Pulse
Abbott’s Pain Patrol
Anesthesiologists at one Twin Cities hospital now routinely use regional anesthesia to control pain during and after surgery.
By Carmen Peota
Although it’s a good hour before surgery, the doctors and nurses attending to the gray-haired man scheduled for a shoulder procedure on a Thursday morning in February are already focused on controlling the pain he’ll face after the operation. After a nurse anesthetist does a consent check, orthopedic surgeon Frank Norberg, M.D., enters the room in the basement of Abbott Northwestern Hospital in Minneapolis and explains what the arthroscopic synovectomy he’s about to perform will entail and what the patient can expect after the surgery in terms of pain control. He tells the man he’ll be sent home with a week’s worth of Percocet, which he may not need. The patient already knows that he’ll also go home with a pain pump the size of a grapefruit.
When Norberg finishes, anesthesiologist John Mrachek, M.D., takes his place beside the patient and injects anesthetic into his neck and places the catheter that will deliver medication after the surgery. By the time he is finished, the patient has difficulty raising his arm and remarks that his hand has gone to sleep.
This is the second case of the day for Mrachek, director of Abbott’s acute pain service, a unique approach to anesthesiology practice in the Twin Cities. The service is the realization of an idea that had been brewing for years at Abbott.
Growing Interest
In 2000, when anesthesiologist Gerald Holguin, M.D., joined Northwest Anesthesia, which staffs two suburban surgery centers and Abbott’s ORs, the group’s doctors were primarily using general anesthesia. Holguin, having just completed a fellowship in chronic pain management, was aware of the benefits of regional anesthesia and had done nerve blocks. He had read studies that showed that patients who underwent nerve blocks for certain surgeries tended to have less acute pain, were less likely to develop chronic pain, and had shorter hospital stays than those who received general anesthesia followed by narcotics. And if they avoided narcotics, patients also avoided their side effects—nausea, constipation, dizziness, itching, and respiratory depression.
Holguin began doing nerve blocks at Abbott and inspired a few others in the group to do them as well. “We kind of
A Model to Replicate
Anesthesiologist John Mrachek, M.D., says any hospital in the Twin Cities could create a program similar to the acute pain service at Abbott Northwestern. But he cautions that it requires a commitment from the anesthesiologists. “Taking on the responsibility of these patients while the nerve catheters are in place means being available 24/7,” he says. “It sounds burdensome. If I were talking to colleagues across town, this is the part where they’d be like, ‘I don’t know if we want to do this.’” But Mrachek says that on average, he and his colleagues receive less than one page per night (for both inpatients and outpatients). He says that’s because of the extensive patient education the nurses on the team do before patients are sent home or to the wards.
His colleague Gerald Holguin, M.D., agrees. “The one thing I can’t overemphasize is that this kind of a service can’t happen without the help of dedicated acute pain service nurses,” he says. The three nurses who support the anesthesiologists at Abbott educate new nurses on the floors about how to manage patients with peripheral nerve catheters and pain pumps, assist with pain rounds, and troubleshoot peripheral catheters that may not be providing adequate pain relief. “They allow us to efficiently manage the service in a safe and comprehensive manner,” he says. “They act as our advocates and educators.”—C.P.
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pushed each other along,” he says. But the anesthesiologists struggled with the logistics of both doing nerve blocks, which required them to attend to patients ahead of their surgery, and directing the care of patients during surgery. Holguin realized they needed a better system.
Mrachek, who joined the group in 2006, was also interested in doing nerve blocks. By this time, anesthesiologists elsewhere were doing ultrasound-guided blocks with good results. In addition, he was interested in doing more patient care. “We put them to sleep, we woke them up, we gave them to a nurse to take care of them afterward, and that was it,” he says of the way anesthesiologists had long worked. As he saw it, anesthesiologists were uniquely equipped to help patients with pain, not just during surgery but after. The others in the group encouraged him to take what Holguin had started to the next level.
A Matter of Logistics
Mrachek, fresh out of residency, agreed to take on the project, which turned out to be a tremendous amount of work. The first issue was finding space. The anesthesiologists would need procedure rooms where they could have their equipment and do the blocks. Abbott offered a former cardiac intensive care unit next to its operating suites. In addition, the hospital agreed to purchase ultrasound equipment for the group and hire nurses to support the physicians.
The next step was to bring all the members of the group up to speed on regional anesthesia techniques. At first, only Mrachek, Holguin, and a few other anesthesiologists were confident in their abilities to do ultrasound-guided nerve blocks. “If we were going to deliver this service, we needed to deliver it around the clock every day of the week. To get to that point, we had to have a critical mass of docs doing this,” Mrachek says. He, Holguin, and others worked elbow-to-elbow with colleagues who were less skilled, showing them what they had learned. Mrachek also developed a four-hour session that included having his colleagues use ultrasound on live models to practice finding certain nerves.
The anesthesiologists soon realized they needed to inform the surgeons, hospitalists, and nurses who cared for patients after surgery that patients weren’t going to need as many narcotics as they had in the past. “If you’re used to always giving a lot of narcotics to patients who’ve had their knee replaced, and now we’ve done a nerve block and they don’t require hardly any narcotics, that’s a major change from what they’re used to,” Mrachek says. Furthermore, the other staff needed to know that many patients would be sent home immediately after their surgeries.
Mrachek and his team also had to make changes in their processes, one of which was related to scheduling. Because patients would need their regional anesthetic to take effect just before their surgeons were ready to begin operating, the anesthesiologists needed to sync the timing of the nerve blocks to the timing of the surgeries. Even now, Holguin says, “it can be very stressful in terms of time management.” To make it work, the nurses, doctors, and other staff intently watch monitors that track the progress of cases in each of Abbott’s 45 ORs. When they see that a surgeon is within 30 to 40 minutes of starting a new case, they’ll start the nerve block for that patient.
Safety Advocate
A Minnesotan is heading the American Society of Anesthesiologists (ASA) this year. Mark A. Warner, M.D., dean of the Mayo School of Graduate Medical Education and a professor of anesthesiology at the Mayo Clinic College of Medicine, was installed as president of the ASA during the organization’s annual meeting last October.
Warner’s focus during his term is advancing the cause of patient safety (see p. 27). He currently directs both the Anesthesia Patient Safety Foundation and the Foundation for Anesthesia Education and Research.
Warner has also served as the president of the Minnesota Society of Anesthesiology, president of the American Board of Anesthesiology, and editor of the journal Anesthesiology.
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In addition, the acute pain service team has had to figure out how to inform patients about this new style of anesthesia. “A lot of patients who are coming to Abbott to have their shoulder work done might be caught off guard by an anesthesiologist who tells them he wants to stick a needle in their neck and make their shoulder numb,” Mrachek says. “If you weren’t anticipating that, you’d say, ‘Why are you going to do that, and tell me more about it.’”
And there were a host of other smaller changes that had to be made such as revamping order sets, updating forms, and figuring out how to man a phone line 24/7.
A Win-Win-Win
Mrachek was confident the new system would work. But other anesthesiologists needed to be convinced. He says it wasn’t until many of his colleagues began to do “pain rounds” (they now visit all patients in the recovery room or on the wards, not just those who had a problem in the OR) and saw how well their patients were doing that they fully bought into the new approach. He describes patient satisfaction as “through the roof.”
Holguin says the benefits to patients are “huge.” “You minimize all the side effects of general anesthesia,” he says. He explains that patients who have regional anesthesia are less likely to develop blood clots or emboli relative to those who have general anesthesia. He says it is especially appropriate for patients with heart and lung diseases. “When you intubate someone who smokes, has COPD, or has asthma, there is greater potential for bronchospasms during or after surgery,” he explains.
Holguin adds that pain control is much better under regional anesthesia, and that patients who receive it need fewer narcotics afterward. Thus they avoid the dangerous side effects of those drugs such as respiratory depression, which can be particularly troublesome for people with respiratory problems. Mrachek points out that payers and the hospital have been supportive of the new acute pain service because it reduces the length of hospital stays. He says patients require less physical therapy because they’re able to do more sooner because they have less pain. And they are less likely to develop chronic pain. Mrachek explains that in sedated patients or those under general anesthesia, the cellular signaling that can damage nerves and cause chronic pain is still occurring. Doing the blocks stops those mechanisms. “If you give a 30-year-old a nerve block, you can save millions over a lifetime,” he says.
“We’re doing what everyone in the world wants us to do right now—physicians, policymakers, payers. We’re delivering high-quality care that is safer and is costing less. It’s a win-win-win situation,” Mrachek says. And he thinks it simply makes sense: “Instead of putting a drug through your whole body, if your knee hurts, why not put the medicine in your knee instead?” ■