Picture two starkly different scenarios… In Hospital A, the regional anesthesia team mandates and directs the perioperative analgesic plan. When the acute pain attending for the day and the resident identify a patient on the OR schedule who may benefit from a regional anesthetic block, it is up to them to obtain consent and to coordinate patient care. Preoperative blocks are performed either in the admission room, or preoperative holding area, or sometimes in the OR. Postoperative blocks are done as soon as the patient arrives in the postanesthesia care unit. Determination of block type, single shot versus catheter, and duration of treatment are left to the acute pain team, with little feedback from the surgeons.
In Hospital B, the regional anesthesia team functions as an ancillary service, often at the request of the surgeons, their residents, and nurse practitioners or physician assistants. Blocks may also be identified by the regional anesthesia team, but they must contact the surgical team to assess if they can proceed with a nerve block. Surgeons may also reach out to the anesthesia team directly, or request a block on the surgical schedule. Although intraoperative and postoperative analgesia is directed by the anesthesia team, perioperative planning for analgesia, including PCAs and identification of patients for blocks, is generally under a surgeon’s purview.
The culture of an acute pain service
How do two hospitals operate so differently in their perioperative management of regional anesthesia and associated direction of care? The answer lies in the culture of perioperative medicine. Culture in any workplace is hard to change, and inertia often dictates “how things are done.” In Hospital A, the anesthesia team operates in a manner in which the surgeons, nurses, and anesthesiologists are often on the same page regarding which patients will automatically get a nerve block, the type to be administered, and the duration of treatment. For example, every total knee arthroplasty in an institution will get a preoperative adductor canal block, with a catheter, to be infused for the duration of their hospital stay. In Hospital B, the regional team often waits to be called for blocks, or spends their day reaching out to surgeons seeking permission to perform regional anesthesia for their patients. Perhaps the surgeons notify anesthesiologists of the need for a block via an order in an electronic health record (EHR). Ownership of the patients’ perioperative pain management is ultimately different in these institutions.
These two examples represent opposite ends of the spectrum – one in which anesthesia teams dominate and dictate perioperative analgesia, and one in which they are passive participants awaiting a decision made by the primary surgeons. In many, if not most, instances, the true culture often rests somewhere in the middle. But it is this culture that often dictates how decisions are made regarding regional anesthesia utilization and techniques. A formal or informal understanding between surgical and anesthesiology departments can establish protocols in which all patients undergoing joint surgery, for example, undergo the same standard block for a set procedure. Conversely, communication between departments can create a dynamic in which the anesthesia team must consult with each individual surgeon to assess their preference or desire for a regional anesthetic technique for perioperative analgesia for their patients.
Creating a strong culture
There is no “one size fits all” approach to creating a culture regarding the implementation of a regional anesthesia service, unless it impacts patient care in a negative manner. If, for example, patients do not receive blocks who would greatly benefit from avoidance of opiates due to surgeon preference, a system in which choice of perioperative analgesia is deferred to surgery may not improve patient safety and satisfaction. On the other hand, a system in which the anesthesia team makes all perioperative analgesic choices without surgeon input may result in a regional technique that may be detrimental, such as in patients prone to compartment syndrome or peripheral neuropathy.
If we define workplace culture as the characteristics of a physical and social environment that affect behaviors and attitudes regarding employee well-being, we may begin to understand how to implement effective change (J Occup Environ Med 2015;57:571-7; J Occup Environ Med 2019;61:863-7). How do we go about creating a positive and beneficial culture regarding a robust regional anesthesia service for an inpatient facility? We should first start with a discussion of changing overall workplace culture. Workplace culture is a construct influenced by leadership, policies, programs, morale, and supervisor/peer support (Int J Environ Res Public Health 2022;19:12318). It may be built on a foundational structure upon which processes are implemented and outcomes ultimately measured (Figure 1).
There are numerous different paradigms or algorithms that may be employed to facilitate a change in working culture. Establishing and supporting values is critically important for effective change. Figure 2 shows an algorithm wherein the leadership team must first establish and identify core values. For a hospital or health care organization, these may be in areas such as patient safety and compassionate/empathetic care. For a regional anesthesia service, this may be a more targeted value, such as increased utilization of regional anesthesia and a decrease in use of perioperative narcotics. Next, it is important to develop trust and represent the intended values consistently. Leaders must be proactive in taking steps such as educating patients and providers and improving systemic processes.
Clear and consistent expectations are critically important to successful culture shifts. If, for instance, the regional anesthesia team sets the expectation that patients be educated on regional anesthesia techniques preoperatively, such as in the surgeons’ offices or preanesthesia clinic, it is important that these standards are communicated effectively and routinely monitored to ensure timely compliance. Finally, it is crucial that stakeholders feel empowered and valued in order to understand their critical role and valuable contributions toward improved patient care.
Ultimately, perioperative medicine is a team sport, and this principle is chiefly on display for acute pain and regional anesthesia. For a successful service, communication and institutional “buy-in” are necessary for all personnel, from the nurses in the admissions unit, preoperative holding area, ORs, postanesthesia care units, and wards, to the surgical attendings and house-staff, and physical therapists and pharmacy representatives.
It is important to understand the anesthesiology department’s goals for the regional service and to adjust the culture to meet those expectations. If the goal is to implement a system wherein anesthesiologists assess perioperative pain and implement a regional anesthesia-centric approach for patients, this must be communicated effectively with surgical and nursing colleagues. All structure, processes, and measured outcomes should be reoriented to meet this goal. If the goal is to create a consultation service, driven by surgical preference or referral, this should also be implemented at every level and communicated with all providers and stakeholders. Maintaining a focus on exemplary patient care and improving perioperative efficiency, while assessing one’s own institution for its needs and available resources, is the only way to implement a successful culture that ensures optimal utilization of an ancillary service such as the regional anesthesia team.