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Developing a business case for a regional anesthesia block room: up with efficiency, down with costs
  1. Yusuke Mazda1,
  2. Sharon Peacock2,
  3. Jesse Wolfstadt3,
  4. John Matelski4,
  5. Vincent Chan5 and
  6. Yehoshua (Josh) Gleicher2
  1. 1Division of Obstetric Anesthesia, Department of Anesthesiology, Saitama Medical Center, Kawagoe, Japan
  2. 2Anesthesiology and Pain Medicine, Sinai Health, Toronto, Ontario, Canada
  3. 3Surgery, Division of Orthopaedics, Sinai Health, Toronto, Ontario, Canada
  4. 4Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
  5. 5Department of Anesthsia, University Health Network-, Toronto, Ontario, Canada
  1. Correspondence to Dr Yehoshua (Josh) Gleicher, Anesthesia, University of Toronto, Toronto ON M5G 1X5, Canada; josh.gleicher{at}sinaihealthsystem.ca

Abstract

Background Regional anesthesia techniques offer many benefits for total joint arthroplasty (TJA) patients. However, they require personnel and equipment resources, as well as valuable operating room (OR) time. A block room offers a dedicated environment to perform regional anesthesia procedures while potentially offsetting costs.

Methods The goal of this prospective quality improvement study was to develop a business case for implementation of a regional anesthesia block room and to demonstrate the cost-effectiveness of this program in decreasing OR time for TJA. All elective TJA patients presenting between January 2019 and March 2020 were included in our analysis.

Results Our detailed business plan was approved by the hospital leadership. 561 patients in the preintervention group and 432 in the postintervention group were included for data analysis. Mean total OR time per surgical case decreased from 166 to 143 min for a difference of 23 min (95% CI 17 to 29). Similarly, anesthesia controlled OR time decreased from 46 min to 26 min for a difference of 20 min (95% CI 17 to 22). The block room resulted in an additional primary TJA case per daily OR list. The percentage of TJA patients receiving a peripheral nerve block increased from 63.1% to 87.0% (p<0.001). No safety events or block room associated OR delays were observed.

Conclusion Implementing a regional anesthesia block room required a comprehensive business plan for securing the necessary resources to support the program. The regional anesthesia block room is a cost-effective method to improve patient care and OR efficiency.

  • analgesia
  • lower extremity
  • economics
  • nerve block
  • injections
  • spinal

https://doi.org/10.1136/rapm-2021-102545

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    Introduction

    The majority of surgical patients undergoing total joint arthroplasty (TJA) experience moderate to severe acute postoperative pain.1 To optimize TJA postoperative pain control and curb opioid use and opioid-associated side effects, most centers performing TJA now advocate for evidence-based opioid sparing analgesia strategies such as neuraxial anesthesia and multi-modal analgesia including peripheral nerve blocks (PNBs).2–5

    Between 2017 and 2018, TJA management at our center underwent a significant overhaul by implementing an enhanced recovery after surgery bundle which included placement of PNB.6 This quality improvement (QI) intervention yielded significant improvements in the quality of care, including a 36% reduction in 24-hour opioid use, 25% reduction in moderate to severe pain, 25% decrease in acute hospitalization length-of-stay, and 10% reduction in need for inpatient rehabilitation. Despite these improvements, challenges and barriers to providing PNBs in a sustainable manner remained. Local data revealed that in 2018, only 42% of the total knee arthroplasty (TKA) patients at our center received a PNB due to lack of resources and limited operating room (OR) time. When the PNBs were performed, it was usually in the OR, adding an average of 15 min per case. This added approximately 1 hour per day to most OR lists, resulting in the lists running overtime or last cases being canceled. Both of these consequences have significant implications for quality and costs of patient care.

    The term “block room” describes both an actual location as well as a system of parallel processing, where regional anesthesia (PNBs and neuraxial anesthesia) is administered outside the OR. A block room offers two main advantages: (1) having the space and resources to perform PNBs, such as a trained anesthesiologist and equipment (which may not be easily available in the OR itself), and (2) the ability to decrease non-surgical OR time by moving procedures such as intravenous insertion, PNB and neuraxial anesthesia to the block room.7 Previous studies demonstrated net savings of 10–50 min per case when a parallel-processing model was used for regional anesthesia.8–15 However, these studies compared regional and general anesthesia or encompassed a variety of surgeries and regional anesthesia techniques, and these results cannot be applied to TJA patients.

    The main obstacle to implementing a block room is the added cost for equipment, space, and personnel.7 Care providers advocating for such resources are often met with resistance unless they are able to clearly outline the value added. Business cases can help clinicians “sell” the intervention to hospital decision makers by clearly weighing the potential benefits against the added costs.16 17 Despite business cases being a useful tool for local/regional QI leaders, there is very little in the literature to guide clinicians on how to do develop them.

    Our aim was to use a business case in order to implement a financially viable regional anesthesia block room intended to increase proportion of PNBs for elective TJA patients, and to decrease anesthesia-controlled operating room (ACOR) time and total operating room (TOR) time by 20 min each over a 6-month period.

    Methods

    This QI study was conducted at an academic tertiary hospital that performs 600 primary and 400 revision TJA annually by fellowship trained surgeons. The study was a prospective before-and-after study design. A multidisciplinary QI project team consisting of anesthesiologists, orthopedic surgeons, nurses, and surgical services leadership was formed and met periodically. The team collected local data and care provider feedback, reviewed best practices at other TJA centers, and performed a literature review. With this initial survey, we concluded that developing and implementing a dedicated block room will help address barriers to providing PNBs for TJA and reduce OR time by moving other anesthetic procedures outside of the OR. The next step was to justify the value-added by implementing a block room.

    A business case was developed based on known frameworks and presented to hospital leadership.16 17 The aim of business case was to predict the net value (benefit/cost) of implementing a regional anesthesia block room (henceforth referred to as block room). The business case consisted of five steps.

    Assessing organization readiness

    A brief review of the organization’s current capacity and willingness to provide regional anesthesia was performed. Feedback from care providers identified a positive culture with regards to the evolving regional anesthesia program, with surgeons, anesthesiologists, nurses and allied health all expressing interest in expanding and optimizing the program. Available resources were cataloged including equipment, personnel, and potential block room spaces. Champions were identified and recruited to the project team.

    Data collection and analysis

    Pre-existing surgical case volumes, case duration and costs were collected from the OR Scheduling and Office System (ORSOS) database. Average anesthesia-controlled OR time (ACOR) per case for the previous year, defined as time from patient arrival to the OR to surgical incision, was measured.15 ACOR time encompassed patient positioning on the operating table, placement of monitors, peripheral intravenous insertion, PNB(s), neuraxial anesthesia, induction of general anesthesia and invasive monitoring placement (if indicated), and surgical site preparation. The data were used estimate the potential impact of a block room on OR time and surgical caseload output (table 1).

    View this table:
    Table 1

    Baseline ACOR for TJA (2018)

    Drafting of business case

    Based on previous studies,8–15 the project team hypothesized that a block room would significantly reduce ACOR and consequently TOR by at least 20 min per case, resulting in over 300 OR hours saved per year. The time saved could then be used for other surgical procedures based on prioritization. The final report included appraisal of available intervention options, cost and benefit analysis, risk analysis, opportunities for institutional synergism, and final recommendations. An overview of the business case is presented in table 2.

    View this table:
    Table 2

    Overview summary of the regional anesthesia block room business case proposal

    Presentation of case to hospital leadership

    The business case was presented to the hospital’s Director of surgical services, Chief Operations Officer, and Senior Vice-President of Medical Affairs. By using the Institute for Healthcare Improvement’s (IHI) Triple Aim framework for optimizing health system performance,18 the business case presentation emphasized the block room’s potential to positively impact cost-effectiveness, patient experience, and patient outcomes.

    Business case approved—next steps

    Following approval, a timeline for project execution was set. Guidelines for equipment procurement and personnel recruitment were finalized. The project team committed to providing quarterly reports for expenses and block room outcomes.

    Block room intervention

    The Model for Improvement QI framework was used as an implementation framework and the block room intervention was trialed through iterative Plan-Do-Study-Act (PDSA) improvement cycles.19 The project team initially met weekly for 8 weeks to study the data, review feedback from care providers, and refine the block room workflow and functionality. After achieving a steady state, the group met on a monthly basis.

    A dedicated space in the pre-existing postanesthetic care unit (PACU) was designated as the block room and included two bays with monitored beds. Two new ultrasound machines were procured. New block room personnel hires included a critical care-trained registered nurse (RN) and an anesthesia assistant (AA). Surgical cases intended for block room use included all primary and revision TJA. Procedures performed in the block room included placement of intravenous, PNB, and neuraxial anesthetic (when indicated). Anesthesiologists trained in PNB placement were booked in the OR. The same anesthesiologist performed the anesthetic procedures in the block room. They were relieved from the OR to perform this by the AA near the end of the previous case. The surgeries were performed in one OR by one surgeon with the exception of 1 day a week, where the surgeon was allowed to use two ORs to stagger cases and reduce turnover time. The same model was used throughout the preintervention and postintervention periods.

    Key stakeholders were identified and engaged to achieve institutional buy-in (online supplemental appendix A). Potential challenges and barriers to block room implementation were identified and included: (1) efficiency of patient flow; (2) ensuring patient safety; (3) standardization of block room procedures; (4) limited block room space and equipment

    Supplemental material

    Process maps were created and reviewed by stakeholders to map patient flow in and out of the block room (online supplemental appendix B). Dissemination of work flow and block room training occurred in combined surgical, anesthesia, and nursing seminars prior to launch. The block room protocol and algorithm both emphasized the need to maintain patient safety using a multidisciplinary safety checklist and a procedural timeout (online supplemental appendix C).

    Supplemental material

    Supplemental material

    Primary outcome measures were TOR time and ACOR time. TOR time was defined as the time from the patient entering the OR to the time of departure from the OR. These data points are recorded in the ORSOS database. A secondary outcome measure was the total number of primary TJA cases performed for a primary TJA surgical list.

    Evaluation of process measures assessed whether the block room was being used as intended; measures included the percentage of TJA patients who received their PNB and/or neuraxial anesthetic in the block room. Balance measures included any patient safety events associated with the block room, as well as anesthesia associated OR delays including those associated with the block room. At our institution OR delays are defined as delay >15 min for patient arrival to the OR once the OR is ready.

    All data were prospectively recorded and collected from the ORSOS database. The data collected from January to September 2019 served as the preintervention period and data from October 2019 to March 2020 was considered postintervention.

    Standard bivariate methods were used to compare baseline demographic variables between the pre/post phases. For TOR and ACOR outcomes, linear regression was used to compute adjusted intervention effects. For each outcome, a bi-directional Akaike information criterion (AIC) based step selection algorithm was used for feature selection from these potential confounders: gender, age, body mass index, procedure, American Society for Anesthesiologists score, month of year, and overall temporal trend (linear in day number on study). Estimates are reported with 95% CIs and Wald test p values. The analyses were performed using R V.3.6.2. An alpha level of 0.05 was used as the threshold for statistical significance.

    Results

    Following provision of funding and resource allocation, block room protocol development, and implementation commenced in July 2020. New block room personnel (RN and AA) were hired in September 2019. The block room was launched October 2019. Initial implementation challenges included optimizing and refining patient flow and difficulty in staffing the block room with a dedicated anesthesiologist due to personnel shortages. These challenges were addressed using PDSA cycles as part of our QI framework (online supplemental appendix D). Due to the COVID-19 pandemic, the block room project was halted on March 15, 2020 for reallocation of resources and subsequently restarted on July 2020.

    Supplemental material

    A total of 561 and 432 TJA cases were included in the preintervention and postintervention groups, respectively. Demographic and perioperative data are summarized in table 3.

    View this table:
    Table 3

    Characteristics of preblock and postblock room intervention arthroplasty patients

    Following implementation of the block room, mean TOR decreased from 166 min to 143 min for a difference of 23 min (95% CI 17 to 29) (figure 1). Similarly, mean ACOR time decreased from 46 min to 26 min for a difference of 20 min (95% CI 17 to 22) (figure 2). A subgroup analysis based on type of procedure was performed and revealed significant reductions in TOR and ACOR for all TJA procedures (figure 3). TOR time savings facilitated adding a primary TJA case to primary TJA OR lists, resulting in 24 primary TJA cases added throughout the study period. Lists that included revision TJA or a combination of primary and revision TJA did not result in an extra case added due to the longer duration of revision cases. TOR time saved was also used for non-elective orthopedic and oncology cases, although these data were not captured as part of our QI study.

    Figure 1
    Figure 1

    A run chart illustrating the block room development timeline, and its impact on total OR time. OR, operating room; PDSA, Plan-Do-Study-Act; QI, quality improvement; THA, total hip arthroplasty; TKA, total knee arthroplasty.

    Figure 2
    Figure 2

    A run chart illustrating the block room development timeline, and its impact on anesthesia-controlled operating room time. OR, operating room; PDSA, Plan-Do-Study-Act; QI, quality improvement; THA, total hip arthroplasty; TKA, total knee arthroplasty.

    Figure 3
    Figure 3

    Subgroup analysis based on the type of arthroplasty procedure for block room impact on total and anesthesia-controlled operating room times, with 95% CIs. OR, operating room; THA, total hip arthroplasty; TKA, total knee arthroplasty.

    The overall percentage of TJA patients receiving PNBs increased from 63.1% to 87.0% for a difference of 23.9% (p<0.001). All PNBs placed for TKA were adductor canal blocks. Ninety-two per cent of PNBs for total hip arthroplasty were supra-inguinal fascia iliaca compartment blocks and 8% were Pericapsular Nerve Group blocks. No block room associated safety events were observed. The rate of anesthesia associated OR delays for the preintervention and postintervention periods were 4.5% and 6.3%, respectively (p=0.546), indicating no significant increase in anesthesia associated delays OR delays.

    Discussion

    The results from our study demonstrated that the development of a comprehensive business case and implementation of a block room resulted in significant improvements in OR efficiency and patient care. Our block room also directly contributed to an increase in the volume of funded TJA procedures (one case per day), although this increase was limited for primary TJA lists only, as revision TJA cases require longer surgical time. Previous studies have evaluated the potential costs savings block rooms generate,8–15 but none of them have provided the reader with a systematic approach for how to predict the value added (benefit/cost) by a block room. Our study is novel as it provides the regional anesthesiologist with a detailed framework for how to develop and present a business case for a financially viable block room program.

    It is well established that neuraxial and regional anesthesia techniques improve quality of care to joint arthroplasty patients, with a trend toward decreased morbidity and mortality.20 21 PNB is often recommended as a first line treatment for optimizing analgesia and reducing opioid requirement in the perioperative period, and block rooms facilitate placement of these procedures.22 23 Despite PNB for arthroplasty procedures being a proven evidence-based strategy for optimizing analgesia, an Ontario study revealed that from 2002 to 2013 only 34.6% of TKA patients received a PNB.24 This study highlights the challenge of knowledge translation, the slow diffusion of evidence-based regional anesthesia techniques, and the importance of cost-effective QI projects.

    A key benefit of a block room is that it enables a parallel-processing model through which the anesthetic of the next case can be induced before finishing the previous case, thereby reducing TOR. Previous studies investigated the efficiency of a block room and demonstrated its effectiveness in reducing TOR.10–15 For example, for upper extremity surgeries, implementing block room saves on average 17–22 min per case.8 Chazapis et al demonstrated that the implementation of the block room allowed nerve blocks to be performed in parallel to surgical operations, reducing the ACOR time from 44 min to 27 min, although this study did not evaluate the cumulative benefit of performing both neuraxial and nerve block placement in the block room.15 Gleicher et al demonstrated that when used for thoracic epidural placement, a block room can reduce ACOR and TOR by 22.9 and 19.1 min, respectively.25 With regards to TJA, a recent retrospective study determined that spinal anesthesia placement in a designated block room reduced time to incision by 5.37 min.26 Finally, a recent meta-analysis and systematic review found that block rooms reduce TOR by an average of 10.4 min and increase daily OR productivity by 1.7 cases per day.27 Adding to this body of evidence, our study is the first prospective study to clearly outline the project and change management processes, including a well-defined business case, that are needed to successfully implement a block room.

    For front line clinicians not involved with day-to-day hospital administration, preparing business a case for an intervention may be challenging. In order to effectively articulate the value added, clinicians need to be able to appraise available resources, justify funding required for new capital and personnel, and have insight on whether there are revenue generating or cost saving implications. We found that having an inter-professional project team comprised clinicians and administrators was highly effective, as this facilitated effective stakeholder engagement and evaluation of the value added for the block room.

    Ilfeld and Liguori argue that the cost of a block room must be weighed against the total value added.7 The cost of a block room will vary from center to center, and is inherently dependent on the procedural volumes, available resources, and institutional priorities.7 The total cost is comprised fixed costs for equipment such as ultrasound machines and monitoring equipment, and recurring costs for personnel and disposable equipment.28 Reallocation and repurposing of pre-existing resources (such as PACU space in our study) can reduce the initial investment required.29 Evolving regional anesthesia programs such as ours need to initially share and shift existing resources in this manner until more definitive institutional funding is provided.

    The economic benefit of a block room is difficult to quantify as it is highly contextual and relies on the institutional cost of OR time, and how the time saved is used.7 Utilizing the TOR time saved to decrease OR overtime, complete non-elective cases in a timely manner, or add funded cases, each have their own merits and economic impact. One review estimated that the cost of 1 min of OR time ranges from $22 to $133, not including physician provider fees.30 A similar analysis of California hospitals reported a mean OR cost of $36/min.31 At our institution, the cost of 1 min of OR time averages out to $C20 according to our Director of Performance and Health Information Management. This does not include physician labor costs. In theory, the block room saved approximately $C460 per TJA case and over $C170,000 throughout the study period, although we concede this analysis is somewhat simplistic as many of these cost savings are unrealized. In practice, newly available OR time was used for other surgical cases including TJA, non-elective orthopedic cases, and surgical oncology cases. Nonetheless, the TOR time saved justified funding for the block room and gained institutional leadership support. Finally, during the COVID-19 pandemic, our block room helped facilitate patient care for our center’s new outpatient TJA pathway, reducing inpatient bed utilization and enabling a rapid re-design of patient care.32

    In addition to outlining the approach to a business case as described earlier, other notable strengths of this project are the design and implementation of the processes, which ultimately resulted in the successful funding and execution of the block room project. This highlights the importance of a structured project management approach: conception of the project, defining the problem and opportunity for improvement, developing a business case, planning and execution of the block room, quality and safety control, and finally achieving sustainability.33 Furthermore, in order for perioperative based QI initiatives such as this one to succeed, it is important to use established QI frameworks. During the diagnostic and business case development phase, a change management approach was implemented to obtain key stakeholders buy-in and gain momentum, similar to Kotter’s model of change.34 Additionally, the Model for Improvement was used in order to maintain focus on the block room’s overall aim and employ iterative PDSA improvement cycles.19 Finally, tying in a regional anesthesia QI project’s aim to the IHI’s Triple Aim (patient outcomes, experience of care, and costs of care) is a useful way to ensure meaningful improvement is achieved and demonstrate value to hospital executives.18 In the case of this block room project, both costs of care and patient experience (via administration of evidence based PNB) were targeted and successfully improved.

    Our study has several limitations. First, the generalizability of our study may be limited given that the findings are specific for TJA procedures. Second, the block room’s impact on TOR and costs of care may not be generalizable to other centers due to the variability of logistics across different institutions. These results may not apply to centers that complete surgical lists with longer case duration and little OR turnover, or those that have anesthesia induction rooms.7 Finally, we may have underestimated the block room’s impact on ACOR, as there are anesthesia related tasks performed during the surgical procedure time, thereby accounting for the difference in improvement between TOR and ACOR.

    Conclusions

    Implementing a regional anesthesia block room for TJA increased OR efficiency and OR caseload. Our improvement process and findings provide a framework for developing a business case and implementing a regional anesthesia block room for a TJA program.

    Ethics statements

    Ethics approval

    Institutional approval was granted for implementation this QI project. Research ethics board approval was granted for retrospective data collection. This quality improvement study follows the SQUIRE 2.0 publication guidelines for Quality Improvement Reporting.

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    Supplementary materials

    Footnotes

    • YM and SP are joint first authors.

    • Twitter @yusuke_mazda

    • Correction notice This article has been corrected since it published Online First. Dr Peacock's name has been corrected.

    • Contributors YM contributed to data collection. SP helped design and implement the study, and write the manuscript. JW helped design and implement the study, and critically reviewed manuscript. JM contributed to data and statistical analysis. VC critically reviewed manuscript. YG helped design and implement the study, analyze the data, and write the manuscript.

    • Funding Funding was provided by Sinai Health.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.