Making It Work: Setting up a Regional Anesthesia Program that Provides Value
Section snippets
Why perform regional anesthesia?
The definition of “outpatient” surgery is constantly evolving. Surgeries that required overnight hospitalization 10 years ago are currently considered ambulatory care. For example, total joint replacement postoperative protocols have been refined to the point that it is currently feasible to practice same-day discharge or short-stay admission for appropriate cases.1, 2, 3 The causes of prolonged recovery after scheduled ambulatory surgery have been studied and are multifactorial. In addition to
Who are the customers?
When considering the “business” of health care and a new regional anesthesia service, it is essential to identify prospective customers. The patient is the most important customer, and the improvement in the quality of the postsurgical experience provided by regional anesthesia is a clear benefit to patient care. The surgeons are also important customers in any anesthesiology practice or surgical center, and their needs must be considered for a new regional anesthesia service to succeed. For
Cost, charge, and reimbursement
Before presenting a new regional anesthesia program to administration for approval and support, the definitions of cost, charge, and reimbursement should be understood clearly. In terms of regional anesthesia, cost is defined as the amount of money spent in order to perform a nerve block procedure, including the equipment involved, supplies, medications, and salary support. Costs can be further divided into fixed costs and variable costs,21 with most of the overhead being included among fixed
Potential cost savings
In outpatient surgery, the use of peripheral nerve blocks leads to a greater likelihood of post-anesthesia care unit (PACU) bypass and shorter time to home readiness and discharge compared with general anesthesia.5, 6, 7 Cost savings can result from reduced nursing time or decreased recovery time associated with PACU bypass.22 Based on the economic study performed by Williams and colleagues22 on nerve block pain management after anterior cruciate ligament reconstruction, PACU bypass reduces
Generating new charges
Anesthesia charges for equipment, professional fees, and pharmacy fees amount to a small percentage of the overall perioperative bill that patients and insurance companies receive after most surgical procedures that require inpatient admission.21 At institutions that choose not to itemize anesthesia equipment and pharmacy charges, patients receive flat charges of a fixed amount in these areas. Regional anesthesia procedures, particularly CPNB, introduce additional equipment and medications not
Professional fees and “rules to bill by”
Taking a hands-on approach to billing maximizes charges and leads to revenue generation for the hospital and the anesthesiology group.
Putting it all together
To make a regional anesthesia service successful and provide value, many pieces must fit together. All customers must be satisfied, including the patients, surgeons, and administrators. Although patients may be satisfied by superior pain control and improvement in the quality of postanesthesia recovery afforded by peripheral nerve blocks and CPNB, surgeons and administrators also demand efficiency. In the busy outpatient surgery setting, the addition of a new regional anesthesia service does
Summary
Regional anesthesia offers many benefits for the patient, surgery center, anesthesiology practice, and hospital. Unfortunately, there are no evidence-based guidelines to follow when starting a new regional anesthesia service. A regional anesthesia program adds value to perioperative services by improving the quality of postoperative analgesia and recovery after surgery and provides value in the fiscal sense to offset startup costs. A hands-on approach ensures proper billing and accurate charges
References (35)
- et al.
Total hip arthroplasty as an overnight-stay procedure using an ambulatory continuous psoas compartment nerve block: a prospective feasibility study
Reg Anesth Pain Med
(2006) - et al.
Continuous peripheral nerve block for ambulatory surgery
Reg Anesth Pain Med
(2001) - et al.
Indwelling interscalene catheter use in an outpatient setting for shoulder surgery: technique, efficacy, and complications
J Shoulder Elbow Surg
(2007) - et al.
Total elbow arthroplasty as an outpatient procedure using a continuous infraclavicular nerve block at home: a prospective case report
Reg Anesth Pain Med
(2006) - et al.
Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case-control, cost-minimization analysis
Reg Anesth Pain Med
(2007) - et al.
Development of a standardized peripheral nerve block procedure note form
Reg Anesth Pain Med
(2005) - et al.
The practice of peripheral nerve blocks in the United States: a national survey
Reg Anesth Pain Med
(1998) - et al.
A survey of exposure to regional anesthesia techniques in American anesthesia residency training programs
Reg Anesth Pain Med
(1999) - et al.
The introduction of a regional anesthesia rotation: effect on resident education and operating room efficiency
J Clin Anesth
(2006) - et al.
Ambulatory perineural infusion: the patients' perspective
Reg Anesth Pain Med
(2003)
Total knee arthroplasty as an overnight-stay procedure using continuous femoral nerve blocks at home: a prospective feasibility study
Anesth Analg
Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study
Anesthesiology
Factors contributing to a prolonged stay after ambulatory surgery
Anesth Analg
For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia
Anesthesiology
Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy
Anesth Analg
A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries
Anesthesiology
Which clinical anesthesia outcomes are important to avoid? The perspective of patients
Anesth Analg
Cited by (35)
Updates on multimodal analgesia and regional anesthesia for total knee arthroplasty patients
2019, Best Practice and Research: Clinical AnaesthesiologyCitation Excerpt :These data suggest that TKA patients may be ideal candidates for CPNB. However, being able to provide CPNB for patients on a regular basis requires a system that may not be available for various reasons in every practice setting [64], and implementation of new CPNB programs remains challenging [65]. When choosing which peripheral regional analgesic techniques to offer patients, many factors have to be considered.
Establishing an Acute Pain Service in Private Practice and Updates on Regional Anesthesia Billing
2018, Anesthesiology ClinicsSetting up an ambulatory regional anesthesia program for orthopedic surgery
2014, Anesthesiology ClinicsCitation Excerpt :One model involves a block area, which may be located in a preoperative holding area or in a PACU. This area should be equipped with beds, standard monitors (American Society of Anesthesiologists), resuscitation equipment including lipid emulsion, and regional anesthesia supplies.30 Having a separate block area can permit additional teaching with less time pressure to perform the block.
The Expanding Role of Multimodal Analgesia in Acute Perioperative Pain Management
2013, Advances in AnesthesiaCitation Excerpt :For multimodal analgesic protocols that incorporate regional anesthesia, efficiency is one of the key concepts. When regional anesthesia procedures are offered preoperatively to maximize the opioid-sparing benefits [7], they are best performed in a regional anesthesia induction area or “block room” while the preceding case is still in the operating room [85]. The use of a block-room model can actually improve operating-room efficiency by decreasing anesthesia-controlled time, when compared with both general anesthesia and nerve blocks performed in the operating room [90].
Erector spinae plane blocks for analgesia after percutaneous nephrolithotomy: A pathway to reduce opioids
2023, Canadian Urological Association Journal
Financial Support: Dr. Mariano is supported by the University of California, San Diego Department of Anesthesia. The contents of this article are solely the responsibility of the author and do not necessarily represent the official views of this entity.
Conflicts of Interest: Dr. Mariano conducts regional anesthesia workshops for Stryker Instruments and I-Flow. He also receives material research support from Stryker, Sorenson Medical, Arrow International, and B Braun. These companies have had no input into any aspect of this manuscript.