Post on 27-Jul-2020
Regional Anesthesia and Bundled Payments -
Opioid-sparing Pain Management
for Optimal Outcomes
Sonia Szlyk, MDDirector of Regional Anesthesia
North American Partners in Anesthesia,
Mid-Atlantic Division
INOVA Fair Oaks Hospital, VA
Disclosure
• National Speakers’ Bureau
– Halyard Health
SM
Large academic hospital
Private practice hospital
Freestanding Orthopedic ASC
My Perspective
The Era of Bundled Payments
PatientSatisfaction
PreventReadmissions
BetterOutcomes
CoordinateCare
LowerCost
BUNDLED PAYMENTS & OUTCOMES
PATIENT & SURGEON SATISFACTION
REDUCING OPIOID USE
OUTPATIENT TOTAL JOINTS
There’s a BLOCK for THAT!
IF YOU CARE ABOUT…
-Excellent pain control
-Minimize narcotics & nausea
-Decrease LOS
-High patient/surgeon satisfaction
-Complex cases as outpatient
-Complex patients as outpatient
ThePerfectStorm
Narcotics
NauseaImmobility
Surgical Pain
Respiratory Depression
What Keeps Patients in the ASC/Acute Rehab?
Pain
Narcotics
Nausea
Respiratory Depression
Immobility
Regional Anesthesia Nerve Blocks
Regional Anesthesia!
Pain controlOpioid-sparing
Reduced cognitive impactEarly ambulationDecreased LOS
The Service Experience... For Surgeons
Oldman, M., Anest Analg 2004.
Do you want your patient to have regional anesthesia?
Support for Regional Anesthesia
84% of surgeons said YES
– Less postoperative pain (32%)
– Safety (14%)
– Decreased nausea & vomiting (12%)
Oldman, M., Anest Analg 2004.
Surgeons’ Concerns
• Why surgeons said NO
– Delays in induction of anesthesia (43%)
– Unpredictable success rate (12%)
Oldman, M., Anest Analg 2004.
Avoid Delay to OR
Nerve Blocks that Work
14
YOUR FATHER’S NERVE BLOCKNOT
Tick, Tock, Tick, Tock...
• Improved Efficiency
– Faster block placement
– Faster onset
Liu, S. Ultrasound-Guided Regional Anesthesia and Analgesia. A
Qualitative Systematic Review. Reg Anesth Pain Med 2009;34: 47 - 59.
Sites, B. et al. A comparison of sensory and motor loss after a femoral nerve block
conducted with ultrasound versus ultrasound and nerve stimulation. Reg Anesth Pain
2009; 34:508-513.
Choi, S. et al. Femoral nerve block does provide significant analgesia after
anterior cruciate ligament reconstruction. Arthroscopy 2010; 26(11), 1416.
In-plane
SAFETY EFFICIENCY PRECISION
Sites, B. et al. A comparison of sensory and motor loss after a femoral nerve block conducted with ultrasound versus ultrasound and nerve stimulation. Reg Anesth Pain Med 2009; 34:508-513.
Choi, S. et al. Femoral nerve block does provide significant analgesia after anterior cruciate ligament reconstruction. Arthroscopy 2010; 26(11), 1416.
Adductor Canal Block
Avoid Delay to OR
• Triage– Identify “Block patients” on OR schedule
– Patients arrive 30 minutes earlier to facility
– Prioritize block patients in registration process
• Efficiency – Surgical consent signed prior to DOS
– Blocks performed in preop area
– Designated block bays and equipment
– Trained Nursing staff to assist • Monitors, sedation, documentation
SM
Block Nurses
• Maximal efficiency
– On-time starts
• Enables safety
– Time-out process
• Patient education
• RN Staff satisfaction
– Block RN course
Surgeons: Please Do Your Part...
• In the office– Mention “nerve block” to the patient
• Scheduling– Request nerve block when scheduling case
• Surgical consent– Signed and in chart before day of surgery
• Dictation– State nerve block needed for pain management
• Communicate– PT goals, specific concerns, feedback from patients
SM
Expectations are Everything
BUSY
1. Don’t delay my case2. Don’t hurt my patient3. It had better work4. Don’t slow down rehab
And...Don’t delay my case!
Wulf, H. Femoral nerve block with ropivacaine or bupivacaine in day case anterior cruciate ligament reconstruction. Acta Anaesthesiol Scand 2010; 54:414-420.
Pain
control
Quad
weakness
Quad weakness involves multiple factors…
not always the local anesthestic to blame
• Preop dysfunction
• Tourniquet
• Pain limiting
Balancing Act
Adductor Canal Catheter
ERAS for…
• Partial knee replacement
• Total knee replacement
• ACL repair
orthoinfo.aaos.org
Decreased LOS & readmission rate, Increased DC to home
Auyong DB, et al, J Arthroplasty (2015).
Femoral Block
Saphenous Block
Adductor Canal or“Mid-thigh Femoral”
Block
Location is Everything!
Adductor Canal Catheter
Nerve Block Infusion Pump
• Connected in PACU by RN
• Lasts ~ 3 days
• Adjustable rate
• Pt removes at home
• Easy, no sharps
0.2% Ropivacaine @ 8 mL/hr550 mL reservoir
Jaegar, P. Adductor Canal Block versus Femoral Nerve Block for Analgesia after Total Knee Arthroplasty. Reg Anesth Pain Med. 2013;38: 526–532.
ACBC preserved quad strength
better than FNBC (52% vs 15% baseline)
NO differencemorphine consumption
pain at rest, flexionadductor muscle strength
n/v, antiemeticsmobilization ability
Physical Therapists, Patients & Surgeons Rejoice!
Same-day Physical Therapy!
• Decreased LOS (76.6 to 56.1 hrs)
• Increased DC to home (52% vs 27%)
• No increase in readmission
• Decreased 30-day readmission rate (3% post vs 7% pre-pathway)
Auyong DB, et al, J Arthroplasty (2015).
UPDATED ERAS PATHWAY
RESULTS• Mepivacaine spinal
• TXA
• Adductor canal catheter x 48 hrs
• PT DOS
Secondary Functional Outcomes
• Increased ambulation distance POD 1-2
• Decreased falls (0% post vs 2% pre-pathway)
• Decreased transfusion • Decreased nausea
Auyong DB, et al, J Arthroplasty (2015).
Multimodal Premeds
• NSAIDs
- Improved pain score, decreased opioid requirements, improved ROM in physical therapy
- Cyclooxygenase inhibition (mitigate central and peripheral prostaglandin production)
• Acetaminophen
- Decreases 24-h usage of morphine and pain scores
- Inhibits central prostaglandin synthesis
• Gabapentin & Pregabalin
- Decreases opioid use over first 24 – 48 hrs, use beyond POD 4 is not supported
- Membrane stabilizers (inhibit x-2-delta subunit of L-type calcium channels)
Webb & Mariano. Pain Management (2015) 5(3). 185 – 196.
Chronic Pain Patients
• Preoperative consult with existing pain specialist
• Continue chronic outpatient pain medications perioperatively
• Gabapentin 300 – 600 mg po preop
• Ketamine IV
- 0.5 mg/kg bolus then 0.25 mg/kg/hr infusion
• Set expectations and goals
- Baseline pain score
Webb & Mariano. Pain Management (2015) 5(3). 185 – 196.
Adductor
canal
catheterLMA or Spinal (no
narcotics in spinal)
TXA
20 mL 0.5% Ropivacaine
Adductor canal catheter
Celecoxib, Oxycontin, Percocet or Vicodin
DOS Physical Therapy
0.2% Ropivacaine @ 8mL/hr
TKR ERAS PATHWAY
Premed Celecoxib, Acetaminophen, Decadron
Preop Block Adductor canal catheter 20mL 0.5% Ropivacaine
ORSpinal (Mepivacaine, no narcotics) or LMATXA
Postop & Home
Adductor canal catheter0.2% Ropivacaine @ 8mL/hr
Celecoxib, Oxycodone/Acetaminophen, Ondansetron
DOS Physical Therapy
How Does Pain Management
Affect the Bottom Line?
SM
Average Target Cost:
469 ~ $50,000470 ~ $25,000
Reduced PACU Time
Impact of Regional Anesthesia
30 minutes in Phase 1 PACU
$400
Reduced Opioids
Impact of Regional Anesthesia
• 380 US hospitals • 320,000 inpatient surgeries
•12.2% of patients had an opioid-related adverse event (ORADE) •respiratory depression •nausea and vomiting •drowsiness, itching, altered mental status •constipation and paralytic ileus
Oderda, GM. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliate Care Pharmacother. 2013 Mar; 27(1):62-70.
Effect of opioid-related adverse events on outcomes in selected surgical patients.
Oderda GM1, Gan TJ, Johnson BH, Robinson SB.
Decreased LOS
Ave Cost per Inpatient Day(non-profit hospital)
CA $2676
LA $1519
VA $1630
AZ $2092
MN $1929
CO $2329
US Average $2025
$405,000 savings/year
Decrease LOS 1 day
x 200 joints/year
http://www.beckershospitalreview.com/lists/average-cost-per-inpatient-day-across-50-states-in-2010.html
Impact of Regional Anesthesia
Lower After-Hospital Costs
Impact of Regional Anesthesia
Home Health$100/day
Skilled NursingFacility
$700/day
Increased Discharge to HOME
Decreased Readmissions
Impact of Regional Anesthesia
Hospital Readmission
THR $12,300TKR $10,200
ER
$1400 - $2000
Success Drivers
• Index Admission: $13,000 - $15,000 Range
• Hospital Payment
• Surgeon and Anesthesia
• Other Hospital Professional Fees (Hospitalist for fracture)
• Home Health
• Physical Therapy
• Other Follow-up Care (Office Visits, Radiology, DME)
Loss Drivers…Rehab
- Acute Rehab LOS 5 to 10 d $15,000 - $21,000
- SNF at Target LOS 8-10 d $8,000
- SNF with Long LOS 30+ d $17,000 - $28,000
Loss Drivers…Readmission
- Hospital Ortho Surgical $20,000 (Hospital & Physician)
- Hospital Medical $7,500 (Hospital & Physician)
- Surgery/Medical Observ. $5,000 - $20,000
- Other Misc. Part B = High-Cost Drugs, Imaging, Diag. Tests
• Patient satisfaction• Surgeon satisfaction• Ambulation• Physical therapy
participation• D/C to home
Decreased Increased
• Pain scores• PONV• LOS• PACU time• Opioids, ORADE• ER & Hospital
readmission• Need for SNF or
inpatient rehab
Positive Impact of RA on Bundled Payments
It Takes a Village…
Surgeon
Hospital/ASC Administration
Anesthesiateam Patient
PhysicalTherapist
Pharmacy
Familymember
OR &PACU RN
Floor RN
RegistrationBlock RN
EPIC/EMR
Billing
Preop RN
Successful Regional Anesthesia Program
Anesthesia Team
Patient
Surgeon
Nurses
Joint Replacement
Advisory Board
CEO, CFO, CMO, CNO
Physical Therapist
Hospitalist
Evaluation of Bundle Performance
Quarterly Review
PREPARE FOR THE NEW TARGET!
• Readmissions
• Discharge disposition
• Financial assessment
- Ave cost vs. target cost
- Examine high-loss cases
• Identify further cost savings
The Service Experience... For Patients
SM
Edvard Munch
What About the PAIN?!!!
I Know I Need Surgery, but…
In the Media… AAOS
1.Adamson, et al. Hosp Pharm. 2011;46(6 Suppl 1):1-3.2.Alam A, et al. Arch Intern Med, 2012; 172(5): 425-30.3.Carroll I, et al. Anesth Analg, 2012; 115(3): 694-702.
A Growing Opioid Epidemic
• ˃70 million patients per year are prescribed opioids for postsurgical pain 1
• 1 in 15 will go on to long-term use or abuse 2,3
• Rapid proliferation of new opioid users coming from the acute care setting 2,3
INhealth Magazine
52 Inhealth magazine. Spring/Summer 2016.
MAKES IT EASY to...
Do the Right Thing
for the Patient!
Regional Anesthesia
Adductor Canal Catheter
ERAS for…
• Partial knee replacement
• Total knee replacement
• ACL repair
orthoinfo.aaos.org
Decreased LOS & readmission rate, Increased DC to home
Auyong DB, et al, J Arthroplasty (2015).
Interscalene Catheter
ERAS for…• Rotator cuff repair
• Total shoulder
• Reverse shoulder
• AC joint
• ORIF clavicle
Decreased LOS, pain score, opioid use, insomnia
Brockmeier, S. J Bone Joint Surg Am , 2014 Nov 19; 96 (22): 1924.
Fascia Iliaca Catheter
ERAS for…
• Total hip replacement
• Hip arthroscopy
• Hip fracture
Mayo Foundation for Medical Education.
Decreased incidence and duration of delirium, LOS, pain score
Mouzopoulos, G. Fascia iliaca block prophylaxis for hip fracture patients. J Orthop Traumatol 2009 Sep 10(3): 127 – 33.Dulaney-Cripe E et al. A continuous fascia iliaca compartment block in hip fracture patients. J Clin Med Res. 2012 Feb;4(1):45-8.
Neuraxial AnesthesiaLower 30-day mortality
Decreased length of stay
Decreased cost
Lower in-hospital complications
Memtsoudis, S., et al, Anesthesiology 2013 May; 118(5): 1046
- 1058.
Total Hip Arthroplasty
• >380,000 THR, TKR
• 400 hospitals
• GA vs Neuraxial
Neuraxial AnesthesiaDecreased incidence of SSI
Zorrilla - Vaca, A. et al., Regional Anesthesia and Pain Medicine. 2016; 41:
555-563.
• 13 studies
• n = 362,029
• GA vs Neuraxial
Regional Anesthesia & Value-based Payments Overview
http://go.beckershospitalreview.com/revisiting-regional-anesthesia-a-pathway-to-optimal-patient-outcomes-surgeon-satisfaction-and-value-based-payment