REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May...
-
Upload
bernard-watkins -
Category
Documents
-
view
214 -
download
0
Transcript of REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May...
![Page 1: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/1.jpg)
REGIONAL ANESTHESIAAnesthesia Care Teams and Block Areas
NAPAN ConferenceSue Belo MD PhD FRCPC
May 23rd, 2009
![Page 2: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/2.jpg)
HOLLAND CENTRE
![Page 3: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/3.jpg)
The Holland Centre
AMALGAMATION 1998
Orthopedic and Arthritic Hospital
SunnybrookHospital
Orthopedic and Arthritic InstituteSWCHCS
Holland Centre 2005
![Page 4: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/4.jpg)
Resources
• 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
![Page 5: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/5.jpg)
2004
• 3200 cases per year• 1500 total joint arthroplasties• 100% under General Anesthesia• Limited use of femoral nerve blocks• Post-op nurse-managed morphine PCA
![Page 6: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/6.jpg)
2004
• Average length of stay 7 days• In-patient rehab 10 days• 20% to long term rehab 16 days
![Page 7: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/7.jpg)
2004
• Average 16/20 lists per month ran overtime• Average overtime 30 hours/month• Average 18 cancellations/month
![Page 8: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/8.jpg)
• How can patient care be improved at the Holland Centre?
• Wait Time strategy 2004
• Holland Centre of Excellence Aug 2005
• Anesthesia and Nursing shortages
![Page 9: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/9.jpg)
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)
![Page 10: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/10.jpg)
VISION
Convert the Holland Centre to Regional Anesthesia
![Page 11: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/11.jpg)
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
![Page 12: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/12.jpg)
• prolonged operating room time• decreased efficiency• unpredictable success rate• inferior surgical conditions• unacceptable to patients
CHANGE!!
![Page 13: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/13.jpg)
Anesthesia Concerns
•Regional Anesthesia requires time•Regional Anesthesia requires expertise•Regional Anesthesia requires co-operation•Regional Anesthesia requires a team effort
Investment for Improvement
![Page 14: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/14.jpg)
Administration Concerns
$$$$$$
![Page 15: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/15.jpg)
Anesthesia Care Team Model
• Create a separate but adjacent “Block Area” (4 bays)
• “Block RNs” to staff area (2)– check patients, prepare equipment, monitor patients
• Anesthesia Assistants (2) – monitor stable patients under regional anesthesia in OR while
anesthetist performs regional/blocks for next patient
• Anesthesiologists (4)– each anesthesiologist does own blocks in the Block Area
![Page 16: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/16.jpg)
Patient Flow
OR
Same Day Admission
Block Area
PACU
![Page 17: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/17.jpg)
2007
![Page 18: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/18.jpg)
![Page 19: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/19.jpg)
Surgeon Education
• Approached surgeons individually and as a group
• Provided relevant literature (including surgical literature)
• Presented rounds
![Page 20: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/20.jpg)
Nursing Education
• Involved Pre-Assessment Clinic nursing staff, ward nurses, OR nurses
• Provided with literature, in-services• Invited to Block Area and PACU
![Page 21: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/21.jpg)
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
![Page 22: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/22.jpg)
Patient education
• by anesthetist at pre-op visit• patient information pamphlets• DVD video sent home with patient• Web-site
![Page 23: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/23.jpg)
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)
![Page 24: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/24.jpg)
• Developed protocols and standardization for selected procedures initially and introduced new procedures slowly
– 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
![Page 25: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/25.jpg)
2007
• 2100 total joint arthroplasties• Neuraxial anesthesia in 90% • Peripheral nerve blocks used in 90% of TKA• Peripheral nerve block catheters for continuous
infusions
![Page 26: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/26.jpg)
OR Time
KneesHips
Type
125
100
75
50
25
0
Mea
n S
urg
ical
Tim
e
Error bars: +/- 1 SD
2007
2004
Year
17% decrease in time for patient-in to patient-out from 2004 to 2007 in total knee arthroplasties18.6% decrease in time required from patient-in to patient-out for total hip arthroplasties
![Page 27: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/27.jpg)
OR Overtime(* cancellations)
![Page 28: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/28.jpg)
PACU Length of Stay
![Page 29: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/29.jpg)
• 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
![Page 30: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/30.jpg)
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
![Page 31: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/31.jpg)
![Page 32: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/32.jpg)
![Page 33: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/33.jpg)
![Page 34: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/34.jpg)
![Page 35: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/35.jpg)
PACU Discharge CriteriaModifications 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
![Page 36: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/36.jpg)
64.6
40.9
010203040506070
Time (minutes)
2007 2009
Year
PACU readiness for discharge
![Page 37: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/37.jpg)
The Future
Improved patient care• Continuous catheters• Patient controlled oral analgesia• Expanded ultrasound applications• Optimization of drugs and dosages• Best Practice guidelines• Expansion of Anesthesia Care Team model
![Page 38: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/38.jpg)
• Retainment and Recruitment(Anesthesiologists, Block RNs, Anesthesia Assistants)
• Documenting improved outcomes• Continuous improvement• Expansion of program to Sunnybrook site• Maintaining expertise at 2 sites
![Page 39: REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649ddc5503460f94ad4812/html5/thumbnails/39.jpg)
THANK YOU