In 2009, Sunderland Royal Hospital established a separate regional anaesthesia room within its theatre suite to perform nerve blocks for orthopaedic surgical lists. Dr Nat Haslam, a consultant anaesthetist with special interest in regional anaesthetics, was instrumental in creating the new resource, and here he explains how the service has improved both the efficiency and throughput of surgery lists, as well as the overall patient experience.
The idea of a dedicated regional nerve block room for trauma and orthopaedic patients in Sunderland originally came about to allow parallel processing of patients.
By performing blocks for upper and lower limb surgical lists between cases in a different room, anaesthesia and surgery for consecutive procedures would theoretically overlap – the next patient could effectively be started while the previous one was finished – offering considerable savings in time and money.
From the patients’ perspective, the whole experience has become far more relaxed and less rushed
Although a clear cost case had to be made, as with all substantial changes to a service such as this, the cost-effectiveness of regional blocks over general anaesthesia has already been well documented 1,2,3, and the use of ultrasound to guide these procedures has been established as an important factor in improving the speed and reliability of blocks.
The block room in Sunderland is conveniently located within the theatre suite – alongside a ‘cooking area’ where patients wait for their theatre slot – and anaesthetists rely on two SonoSite M-Turbo hand-carried ultrasound systems to help them deliver fast, effective blocks.
The image quality and resolution offered by these systems is particularly important for injecting around nerves that could otherwise be difficult to visualise, and enables anaesthetists to confidently say how soon a block will take effect.
Though originally established for orthopaedic cases, the success of this service means it is now sometimes used by other specialities, including general and vascular surgery
This approach offers numerous advantages for surgeons, anaesthetists and, most importantly, for the patients. From a surgeon’s point of view, appropriately anaesthetised patients are consistently delivered into theatre without any delays. The block room also provides an excellent, relaxed environment for trainee anaesthetists to hone their skills in ultrasound-guided regional anaesthesia without a surgical team hurrying them along. The ease of use of SonoSite systems also plays a role in this; they are very user friendly and exceptionally robust, which is ideal for the hospital theatre environment.
From the patients’ perspective, the whole experience has become far more relaxed and less rushed. Anaesthetists have more time to talk patients through the procedure and patient satisfaction feedback has been overwhelmingly excellent, in part due to the better pain control this approach offers.
Though originally established for orthopaedic cases, the success of this service means it is now sometimes used by other specialities, including general and vascular surgery.
The portability of the SonoSite systems also means that the regional block team can attend patients throughout the hospital, visiting theatres and departments on different floors as required.
Since the introduction of the dedicated regional anaesthesia room, a higher proportion of the surgical lists can now be carried out as day cases, and the quality of analgesia is better, leading to faster recovery and fewer side effects
Since the introduction of the dedicated regional anaesthesia room, a higher proportion of the surgical lists can now be carried out as day cases, and the quality of analgesia is better, leading to faster recovery and fewer side effects, such as nausea and vomiting. This success has very much depended on the use of point-of-care ultrasound systems to guide the blocks, contributing to fewer overnight stays for patients and even significantly reducing the length of hospital stay for many complex cases, such as lower limb arthroplasty.
The overall efficiency in theatre has improved considerably, allowing an extra case per theatre per half day compared with the year before the block room was established.
Prior to its introduction, an average of 2.1 cases were performed per list during a half-day session in surgery. In the year following, this increased to 3.1 cases per session and, after optimising the order of cases on the list to further improve efficiency, this rose to 3.6 cases per session in the subsequent year. The increase in the number of cases performed has been attributed entirely to the more efficient use of theatre time, driven by the use of a dedicated regional anaesthesia room, and not by an increase in the length of the theatre day.
The overall efficiency in theatre has improved considerably, allowing an extra case per theatre per half day compared with the year before the block room was established
Other studies have also reached similar conclusions4. In fact, even with more cases per list, there is still a trend towards the theatre day finishing earlier and, in order to capitalise on its effectiveness, the block room is now in operation five days a week instead of the original two.
These improvements in theatre efficiency, combined with the undeniable advantages to patient care seen in Sunderland, offer a powerful case for the more widespread creation of dedicated regional anaesthesia services.
1 Chan VW et al. A comparative study of general anaesthesia, intravenous regional anaesthesia, and axilliary block for outpatient hand surgery: clinical outcome and cost analysis. Anaes Analg 2001; 93: 1181-1184
2 Gonano C, Kettner SC, Ernstbrunner M, Schebesta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. Br J Anaesth. 2009 Sep;103(3):428-33
3 Song D, Greilich NB, White PF, et al. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000;91:876–81
4 Dexter F and Epstein R. Operating room efficiency and scheduling. Current Opinion in Anaesthesiology 2005; 18 (2):195-198