Speaker: Sonia Szlyk, MD, Director of Regional Anesthesia, Mid-Atlantic Division, North American Partners in Anesthesia This webinar will: -Discuss Enhanced Recovery After Surgery (ERAS) protocols for joint replacement -Review the positive impact of regional anesthesia throughout the episode of care -Spotlight the key components of successful value-based orthopedic care – length of stay, discharge to home, patient and surgeon satisfaction About the Speaker: Sonia Szlyk, MD, is the Director of Regional Anesthesia for North American Partners in Anesthesia’s Mid-Atlantic division. Dr. Szlyk orchestrates an outcomes-based regional anesthesia service focused on patient and surgeon satisfaction, safety, and efficiency. She oversees regional anesthesia quality metrics, billing compliance, strategic growth, and education. Dr. Szlyk specializes in opioid-sparing ERAS protocols for joint replacement, sports medicine, colorectal, general, and cosmetic surgery. Her initiatives highlight the value of regional anesthesia in the evolving era of bundled payments. Dr. Szlyk served as the Director of Regional Anesthesia at the Ambulatory Surgery Center of Bethesda, MD where she oversaw the design and implementation of anesthesia services as well as AAAHC accreditation. The center’s comprehensive pain management program included ultrasound-guided peripheral nerve blocks and catheters for outpatient knee and hip replacements, and sports medicine procedures. Dr. Szlyk is a board-certified anesthesiologist. She completed medical school and anesthesia residency at the George Washington University School of Medicine and was a Clinical Instructor in regional anesthesia at Stanford University Hospital.

1. 5/9/2017 Confidential ©2014 Wellbe, Inc. – All Rights Reserved.
www.periopmed.org – Enter OSLCODE for Early Bird $100 off through tomorrow!

2. 2
Patient Engagement for ERAS Protocols
www.wellbe.me
• Assessment Forms
• Optimization Education
• Patient Preparation
• Post-Op Follow Up
• Outcomes Measurement

3. Regional Anesthesia and Bundled Payments -
Opioid-sparing Pain Management
for Optimal Outcomes
Sonia Szlyk, MD
Director of Regional Anesthesia
North American Partners in Anesthesia,
Mid-Atlantic Division
INOVA Fair Oaks Hospital, VA

4. Disclosure
• National Speakers’ Bureau
- Halyard Health

5. Large academic hospital
Private practice hospital
Freestanding Orthopedic ASC
My Perspective

6. 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…

7. Edvard Munch
What About the PAIN?!!!
I Know I Need Surgery, but…

8. The
Perfect
Storm
Narcotics
Nausea
Immobility
Surgical Pain
Respiratory Depression
What Keeps Patients in the
Hospital/ASC/Acute Rehab?

9. Pain
Narcotics
Nausea
Respiratory
Depression
Immobility
Regional Anesthesia Nerve Blocks

10. The Era of Bundled Payments
Patient
Satisfaction
Prevent
Readmissions
Better
Outcomes
Coordinate
Care
Lower
Cost

11. Average Target Cost:
469 ~ $50,000
470 ~ $25,000

12. Regional Anesthesia!
Pain control
Opioid-sparing
Reduced cognitive impact
Early ambulation
Decreased LOS

13. -Excellent pain control
-Minimize narcotics & nausea
-Decrease LOS
-High patient/surgeon satisfaction
-Complex cases as outpatient
-Complex patients as outpatient

14. 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 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.

15. Expectations are Everything
BUSY
1. Don’t delay my case
2. Don’t hurt my patient
3. It had better work
4. Don’t slow down rehab
And...
Don’t delay my case!

16. 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

17. 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).

18. Femoral Block
Saphenous Block
Adductor Canal or
“Mid-thigh Femoral”
Block
Location is Everything!

19. 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

21. 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/hr
550 mL reservoir

22. 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 difference
morphine consumption
pain at rest, flexion
adductor muscle strength
n/v, antiemetics
mobilization ability

23. Physical Therapists, Patients &
Surgeons Rejoice!
Same-day
Physical Therapy!

24. • 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

25. 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).

26. Adductor
canal catheter
LMA or Spinal (no
narcotics in spinal)
TXA
20 mL 0.5% Ropivacaine
Adductor canal catheter
Celecoxib, Oxycontin, Percocet or Vicodin
DOS Physical Therapy
0.2% Ropivacaine @ 8mL/hr
TKR ERAS PATHWAY
Premed Celecoxib, Acetaminophen, Decadron
Preop Block Adductor canal catheter
20mL 0.5% Ropivacaine
OR
Spinal (Mepivacaine, no narcotics) or LMA
TXA
Postop &
Home
Adductor canal catheter
0.2% Ropivacaine @ 8mL/hr
Celecoxib, Oxycodone/Acetaminophen,
Ondansetron
DOS Physical Therapy

27. 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.

28. 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.

29. 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.

30. Fascia Iliaca Block
• Lateral femoral cutaneous
• Femoral
• Obturator
• “Anterior approach lumbar plexus”
• Less dense versus lumbar plexus

31. Fascia Iliaca Block
• Compartment block = High volume
• 50 - 60 cc local anesthetic
Fujihara. FICB. J Orthop Sci. 2013.

32. Fascia Iliaca Block
• Compartment block = High volume
• 50 - 60 cc local anesthetic
Sartorius
Internal Oblique
Iliacus
SUPERIOR INFERIOR
50 cc Compartment Block
• 20 cc 0.2% Ropivacaine
• 30 cc 0.5% Ropivacaine

33. Incidence of Delirium 10.78%23.8%
Mean Duration of Delirium 5.22 days
FIBPlacebo
10.97 days
Hip Fracture

34. Fascia Iliaca Block
No Block FIB cath
POD 0 Pain
POD 1 Pain
Ave LOS
4.1 1.7
2.9
5.9 days
1.4
4.8 days

35. Neuraxial Anesthesia
Lower 30-day mortality
Decreased length of stay
Decreased 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

36. Neuraxial Anesthesia
Decreased 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

37. How Does
Pain Management
Affect the Bottom Line?
SM

38. Reduced PACU Time
Impact of Regional Anesthesia
30 minutes in
Phase 1 PACU
$400

39. 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.

40. 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

41. Lower After-Hospital Costs
Impact of Regional Anesthesia
Home Health
$100/day
Skilled Nursing
Facility
$700/day
Increased Discharge to HOME

42. Decreased Readmissions
Impact of Regional Anesthesia
Hospital
Readmission
THR $12,300
TKR $10,200
ER
$1400 - $2000

43. 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)

44. 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

45. 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

46. • 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

47. It Takes a Village…
Surgeon
Hospital/ASC
Administration
Anesthesia
team Patient
Physical
Therapist
Pharmacy
Family
member
OR &
PACU RN
Floor RN
Registration
Block RN
EPIC/EMR
Billing
Preop RN
Successful Regional Anesthesia Program

48. Anesthesia Team
Patient
Surgeon
Nurses
Joint Replacement
Advisory Board
CEO, CFO, CMO, CNO
Physical Therapist
Hospitalist

49. 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

50. In the Media… AAOS

51. 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

52. MAKES IT EASY to...
Do the Right Thing
for the Patient!
Regional Anesthesia

53. 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