Case Study: New Pain Management Protocols Improve Efficiency

To shorten their hospital stay after having knee replacement surgery, patients need to get up and get moving. And anesthesia plays a major role in how soon both those things can happen.

NorthStar Anesthesia, which manages anesthesia services at more than 150 facilities in 20 states, is working with the Franciscan Alliance, to do just that. The Franciscan Alliance is a Roman Catholic healthcare system with 13 hospitals in Indiana and Illinois.

NorthStar provides anesthesia services at five  of Franciscan’s hospitals in Illinois and Indiana: Franciscan St. James Health-Chicago Heights; Franciscan St. James Health-Olympia Fields; Franciscan St. Margaret Health-Dyer;  Franciscan St. Margaret Health-Hammond; and Franciscan Healthcare-Munster.

Franciscan’s goal is creating centers of excellence for knee, hip and spine procedures at the three Indiana hospitals,  modeling them after a similar center of excellence at a sister hospital in Indiana, Franciscan St. Francis Health-Mooresville. But before implementing centers of excellence at the Dyer, Hammond and Munster locations, Franciscan executives wanted to reduce the average inpatient length of stay for orthopedic procedures, beginning with knee replacement surgeries.

Challenges

Franciscan faced an uphill battle. At Franciscan St. Margaret Health-Dyer, for example, the average inpatient length of stay for total knee-replacement surgery was about four days in 2015. That’s double the two-day average stay at Franciscan’s Mooresville hospital and above the national average of 3.5 days.

To start shaving days off of those hospital stays, NorthStar in 2015 partnered with Jonathan R. Javors, D.O., who performs about 200 knee surgeries annually at the Dyer hospital, to implement a new approach to manage patients’ pain.

Before the partnership began, general anesthesia was the norm for patients undergoing knee replacement surgery at St. Margaret-Dyer.  Javors and other orthopedic surgeons at the time favored general anesthesia over a multimodal strategy involving a regional anesthetic known as a femoral block. Their preference was based on peer-reviewed medical research that had shown an increased risk of quadriceps tendon rupture in patients who received the femoral block versus general anesthesia.

But reliance on general anesthesia without a regional pain block is not without issues because patients usually needed more narcotics both during surgery and post-operatively to control pain. The combination of pain and reliance on narcotics—which can cause nausea, vomiting and excessive drowsiness—can make it difficult for patients to sit, stand or walk safely, delaying their discharge from the hospital.

Solution

The new anesthesia protocols, which went into effect last year, are designed to address these issues. The centerpiece of the new approach is a regional nerve block known as an abductor canal block. An anesthesiologist and a CRNA work together to complete the brief procedure, using an ultrasound machine to guide the injection of anesthetic agents in the mid-thigh around a sensory nerve that controls pain.

This can be done without impacting nerves that control motor function, explains Eb Tayui, M.D., regional medical director of NorthStar Anesthesia of Indiana. “You can provide pain relief without impairing movement,” he says.

“Our sister hospital in Mooresville has been doing them since 2010. They haven’t had a single case of quadriceps tendon rupture,” Tayui continues. Depending on the anesthetic agent used, the procedure can block pain for up to 18 hours. “Some patients still don’t have much pain the day after surgery,” Tayui adds.

Although only two NorthStar employees had extensive experience with abductor canal blocks before they were adopted at the Dyer hospital in November 2015, Tayui says he expects that all staff members, who rotate among the three hospitals, will be trained on the procedure by the end of 2016.

NorthStar staffs the three hospitals with a total of eight full-time positions for anesthesiologists and 28 full-time-equivalent positions for certified registered nurse anesthetists.

Most NorthStar team members continue to use light general anesthesia in combination with the abductor canal block, but they use fewer narcotics both during surgery and in the post-anesthesia care unit, or PACU.

NorthStar and Javors combined the use of abductor canal blocks with a comprehensive set of protocols to manage patients’ pain during the surgery, hospital stay and after discharge.

The process begins when Javors’ staff explains the surgery process, including the abductor canal block during a pre-surgery office visit. The anesthesia team also discusses the procedure with patients during a clinic visit for pre-admission testing.

Javors also prescribes Celebrex and Neurontin, which patients take four hours prior to surgery, to help manage pain. During surgery, the anesthesia team administers Tylenol to control pain, Pepcid and Zofran for nausea and Tranexamic Acid to control bleeding and swelling, among other medications. While recovering in the PACU and on an inpatient hospital unit, staff members give patients a variety of medications to control pain, including a second dose of IV Tylenol.

On the same day as their surgery, patients practice sitting in a chair and also work with physical therapists on bending and standing.

Results

After the first 14 total-knee replacements done using the new pain-management protocols, the length of stay for Javors’ patients was cut in half—from four days to two days.

“There was less pain, less nausea and vomiting and quicker ambulation,” Tayui says.

Of those 14 patients, only a handful needed narcotics after surgery and four of them refused pain medication of any kind during the first 24 hours after surgery.

“We had an 80-year-old patient who left the hospital the next day,” Tayui says.

By reducing the length of stay for knee surgery patients at the Dyer site through the new pain management protocols, NorthStar is helping Franciscan improve both its clinical and financial performance. Shorter hospital stays mean less safety risk to the patients and less operating cost to the hospital, both of which are critical goals as the industry transitions to value-based reimbursement from fee-for-service medicine.