St. Joseph’s Health Care, London sees an opportunity to expand its ambulatory regional anesthesia/analgesia discharge program, which began in November 2002, due to positive results in a survey of patients.
The program is for patients who have had upper extremity orthopedic surgeries such as shoulder replacements, elbow contracture releases and rotator cuff repairs. A patient leaves the hospital with a small indwelling catheter that provides the patients with a “regional block”. A portable electronic pump infuses local anesthetic around the nerve(s) that pick up sensation from the patient’s surgical site.
The goal of the program is to have a patient return home with the block, and continue almost normal daily activity. The participants have the pump for approximately four days while they proceed through the initial stages of post surgical/rehabilitation. The program is comprehensive, with in-home visits by the Victorian Order of Nurses (VON) to follow up with patient care.
The program was first initiated for patients who have had upper extremity orthopedic surgeries, however there is potential for the program to grow. Kim Horrill, nurse practitioner for pain management at SJHC London, says, “In future we would like to see the program expand to upper and lower limb surgeries and even abdominal and thoracic surgeries. So far the results from the program have been positive – patients are not only satisfied with pain management but with the over-all care.” A follow-up questionnaire of the first group of patients has shown just that.
Sixteen patients in the program were asked to evaluate their experience. To the credit of the program, 15 of the 16 replied yes when asked if they would use another regional block at home. The same number said they would recommend the regional block to a friend or family member.
SJHC London anesthesiologist Dr. Kevin Armstrong says, “The results show patients are pleased with more than the regional block; the program can also help to alleviate anxiety a person may feel about going home while still needing care. The program provides all-around support, with access to nurses and physicians for trouble shooting. Though they are going home, patients feel looked after.”
St. Joseph’s has been working with “regional blocks” for 10 years, but the practice of patients taking this analgesia home began only two years ago. Because the program is relatively new, Dr. Armstrong says, it’s important to evaluate its effectiveness and safety. “Problems can be part of any program – if a pump is not functioning the patients will still have care when they need it. There is support through oral medication and access to a VON. If a block is not effective there is always recourse.” The 16 patients were also questioned about side effects; 100 per cent of the respondents reported none.
Sixty percent felt they did not need prescribed anti-inflammatory medication because they had very little pain; however nine of the 16 did take other pain medications such as Tylenol 3. Horrill says, “A goal of the program is to help minimize the use of opiods and non-steroidal drugs.”
Each pump costs about $4,000 and will last approximately 10 years. Margo Bettger-Hahn, SJHC London clinical nurse specialist for upper limb orthopedics and plastic surgery, says, “It’s very satisfying to be meeting patient needs for pain management safely at home. The program is patient focused, so the patient is educated and understands what the block is doing.”
The respondents were asked to rank the regional analgesia block as an overall method of managing pain. Twelve of the 16 said the block was excellent, and the remaining four said it was good. Bettger-Hahn says, “With such positive patient response to the program, and support from our physician colleagues and the interdisciplinary team members, we see the opportunity to expand.” In future, the program is hoping to have patients go home with the pump the same day as their surgery; right now the patient must stay in hospital over night.
Dr. Armstrong acknowledges the program has only reached a small number of candidates; residence of the patients, the type of injury and resources are limiting its availability. He says, however, everyone involved is staying positive. “I hoped the program would be bigger by now. Having a process as extensive as this will take time, but we are moving in the right direction.”