patients Satisfaction Provides Effective Dynamic Pain Control Least or No Adverse Effects Early Return Of Bowel Function Decrease DVT/ Pneumonia Prevents Chronic Pain Syndromes Facilitates Early Discharge More Direct & Indirect Incomes 6 Adapt Techniques That…… Regional Anesthesia Provides Effective Pain Control As A Part of Multimodal Analgesia Regional Anesthesia Provides Effective Pain Control As A Part of Multimodal Analgesia

7. Regional Anesthesia Service Models RA in separate dedicated area (RA Wing) Expensive but Best Results Best for teaching (Not rushed) $ Generating Even for Follow Up Recognition For RA Service Moderately Expensive Needs at least TWO providers Juggle two cases simultaneously Facility Fee split? Most Expensive with poor results Million Eyes Watching You & Surgeon breathing down your neck. RA in Induction Room (Ante room) RA in Theater as a part of Anesthesia

8. Which Regional Anesthesia model is best for your hospital? Based on workload & manpower In Operating Room: Only Specialist or Trainee In Induction Room: Specialist + Trainee/ CRNA Dedicated RA area: Dedicated RA team ------------------------------------------------------------------------ Based on number of cases per day Based on reimbursement structure Most of the Teaching Hospitals Should Have Dedicated Regional Anesthesia Team

9. OR/Theater Time Is Very Valuable If Surgeon & Anesthesiologist Are Not Working Simultaneously, OR Time Is Considered As “Non Productive” Time Anesthesia Time Productive When Surgical Team In Action Not Productive When Surgeon Is Sitting Doing Nothing while Paid. Examples: Pre Anesthesia Assessment IV Line Placement Nerve Blocks

10. Cost Savings By Conducting Blocks Outside OR 15 Blocks/dayAverage # surgical cases per day with nerve blocks 20 min/ blockAverage time taken for conducting nerve block 5 hours/ day# hours OR is in use for nerve blocks per day 250 day/ yearDays in year surgeries take place $80/ minAverage cost per minute in OR - Not including Surgeon $4,800/ hourAverage cost in OR per hour - Not including Surgeon $48,000/ dayTotal cost per 10 hour day for OR - Not including Surgeon 20 min/ blockTime savings per nerve block conducted (in minutes) 300 min/dayMinutes saved per day $24,000/ dayCost savings per day $ 6,000,000/ yearTotal cost savings per year to hospital (250 working days/ year)

11. If Surgeon Is Breathing Down Your Neck, You Tend To Do Single Shot Nerve Block Single Shot Nerve Block Patient Very Comfortable Early Discharge from PACU Tired Surgical Resident Sleeping Block Wore Off & in Pain Frustrated Nurse Calls Primary Un-happy Resident Anesthesia- Surgery War !!!!

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13. Dedicated RA Team Model Man Power & BillingEquipment & DrugsDocumentation & Follow up Attending *Regional Anesthesia CartProcedure Notes Nurse/ Tech *Ultrasound MachineFollow-up Notes Resident/ CRNANerve StimulatorAudits Nerve Block NeedlesConsult Forms Catheters & Pumps Communication Devices Regional Anesthesia Team (Mobile Phones/ Pagers) Theater/ OR Team APS Team Board Runner Theater/ OR Scheduling OrderliesPACU PharmacyPT/OT Over $650,000 investment by Hospital to save over $10,00,000

14. Man Power & Interest Survey Survey Your Department: For experience /comfort levels with various blocks, local anesthetics and catheter techniques How much your team is interested in introducing RA practice Their Educational Needs Identify core group of PARTNERS Gather Similar Information from Nursing & Technicians

15. Be Prepared To Answer The Question: Why Regional Anesthesia? From the Anesthesia standpoint From the Patient’s standpoint From the Surgeon’s standpoint From the Facilities standpoint From management standpoint From PACU standpoint From Physiotherapy/ Occupational Therapy standpoint

16. Challenge Yourself Why Not Regional Anesthesia? & What are the limiting factors? Forethought / logistic coordination Proficiency/ thorough knowledge of anatomy/ drugs Need more manpower Would it be warranted by more revenues ?

17. Your “Trump Card” To Convince For Regional Anesthesia Will Be… Any Method Of Pain Control That Reduces Adverse Effects/ Events Translates to Superior Method With Improved Outcomes Regional Anesthesia Basically Removes Pain From Surgical Equation

18. Hadzic et al. Results Nerve BlockGA Bypass PACU79%25% Pain Scores >3 on Arrival in PACU3%48% Additional Pain Meds Requested in PACU0%48% Time to home readiness100 min203 min Discharge times121 min218 min Adverse EffectsLess Pavlin et al.¹- 90 min. reduction in discharge time in RA vs GA pts. Pavlin et al.² showed max. pain score predicted recovery time, cumulative fentanyl predicted PONV Williams et al.³ – each nursing intervention assoc. w/ 27 to 45 min delay in discharge 1) Pavlin DJ, et al. Anesth Analg 2002; 95:627-34 2) Pavlin DJ, et al. Anesth Analg 1998; 87:816-26 3) Williams, BA et al. Best Pract Res Clin Anesthes 2002: 16: 175-94

19. Any equipment you purchase is expected to be money generating Money Cow Money Office

20. Why should we invest more money? Will it improve patient outcome? Will it decrease complications? Will it improve patient satisfaction? Will it improve the OR turn around time? Will it decrease hospital stay for the patient? Will insurance companies reimburse? Be Prepared For Other common management questions: The above are equivalents for generation of money

21. Create The Service Formally create a Regional Anesthesia Service Appoint leadership of the service START SLOWLY Gather all success stories & data for obtaining further support Realize success depends on a safe, efficient, and well coordinated service

22. Official inauguration of RA Service Invitees 1.CEO or Health Minister 2.Head of the Department 3.Other Hospital Executives (CNO. CMO, COO, CFO etc) 4.All department heads and all surgical consultants 5.All charge nurses of every ward 6.All OR/ theater staff (nurses, technicians, orderlies etc) 7.Physical Therapy, Occupational Therapy, Pharmacy 8.Also invite all key people from other hospitals in your town Make it a big deal. Make it as a Project for the Hospital not just yours

23. 23 Ask Yourself Where ?

24. Educate the Masses Must establish educational programs for Anesthesiologists, R.N.’s, and Surgeons Patients need information too Communicate Identify block candidates ahead of time and prepare for them Know the Surgeon’s needs, likes & dislikes Close follow-up with patients an absolute must Regular meetings / discussions within your group

25. 25 A SMALL TRUTH TO MAKE SUCCESS 100% Hard Work ( Hard Work (H+A+R+D+W+O+R+K) 8+1+18+4+23+15+18+11 = 98% ( Knowledge (K+N+O+W+L+E+D+G+E) 11+14+15+23+12+5+4+7+5 = 96% Love (L+O+V+E) 12+15+22+5 = 54% Luck ( Luck (L+U+C+K) 12+21+3+11 = 47%

26. 26 Then what makes 100% ? Money Is it Money (M+O+N+E+Y) ?... NO ! 3+15+14+5+25 = 72% Leadership Is it Leadership? NO ! (L+E+A+D+E+R+S+H+I+P)? 12+5+1+4+5+18+19+9+16 = 89% Every problem has a solution, only if we perhaps change our attitude.