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Patient Engagement for ERAS Protocols

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• Assessment Forms• Optimization Education• Patient Preparation• Post-Op Follow Up• Outcomes Measurement

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

Large academic hospital

Private practice hospital

Freestanding Orthopedic ASC

My Perspective

PATIENT & SURGEON SATISFACTION

BUNDLED PAYMENTS & OUTCOMES

REDUCING OPIOID USE

INCREASED DISCHARGE TO HOME

ERAS & FAST-TRACKING JOINTS

There’s a BLOCK for THAT!

IF YOU CARE ABOUT…

Edvard Munch

What About the PAIN?!!!

I Know I Need Surgery, but…

ThePerfectStorm

Narcotics

NauseaImmobility

Surgical Pain

Respiratory Depression

What Keeps Patients in the Hospital/ASC/Acute Rehab?

Pain

Narcotics

Nausea

Respiratory Depression

Immobility

Regional Anesthesia Nerve Blocks

The Era of Bundled Payments

PatientSatisfaction

PreventReadmissions

BetterOutcomes

CoordinateCare

LowerCost

Average Target Cost:

469 ~ $50,000470 ~ $25,000

Regional Anesthesia!

Pain controlOpioid-sparing

Reduced cognitive impactEarly ambulationDecreased LOS

-Excellent pain control

-Minimize narcotics & nausea

-Decrease LOS

-High patient/surgeon satisfaction

-Complex cases as outpatient

-Complex patients as outpatient

Benefits of Ultrasound-guided Nerve Blocks

• 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 PainMed 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.

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!

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

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).

Adductor canal catheter

LMA or Spinal (no narcotics in spinal)TXA

20 mL 0.5% Ropivacaine

Adductor canal catheter

Celecoxib, Oxycontin, Percocet or VicodinDOS 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

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.

Fascia Iliaca Catheter

ERAS for…

• Hip fracture

• THR

• Hip arthroscopy

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.

Fascia Iliaca Block

• Lateral femoral cutaneous

• Femoral

• Obturator

• “Anterior approach lumbar plexus”

• Less dense versus lumbar plexus

Fascia Iliaca Block

• Compartment block = High volume

• 50 - 60 cc local anestheticFujihara. FICB. J Orthop Sci. 2013.

Fascia Iliaca Block

• Compartment block = High volume

• 50 - 60 cc local anestheticSartorius

Internal Oblique

Iliacus

SUPERIOR INFERIOR

50 cc Compartment Block• 20 cc 0.2% Ropivacaine• 30 cc 0.5% Ropivacaine

Incidence of Delirium 10.78%23.8%

Mean Duration of Delirium 5.22 days

FIBPlacebo

10.97 days

Hip Fracture

Fascia Iliaca Block

No Block FIB cathPOD 0 Pain

POD 1 Pain

Ave LOS

4.1 1.7

2.9

5.9 days

1.4

4.8 days

Neuraxial AnesthesiaLower 30-day mortality

Decreased length of stayDecreased 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

How Does Pain Management

Affect the Bottom Line?

SM

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 ReplacementAdvisory 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

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

MAKES IT EASY to...

Do the Right Thing

for the Patient!

Regional Anesthesia

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