Category Archives: Anesthesiology

5 Reasons to Put Physicians in Charge of Hospitals

This post was first released on KevinMD.com.

Putting physicians in charge of hospitals seems like a no-brainer, but it isn’t what usually happens unfortunately. A study published in Academic Medicine states that only about 4% of hospitals in the United States are run by physician leaders, which represents a steep decline from 35% in 1935. In the most recent 2018 Becker’s Hospital Review “100 Great Leaders in Healthcare,” only 29 are physicians. 

The stats don’t lie, however. Healthcare systems run by physicians do better. When comparing quality metrics, physician-run hospitals outperform non-physician-run hospitals by 25%. In the 2017-18 U.S. News & World Report Best Hospitals Honor Roll, the top 4 hospitals (Mayo Clinic, Cleveland Clinic, Johns Hopkins Hospital, and Massachusetts General Hospital) have physician leaders. Similar findings have been reported in other countries as well.

While not all physicians make good leaders, those that do really stand out. For those physicians who may consider applying for hospital leadership positions, there are certain characteristics that should distinguish them from non-physician applicants and help them make the transition successfully. Of course, this is my opinion, but I think it comes down to these 5 things:

  1. Physicians are bound by an oath. The Hippocratic Oath in some form is recited by every medical school graduate around the world. This oath emphasizes that medicine is a calling and not just a job: “May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.” Physicians commit themselves to the treatment of disease and the health of human beings. There is no similar oath for non-physician healthcare executives.
  2. Physicians know how to make tough decisions. This is crucial to every informed consent process. Physicians need to curate available evidence, weigh risks and benefits, and share their recommendations with patients and families in situations that can literally be life or death. This is essential to the art of medicine. Effectively translating technical jargon into language that lay people can understand allows others to participate in the decision making process. This applies both to the bedside and the boardroom.
  3. Physicians are trained improvement experts. They learn the diagnostic and treatment cycle which requires listening to patients (also known as taking a history), evaluating test results, considering all possible relevant diagnoses, and instituting an initial treatment plan. As new results emerge and the clinical course evolves, the diagnosis and treatment plan are refined. In my medical specialty of anesthesiology, this cycle occurs rapidly and often many times during a complex operation. These skills translate well to diagnosing and treating sick healthcare systems.
  4. Physicians are lifelong learners. When laparoscopic surgical techniques emerged, surgeons already in practice had to find ways to learn them or be left behind. Medicine is always changing. To maintain medical licensure, physicians must commit many hours of continuing medical education every year. New research articles in every field of medicine are published every day. For these reasons, physicians cannot hold onto “the way it has always been done,” and this attitude serves them well in healthcare leadership.
  5. Physicians work their way up. Every physician leader started as an intern, the lowest rung of the medical training ladder. Interns rotate on different services within their specialty, working in a team with higher-ranked residents under the supervision of an attending physician. As physicians progress in training through their years of residency, they get to know more and more hospital staff in other disciplines and take on more patient care responsibility. A very important lesson learned during residency is that the best ideas can come from anyone; occasionally the intern comes up with the right diagnosis when more senior team members cannot.

While these qualities are necessary, they are not sufficient. To be effective healthcare leaders, physicians need to develop their administrative skills in personnel management, team building, and strategic planning. They will have to learn to understand and manage hospital finances, meet regulatory requirements and performance metrics, and find ways to support and drive innovation. For physicians who have already completed their medical training, a commitment to effective healthcare leadership will require as much time and dedication as their medical studies. However, if they don’t do this, there are plenty of non-physicians who will.

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My Reasons to Visit San Francisco for #ANES18

This year’s American Society of Anesthesiologists meeting (#ANES18) happens to be in my “neck of the woods”—one of the greatest cities in the world—San Francisco, California. Here are a few things you may or may not have known about San Francisco.

San Francisco is the biggest little city. At just under 47 square miles and with more than 200,000 inhabitants, San Francisco is second only to New York City in terms of population density. Despite its relatively small size, “the City” (as we suburbanites refer to it) consists of many small neighborhoods, each with its own charm and character: Union Square, the Financial District, Pacific Heights, the Marina, Haight-Ashbury, Chinatown, Little Italy, Nob Hill, Russian Hill, SoMa (South of Market), the Fillmore, Japantown, Mission District, Noe Valley, Twin Peaks, Castro, Sunset, Tenderloin, and others. This is probably why die-hard New Yorkers love it so much.

In the summer especially, San Francisco weather is somewhat unpredictable even when going from one side of the city to the other (part of the unique experience of visiting the city). “The coldest winter I ever spent was a summer in San Francisco,” a quote often mistakenly attributed to Mark Twain (no one really knows who actually said it), is nevertheless often true. Here in the San Francisco Bay Area, our local meteorologists provide daily forecasts for each of the region’s microclimates. The western side of the City along California’s coast is regularly plagued with fog while the eastern side of the City tends to be sunny most days of the year. It’s always a good idea to check the microclimate forecast before heading over to see the Golden Gate Bridge just in case it happens to be shrouded in fog. Average July temperatures in the City range in the 50s-60s Fahrenheit (no different than average November temperatures), so summer tourists often contribute to the local economy by buying “SF” logo sweatshirts for their walk across the City’s most famous bridge. Fortunately, #ANES18 is in the fall, and the weather near Moscone Center and the popular shopping area Union Square tends to stay reliably nice most of the year.

San Francisco is very family-friendly. If you’re debating whether or not to make a family trip out of #ANES18, my advice is to do it. Right around the convention center there are a number of attractions and events worth checking out. I highly recommend visiting the farmers market at the Ferry Building. While there, you can also take a ferry ride to a number of other destinations in the Bay Area (try Sausalito, a short trip that takes you past Alcatraz). For kids, there are parks within walking distance as well as the Children’s Creativity Museum, the San Francisco Railway Museum, Exploratorium, and the cable car turnabout at Powell and Market Street. Trips to Fisherman’s Wharf, Ghiradelli Square, or the aquarium are a short taxi or cable car ride away. In addition, runners will love running up and down the Embarcadero which gives you a view of the Bay Bridge and takes you past the City’s many piers. Shoppers will be in heaven, and foodies will have to make the impossible decision of choosing where to eat for every meal.

But don’t take my word for it—come to #ANES18 and see for yourself!

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Social Media and Academic Medicine

I was recently interviewed by Dr. Alana Flexman (@AlanaFlex), Chair of the Scientific Affairs Committee for the Society for Neuroscience in Anesthesiology and Critical Care (SNACC), on the topic of social media and academic medicine.

Read the full interview here and join me for a live discussion on this topic at the SNACC annual meeting in San Francisco October 11-12, 2018.

For resources to help you get started on social media, visit my resources page.

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Why We Should Worry about Drug Shortages in Regional Anesthesia

The crisis of prescription opioid overuse and abuse has affected countries around the world, and anesthesiologists are well-positioned to make positive changes (1).  Even minor outpatient surgical procedures, and their associated anesthesia and analgesia techniques, can lead to long-term opioid use (2,3).  Patients who present for surgery with an active opioid prescription are very likely to still be on opioids after a year (4).

Anesthesiologists have been working to set up regional anesthesiology and acute pain medicine programs with careful coordination of inpatient and outpatient pain management to improve patient outcomes.  Regional anesthesia, especially with continuous peripheral nerve block (CPNB) techniques, has been shown repeatedly to reduce patients’ need for opioid analgesia (5).

Today, the crisis of drug shortages threatens to reverse the many advances in perioperative pain control that have been achieved.  Local anesthetics or “numbing medications” represent a class of drugs that is our strongest weapon against opioids.  These drugs (e.g., bupivacaine, lidocaine, ropivacaine) are currently in shortage.  Targeted injections of local anesthetic in the form of regional anesthesia eliminate sensation at the site of surgery and can obviate the need for injectable opioids (e.g., fentanyl, hydromorphone, morphine) which also happen to be in short supply.  Local anesthetics are also the critical ingredient in providing epidural pain relief and spinal anesthesia for childbirth.  Without them, new moms will miss the first moments of their babies’ lives.

The following are potential ramifications of the current drug shortages affecting anesthesia and pain management on patient care:

Decreased Quality of Acute Pain Management

Regional anesthesia techniques, which include spinal, epidural, and peripheral nerve blocks, offer patients many potential advantages in the perioperative and peripartum period.  Human studies have demonstrated the following benefits: decreased pain, nausea and vomiting, and time spent in the recovery room (6,7).  Long-acting local anesthetics (e.g., bupivacaine, levobupivacaine, and ropivacaine) generally provide analgesia of similar duration for 24 hours or less (8-11).  These clinical effects of nerve blocks typically last long enough for patients to meet discharge eligibility from recovery and avoid unnecessary hospitalization for pain control (12).  CPNB techniques (also known as perineural catheters) permit delivery of local anesthetic solutions to the site of a peripheral nerve on an ongoing basis (13).  Portable infusion devices can deliver a solution of plain local anesthetic for days after surgery, often with the ability to titrate the dose up and down or even stop the infusion temporarily when patients feel too numb (14,15).  In a meta-analysis comparing CPNB to single-injection peripheral nerve blocks in humans, CPNB results in lower patient-reported worst pain scores and pain scores at rest on postoperative day (POD) 0, 1, and 2 (16).  Patients who receive CPNB also experience less nausea, consume less opioids, sleep better, and are more satisfied with pain management (16).  By using local anesthetic medication to interrupt nerve transmission along peripheral nerves, patients continue to experience decreased sensation as long as the infusion is running.  A shortage of local anesthetic medications makes it impossible for anesthesiologists to provide this potent form of opioid-sparing pain control for all surgical patients.  This also means that local anesthetics cannot be administered by surgeons as wound infiltration to help patients with incisional pain, and epidural analgesia for laboring women may not be universally available.

Increased Incidence of Postoperative Complications

Based on the study by Memtsoudis and colleagues, overall 30-day mortality for total knee arthroplasty patients is lower for patients who receive regional anesthesia, either neuraxial and combined neuraxial-general anesthesia, compared to general anesthesia alone (17).  In most categories, the rates of occurrence of in-hospital complications (e.g. all-cause infections, pulmonary, cardiovascular, acute renal failure) are also lower for the neuraxial and combined neuraxial-general anesthesia groups vs. the general anesthesia only group, and transfusion requirements are lowest for neuraxial anesthesia patients compared to all other groups (17).  The inability to offer regional anesthesia (e.g., spinal or epidural) to all patients due to lack of local anesthetics therefore represents a threat to patient safety.

Increased Risk of Persistent Postsurgical Pain

Chronic pain may develop after many common operations including breast surgery, cesarean delivery, hernia repair, thoracic surgery, and amputation and is associated with severe acute pain in the postoperative period (18).  A Cochrane systematic review and meta-analysis reviewed published studies on this subject, and the results favor epidural analgesia for prevention of persistent postsurgical pain (PPSP) after thoracotomy and favor paravertebral block for prevention of PPSP after breast cancer surgery at 6 months (19).  Only regional blockade with local anesthetics can block patients’ sensation during and after surgery.  Without local anesthetics for nerve blocks, spinals, and epidurals, patients will experience greater than expected acute pain, require additional opioid treatment, and potentially be at higher risk of developing chronic pain.

Increased Health Care Costs

Approximately 31% of costs related to inpatient perioperative care is attributable to the ward admission (20).  Anesthesiologists as perioperative physicians have an opportunity to influence the cost of surgical care by decreasing hospital length of stay through effective pain management and by developing coordinated multi-disciplinary clinical pathways (21,22).  Regional anesthesia and analgesia can improve outcomes through integration into clinical pathways that involve a multipronged approach to streamlining surgical care (23,24).  Inadequate pain control can delay rehabilitation, prolong hospital admissions, increase the rate of readmissions (25), and increase the costs of hospitalization for surgical patients.

In summary, regional anesthesia and analgesia has been shown in multiple studies to improve outcomes for obstetric and surgical patients.  The current shortage of local anesthetics and other analgesic medications negatively affects quality of care and pain management and is a threat to patient safety.

References

  1. Alam A, Juurlink DN. The prescription opioid epidemic: an overview for anesthesiologists. Can J Anaesth 2016;63:61-8.
  2. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA internal medicine 2016;176:1286-93.
  3. Rozet I, Nishio I, Robbertze R, Rotter D, Chansky H, Hernandez AV. Prolonged opioid use after knee arthroscopy in military veterans. Anesth Analg 2014;119:454-9.
  4. Mudumbai SC, Oliva EM, Lewis ET, Trafton J, Posner D, Mariano ER, Stafford RS, Wagner T, Clark JD. Time-to-Cessation of Postoperative Opioids: A Population-Level Analysis of the Veterans Affairs Health Care System. Pain Med 2016;17:1732-43.
  5. Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Cohen SR, Wu CL. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006;102:248-57.
  6. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg 2005;101:1634-42.
  7. McCartney CJ, Brull R, Chan VW, Katz J, Abbas S, Graham B, Nova H, Rawson R, Anastakis DJ, von Schroeder H. Early but no long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology 2004;101:461-7.
  8. Casati A, Borghi B, Fanelli G, Cerchierini E, Santorsola R, Sassoli V, Grispigni C, Torri G. A double-blinded, randomized comparison of either 0.5% levobupivacaine or 0.5% ropivacaine for sciatic nerve block. Anesth Analg 2002;94:987-90, table of contents.
  9. Hickey R, Hoffman J, Ramamurthy S. A comparison of ropivacaine 0.5% and bupivacaine 0.5% for brachial plexus block. Anesthesiology 1991;74:639-42.
  10. Klein SM, Greengrass RA, Steele SM, D’Ercole FJ, Speer KP, Gleason DH, DeLong ER, Warner DS. A comparison of 0.5% bupivacaine, 0.5% ropivacaine, and 0.75% ropivacaine for interscalene brachial plexus block. Anesth Analg 1998;87:1316-9.
  11. Fanelli G, Casati A, Beccaria P, Aldegheri G, Berti M, Tarantino F, Torri G. A double-blind comparison of ropivacaine, bupivacaine, and mepivacaine during sciatic and femoral nerve blockade. Anesth Analg 1998;87:597-600.
  12. Williams BA, Kentor ML, Vogt MT, Williams JP, Chelly JE, Valalik S, Harner CD, Fu FH. Femoral-sciatic nerve blocks for complex outpatient knee surgery are associated with less postoperative pain before same-day discharge: a review of 1,200 consecutive cases from the period 1996-1999. Anesthesiology 2003;98:1206-13.
  13. Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg 2011;113:904-25.
  14. Ilfeld BM. Continuous peripheral nerve blocks in the hospital and at home. Anesthesiol Clin 2011;29:193-211.
  15. Ilfeld BM, Enneking FK. Continuous peripheral nerve blocks at home: a review. Anesth Analg 2005;100:1822-33.
  16. Bingham AE, Fu R, Horn JL, Abrahams MS. Continuous peripheral nerve block compared with single-injection peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med 2012;37:583-94.
  17. Memtsoudis SG, Sun X, Chiu YL, Stundner O, Liu SS, Banerjee S, Mazumdar M, Sharrock NE. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013;118:1046-58.
  18. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;367:1618-25.
  19. Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth 2013;111:711-20.
  20. Macario A, Vitez TS, Dunn B, McDonald T. Where are the costs in perioperative care? Analysis of hospital costs and charges for inpatient surgical care. Anesthesiology 1995;83:1138-44.
  21. Ilfeld BM, Mariano ER, Williams BA, Woodard JN, Macario A. 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;32:46-54.
  22. Jakobsen DH, Sonne E, Andreasen J, Kehlet H. Convalescence after colonic surgery with fast-track vs conventional care. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2006;8:683-7.
  23. Macario A, Horne M, Goodman S, Vitez T, Dexter F, Heinen R, Brown B. The effect of a perioperative clinical pathway for knee replacement surgery on hospital costs. Anesth Analg 1998;86:978-84.
  24. Hebl JR, Kopp SL, Ali MH, Horlocker TT, Dilger JA, Lennon RL, Williams BA, Hanssen AD, Pagnano MW. A comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint Surg Am 2005;87 Suppl 2:63-70.
  25. Hernandez-Boussard T, Graham LA, Desai K, Wahl TS, Aucoin E, Richman JS, Morris MS, Itani KM, Telford GL, Hawn MT. The Fifth Vital Sign: Postoperative Pain Predicts 30-day Readmissions and Subsequent Emergency Department Visits. Ann Surg 2017;266:516-24.

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Why I Still Love Being an Anesthesiologist

When I first wrote “What I Love about Being an Anesthesiologist” for KevinMD in 2014, it was shared over 14,000 times!

Nearly 4 years later, I still love what I do – in fact, I think I love it even more now! My wife and I were at a party recently attended by healthcare and non-healthcare people. Of course, I was asked the inevitable questions, “What do you do?” and “What is it like?”

Here is how I answered:

Being a physician anesthesiologist is the honor of a lifetime, and it comes with a tremendous amount of responsibility. My patients rely on me to be their personal physician during surgery.  Under general anesthesia, they need me to be their voice because they can’t speak. They need me to act because they cannot protect themselves.

  • I have to understand my patients’ medical conditions.
  • I adapt my anesthetic plans to their needs.
  • I anticipate challenges that may take place during an operation.
  • I recognize problems early and prevent them when possible.
  • I react quickly and appropriately to make sure my patients make it through surgery safely with the best possible outcomes.

In the operating room, I cannot write an order and expect someone else to carry it out. I have to know how everything in my environment works, from top to bottom, so I can take the best care of my patients. I set up my own anesthetic equipment and supplies in preparation for surgery. I prepare all of the medications that I will personally administer to my patients.

I will admit that a big reason I chose this specialty was the people in it. Now my fellow physician anesthesiologists are my colleagues and mentors who continually challenge and inspire me.

I have the best job in the world:  helping patients through the stressful experience of surgery, relieving pain, and making new discoveries through research that will hopefully benefit future patients.

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Starting an Acute Pain Medicine Program: Strategies for Success

Initiating an acute pain medicine program can add significant value to a hospital and anesthesiology practice through improved postoperative pain control, faster recovery, decreased side effects, and higher patient satisfaction. In a special issue of Anesthesiology News, I published an article which presents a few suggested strategies. You can view and download this article here.

In an accompanying video interview, I was asked about the evolution of ultrasound in regional anesthesia practice as well as the growing role of ultrasound in perioperative medicine.

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Partnering with Patients for Patients

As an anesthesiologist, I am a physician who cares for patients when they are most vulnerable.  Under anesthesia, no one is able to call for help.  Every day patients have surgery in operating rooms all over the world, and it is the job of the physician anesthesiologist to watch over them, monitor their bodies’ responses to stress, breathe for them, provide them with pain relief, and fight for them when unexpected crises occur.  It is my job to calm the fears of my patients and families, listen to their requests, manage their expectations, and develop a plan that will provide them with the best outcome after surgery.

My belief in this connection between physicians, patients, and families as an anesthesiologist stretches into my administrative roles as well.  As Chief of the Anesthesiology and Perioperative Care Service and Associate Chief of Staff for Inpatient Surgical Services at the VA Palo Alto Health Care System (VAPAHCS), I am grateful for the opportunity to work with an incredible team of physicians, respiratory therapists, surgeons, advanced practice providers, technicians, and administrative staff members who are focused on our mission to provide the highest quality Veteran-centered care by leading, educating, and innovating in anesthesiology and perioperative medicine.

In order to accomplish this mission, we need the best information available to guide our decisions and a diversity of perspectives to enhance our ability to train new clinicians and explore relevant research questions.  We have been fortunate to partner with our friends and colleagues in the Veteran and Family Advisory Council (VFAC) on a number of exciting projects.  First, our Service manages the simulation center at VAPAHCS and is responsible for coordinating simulation-based training for all clinicians.  Members of VFAC have been directly involved in simulation activities, even taking on active roles as the patient or family member in standardized training scenarios, to help us educate clinicians from various disciplines and all training levels.  Debriefing after these simulation exercises gives our clinical trainees and practicing clinicians the unique perspective of real patients and family members which is essential to their professional development as modern medicine continues to progress towards a model of patient-centered care.

Once a year, our Service organizes a faculty development retreat during which we reassess our mission, vision, strategic priorities, and tactics and work on one or two big ideas.  Two years ago in 2015, we invited our VFAC partners to join us at our annual retreat to brainstorm improvement ideas related to patient-centered care in the perioperative environment, intensive care unit, and pain management.  The general theme of the retreat addressed public perception and professional reputation of anesthesiologists and the specialty of anesthesiology.  Having members of VFAC present at the retreat to share their knowledge, opinions, and questions has inspired a few subsequent improvement activities and other projects to enhance the range of services that we provide to our patients and their families.

Finally, working together with VFAC, and knowing members personally, has allowed our clinical Service to solicit feedback on a regular basis.  Not all hospitals enjoy the level of access to a community of engaged patients and families like we do at VAPAHCS.  When we revised our preoperative education materials for patients, we went to VFAC for input.  When we were critically reviewing our website to update our online patient educational materials on anesthesia and perioperative care, we presented at the VFAC meeting to get the members’ feedback and suggestions.  With their help, we have been able to improve the accessibility and readability of our online content and provide our patients and their families with useful information that can help prepare them for surgery.

We are very grateful to VFAC for its priceless contributions to our healthcare system, our patients, and our Service.  We look forward to continued collaboration on future projects!

This blog has also appeared as a featured story on the VA Palo Alto Health Care System website.

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A New Era for Regional Anesthesiology and Acute Pain Medicine

It has finally happened–the inaugural class of ACGME-accredited Regional Anesthesiology and Acute Pain Medicine (RAAPM) fellowships has been announced, marking the beginning of a new era.

Congratulations to the following 9 programs that now are the first accredited fellowship programs representing this subspecialty in the United States:

  1. Stanford University
  2. Cedars-Sinai Medical Center
  3. University of California, San Francisco
  4. Massachusetts General Hospital
  5. Brigham and Women’s Hospital
  6. Montefiore Medical Center/Albert Einstein College of Medicine
  7. Icahn School of Medicine at Mount Sinai/St. Luke’s-Roosevelt Hospital
  8. Duke University Hospital
  9. Vanderbilt University Medical Center

Accreditation is immediate and retroactive to the current 2016-17 academic year. This announcement represents a tremendous achievement in anesthesiology training and medical education in general.  Nearly 4 years ago, at our spring RAAPM fellowship directors meeting in 2013, I was appointed to lead the task force that would eventually make contact with the ACGME to request consideration for accreditation of our subspecialty fellowship programs. After submitting the 161-page letter to ACGME, we waited nearly a year to receive a response, and it was positive. The next 2 years were spent drafting the program requirements that would eventually be used as the basis for fellowship design and evaluation. This was an iterative process with multiple revisions based on solicited feedback and public commentary.

When the application period opened for the first time ever in October 2016, programs interested in applying had less than 2 months to prepare their program information forms and other materials, have them reviewed and approved by their local graduate medical education offices, and submit to ACGME in time for the 2017 spring review.

These 9 accredited programs have embarked on a brave new path, but it will not be an easy one. Their programs will be reviewed periodically to evaluate adherence to the program requirements and the quality of fellowship training, and deficiencies identified will need to be resolved or face loss of accreditation. However, their commitment to maintaining accreditation represents, in my opinion, a commitment to their fellows that they will provide a training experience that can be held as a benchmark for all programs.

We need our fellowship training programs to develop leaders in regional anesthesiology and acute pain medicine who can catalyze changes in healthcare that will improve patient outcomes and experience. Today, we have taken a huge step forward.

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The “Top 10” Regional Anesthesia Articles of 2016

I was recently asked to provide a list of my “Top 10” regional anesthesia research articles from 2016 and not to include my own. So for what it’s worth (not much!), I’m sharing them below in no particular order.

In my humble opinion, these articles from 2016 have already influenced my clinical practice, taught me to look at something differently, or made me think of a new research question.

Trends in the Use of Regional Anesthesia: Neuraxial and Peripheral Nerve Blocks. Reg Anesth Pain Med. 2016 Jan-Feb;41(1):43-9. doi: 10.1097/AAP.0000000000000342.

The Second American Society of Regional Anesthesia and Pain Medicine Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia: Executive Summary. Reg Anesth Pain Med. 2016 Mar-Apr;41(2):181-94. doi: 10.1097/AAP.0000000000000331.

Teaching ultrasound-guided regional anesthesia remotely: a feasibility study. Acta Anaesthesiol Scand. 2016 Aug;60(7):995-1002. doi: 10.1111/aas.12695.

Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev. 2016 Feb 21;2:CD009121. doi: 10.1002/14651858.CD009121.pub2.

Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia. 2016 Apr;71(4):380-8. doi: 10.1111/anae.13409.

Continuous Popliteal Sciatic Blocks: Does Varying Perineural Catheter Location Relative to the Sciatic Bifurcation Influence Block Effects? A Dual-Center, Randomized, Subject-Masked, Controlled Clinical Trial. Anesth Analg. 2016 May;122(5):1689-95. doi: 10.1213/ANE.0000000000001211.

A randomised controlled trial comparing meat-based with human cadaveric models for teaching ultrasound-guided regional anaesthesia. Anaesthesia. 2016 Aug;71(8):921-9. doi: 10.1111/anae.13446.

Adductor Canal Block Provides Noninferior Analgesia and Superior Quadriceps Strength Compared with Femoral Nerve Block in Anterior Cruciate Ligament Reconstruction. Anesthesiology. 2016 May;124(5):1053-64. doi: 10.1097/ALN.0000000000001045.

A radiologic and anatomic assessment of injectate spread following transmuscular quadratus lumborum block in cadavers. Anaesthesia. 2017 Jan;72(1):73-79. doi: 10.1111/anae.13647.

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc. 2016 Dec;64(12):2433-2439. doi: 10.1111/jgs.14386.

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Changing Clinical Practice Doesn’t Have to Take So Long

Guest post by Seshadri Mudumbai, MD, MS.  Dr. Mudumbai is an Assistant Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine. He is also a health services researcher and physician anesthesiologist at the Veterans Affairs Palo Alto Health Care System.

time-for-changeChanging physician behavior is rarely easy, and studies show that it can take an average of 17 years before research evidence becomes widely adopted in clinical practice. One study published in JAMA has identified 7 categories of change barriers:

  1. Lack of awareness (don’t know guidelines exist)
  2. Lack of familiarity (know guidelines exist but don’t know the details)
  3. Lack of agreement (don’t agree with recommendations)
  4. Lack of self-efficacy (don’t think they can do it)
  5. Lack of outcome expectancy (don’t think it will work)
  6. Inertia (don’t want to change)
  7. External barriers (want to change but blocked by system factors)

Why Change?

According to the Institute of Medicine’s Crossing the Quality Chasm: a New Health System for the 21st Century:  “Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.”  Our group has focused our efforts on implementing updated evidence-based medicine initiatives for surgical patients with a special emphasis on the total knee replacement population.  Knee replacement is already one of the most common types of surgery in the United States (over 700,000 procedures per year).  Given an aging population, the volume of knee replacement surgeries is expected to increase to over 3 million by the year 2030.

We now have sufficient evidence to support “neuraxial anesthesia” (such as a spinal or epidural) as the preferred intraoperative anesthetic technique for knee replacement patients.  With neuraxial anesthesia, an injection in the back temporarily numbs the legs and allows for painless surgery of the knee.  Several studies have now shown better outcomes and fewer complications after knee replacement surgery with neuraxial anesthesia when compared with general anesthesia.  Despite these known benefits, a large study evaluating data from approximately 200,000 knee replacement patients across the United States reveals that use of neuraxial anesthesia occurs in less than 30% of cases.  At our facility prior to changing our practice, we noted a 13% rate of neuraxial anesthesia utilization.  In the face of growing evidence, we chose to change our practice, and the results of these efforts are reported in our recently published article.

How Did We Start?

An important tool used to coordinate the perioperative care of knee replacement patients has long been the clinical pathway.  A clinical pathway is a detailed care plan for the period before, during, and after surgery that covers multiple disciplines:  surgery, anesthesiology and pain management, nursing, physical and occupational therapy, and sometimes more.   The concept of the clinical pathway should be dynamic and not static.  This requires a process to ensure clinical pathways are periodically updated and someone to take a leadership role in managing the process.

At our institution, we established a coordinated care model known as the Perioperative Surgical Home (PSH).  The PSH provides the overall structure and coordination for perioperative care, and multiple clinical pathways exist within this structure.  With a PSH, physician anesthesiologists are charged with providing leadership and oversight of specific clinical pathways, collecting and reviewing data, engaging frontline healthcare staff and managers across disciplines, and suggesting changes or updates to clinical pathways as new evidence emerges.

Within our PSH model, we invested in a 5 month process to change our preferred anesthetic technique from general anesthesia to neuraxial anesthesia within the clinical pathway for knee replacement patients.  This process involved many steps and followed the Consolidated Framework for Implementation Research:

  1. Literature review and interdepartmental presentation
  2. Development of a work document
  3. Training of staff
  4. Prospective collection of data with feedback to staff.

After one year, the overall percentage of knee replacement patients receiving neuraxial anesthesia increased to 63% from 13%, and a statistically-significant increase in neuraxial anesthesia use took place within one month of the updated clinical pathway rollout.

How Do We Keep It Going?

Neuraxial anesthesia continues to be the predominant anesthetic technique that our knee replacement patients receive today.  We attribute the ongoing success of this change to multidisciplinary collaboration, physician leadership in the form of a departmental champion, peer support and feedback, frequent open communication, and engagement and support from facility leadership.  The results of our study and experience show that a PSH may help facilitate changes in clinical practice quicker than other less-coordinated models of care.  As PSH models continue to be developed, further evidence to support the impact of clinical practice changes on patient-oriented outcomes related to quality and safety and healthcare economics is needed.

For patient education materials regarding anesthetic options for knee replacement surgery, please visit My Knee Guide.

 

 

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