Around the world, acute pain is the most common reason for patients to present to the emergency department (ED).¹ Regional anesthesia services are typically provided by anesthesiologists; however, there are various reasons why not all hospital models can support a dedicated service line run by anesthesiologists including physician shortage.² As the ACEP considers ultrasound guided regional anesthesia a core skill, this leaves a unique opportunity for hospital systems to leverage emergency physicians to provide these services in the inpatient and outpatient setting.

Multiple emergency medicine programs across the United States provide regional anesthesia in the ED; however, to our knowledge, no established programs run by emergency physicians provide regional anesthesia services as consultants to inpatients. We propose a novel concept for the implementation of a regional anesthesia service aimed at providing pain relief to both ED patients and those admitted to the hospital.

Proving Cost Savings

Our ED is a community Level II Trauma Center, Stroke Center, and STEMI [ST-elevation myocardial infarction] Receiving Center with 4,500 trauma activations, 569 hip fractures, and 450 rib fractures per year. Initially when we established this service line, we felt that the hospital itself would benefit directly from the revenue generated by the volume of procedures and the associated reimbursement from these procedures. The actual amount of financial reimbursement is significantly depreciated, however, when inpatient regional anesthesia procedures are “bundled” together with other services performed during a patient’s hospital stay. Therefore, our rationale for establishing this service line was the cost savings associated with decreased length of stay (LOS).

When we first established this service line, we needed to submit a business proposal to justify funding the physicians who would be performing the procedures. Regional anesthesia has been shown to decrease hospital LOS for hip fractures up to 0.9 days.^3-8 The average cost per day of hospitalization in our state is estimated to be $2,813/day.⁹ The previous year’s volume of hip fractures was 569 patients. Therefore, we calculated  yearly cost savings of more than $1.4 million.

The additional amount of procedural revenue was extremely difficult to estimate as it is related to the complexity of the patient’s admission, hospital LOS, and insurance carrier.

Rib fractures are a condition that we commonly treat with ultrasound-guided nerve blocks. Studies indicate that blocks improve respiratory mechanics and decreased opioid consumption, but the actual translation to cost savings was more difficult to ascertain.^10-12 Anecdotally, we have noticed a trend in trauma patients who have fewer than three rib fractures and receive ultrasound-guided nerve blocks either being discharged home or placed in ED observation as opposed to being admitted to the inpatient setting. The monetary effect of a regional anesthesia service in terms of decreased length of hospitalization, increased patient satisfaction, decreased opioid complications, need for readmission, and earlier mobilization is more difficult to extrapolate.

Establishing Workflow

The most complex and labor-intensive task was establishing a workflow, in collaboration with the information technology (IT) department, to allow clinicians to “consult” the service line and, subsequently, perform billing capture on these procedures.

Emergency physicians do not usually perform procedures on hospitalized patients, except for cases where there is a critical need such as intubations, central venous access, and cardiopulmonary resuscitation. Information technology developed a workflow in which a consult order was constructed that would populate a patient list. This list was viewable by physicians who were assigned to the service line. The physicians could then review the patients after the consult was placed and determine a block plan. The patient was consented as appropriate and underwent the procedure. Our workflow then triggered the procedures to be sent to our coding and billing provider once a consultation note was completed.

Although this new service line is still in its infancy, we have had success in its implementation and are looking to expand our services to include pain catheter placements as well as the use of liposomal formulations of local anesthetics. Although numerous studies show the performance of nerve blocks by emergency physicians, we feel that an emergency physician-run regional anesthesia service line is a novel and innovative approach to treat acutely painful conditions in multiple different hospital settings and may offer a new option for management of acutely painful conditions and a new niche for emergency physicians with interest in providing regional anesthesia.

Dr. Slama is the director of the Emergency/Trauma Regional Anesthesia Service and the director of the Advanced Emergency Ultrasound Fellowship at Riverside Regional Medical Center. Further questions can be directed to slamar1@rivhs.com

References

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2. American Society of Anesthesiologists. Anesthesia Workforce Shortage Poses Threat to Health Care. https://www.asahq.org/about-asa/newsroom/news-releases/2024/06/anesthesia-workforce-shortage-poses-threat-to-health-care. Published June 17, 2024. Accessed December 16, 2024.
3. Morrison RS, Dickman E, Hwang U, et al. Regional nerve blocks improve pain and functional outcomes in hip fracture: a randomized controlled trial. J Am Geriatr Soc. 2016;64(12):2433-2439.
4. Chuan A, Zhao L, Tillekeratne N, et al. The effect of a multidisciplinary care bundle on the incidence of delirium after hip fracture surgery: a quality improvement study. Anaesthesia. 2020;75(1):63-71.
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6. Makkar JK, Singh NP, Bhatia N, et al. Fascia iliaca block for hip fractures in the emergency department: meta-analysis with trial sequential analysis. Am J Emerg Med. 2021;50:654-660.
7. Kolodychuk N, Krebs JC, Stenberg R, et al. Fascia iliaca blocks performed in the emergency department decrease opioid consumption and length of stay in patients with hip fracture. J Orthop Trauma. 2022;36(3):142-146.
8. Brox WT, Roberts KC, Taksali S, et al. The American Academy of Orthopaedic Surgeons Evidence-Based Guideline on Management of Hip Fractures in the Elderly. J Bone Joint Surg Am. 2015;97(14):1196-1199.
9. KFF. Hospital Adjusted Expenses per Inpatient Day by Ownership. Accessed December 16, 2024.
10. Johnson B, Herring A, Shah S, et al. Door-to-block time: prioritizing acute pain management for femoral fractures in the ED. Am J Emerg Med. 2014;32(7):801-803.
11. Galvagno SM, Smith CE, Varon AJ, et al. Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936-951.
12. Hernandez N, de Haan J, Clendeninn D, et al. Impact of serratus plane block on pain scores and incentive spirometry volumes after chest trauma. Local Reg Anesth. 2019;12:59-66.