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Perioperative Peripheral Nerve Block Safety Education: A Quality Improvement Project

  • Author Footnotes
    1 At the time of this work, the author was a doctor of nurse anesthesia practice student at Midwestern University, Glendale, AZ.
    Pauline Zelaya
    Correspondence
    Address correspondence to Pauline Zelaya, 8009 Macnish Dr, NE, Albuquerque, NM 87109.
    Footnotes
    1 At the time of this work, the author was a doctor of nurse anesthesia practice student at Midwestern University, Glendale, AZ.
    Affiliations
    Department of Anesthesiology, Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, NM
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  • Author Footnotes
    1 At the time of this work, the author was a doctor of nurse anesthesia practice student at Midwestern University, Glendale, AZ.

      Abstract

      Purpose

      The purpose of the quality improvement (QI) project was to improve patient safety by increasing the consistency of monitor application and oxygen administration during the placement of peripheral nerve blocks (PNBs), advance the knowledge of perianesthesia staff about PNB safety, and develop a PNB hospital policy.

      Design

      QI project using the focus, analyze, develop, and execute model.

      Methods

      The project had two parts, an educational component that was deployed in the three hospitals (hospital A, hospital B, hospital C) and an observation component that was conducted in only one of the hospitals (hospital A). Baseline observation of monitor and oxygen application was recorded at hospital A for 3 months. Assessment of perioperative personnel's baseline knowledge regarding PNB safety was attained using a knowledge assessment tool in the three hospitals. Learners in the three hospitals were given a pretest and post-test to measure the change in knowledge level after a PNB safety presentation was given. Monitor and oxygen application during nerve block placements were observed and recorded after the PNB safety presentation at hospital A. Statistical analysis was completed to determine if significant differences in knowledge levels in the three hospitals and monitor and oxygen application at hospital A existed after an educational intervention was delivered to the perioperative teams.

      Findings

      Participants' knowledge level increased 13% overall with post-test scores greater than 90% after the educational intervention. Monitor application and administration of oxygen during PNB placement improved from 2% to 100% in a preliminary 3-week postintervention review. Systematic changes were implemented to facilitate adherence to best practice measures.

      Conclusions

      PNB safety presentations significantly improved staff's knowledge regarding PNB procedures and potential problems. A multidisciplinary team approach was used to facilitate changes to improve electrocardiogram, blood pressure, pulse oximetry, and oxygen use in this patient population. A proposed PNB policy was accepted as a protocol. Patients are safer with increased monitoring.

      Keywords

      Peripheral nerve blocks (PNBs) are an increasingly common component of multimodal analgesia and routinely incorporated into the anesthetic plan. Although PNBs are considered safe, they are not without risks. This article identifies gaps in knowledge regarding PNB safety and inconsistencies in monitoring during nerve block placement. A quality improvement (QI) project was undertaken within a community hospital system consisting of three hospitals (referred to as hospital A, hospital B, and hospital C) to address knowledge deficits and improve application of electrocardiogram (EKG), blood pressure (BP), pulse oximetry monitors, and oxygen administration during PNB placement in adult orthopaedic patients.

      Description of the Problem

      The use of PNBs has expanded in the last several years as the demand for orthopaedic surgeries has increased.
      • Cozowicz C.
      • Poeran J.
      • Memtsoudis S.G.
      Epidemiology, trends, and disparities in regional anaesthesia for orthopaedic surgery.
      ,
      • Cozowicz C.
      • Poeran J.
      • Zubizarreta N.
      • Mazumdar M.
      • Memtsoudis S.G.
      Trends in the use of regional anesthesia: neuraxial and peripheral nerve blocks.
      Financial incentives, innovation in technology and techniques, changes in Medicare policy for knee replacements as an inpatient-only surgery, and patient preferences feed the steady growth in ambulatory surgeries.
      Health Industry Distributors Association
      2018 Ambulatory Surgery Center Market Report.
      ,

      Total knee arthroplasty (TKA) removal from the Medicare inpatient-only (IPO) list and application of the 2-midnight rule. Centers for Medicare & Medicaid Services. Released January 24, 2019. Outreach and publications. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19002.pdf. Accessed July 22, 2020.

      In addition, the Society of Regional Anesthesia's recommendations to train anesthesia providers has likely contributed to the increase in PNB administration.
      • Cozowicz C.
      • Poeran J.
      • Memtsoudis S.G.
      Epidemiology, trends, and disparities in regional anaesthesia for orthopaedic surgery.
      PNBs have been shown as advantageous in decreasing the hospital length of stay, reducing opioid exposure, increasing patient satisfaction, reducing postoperative (postop) nausea and vomiting, improving postop pain control, lessening the risk of chronic pain, and improving postop recovery.
      • Joshi G.
      • Gandhi K.
      • Shah N.
      • Gadsden J.
      • Corman S.L.
      Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities.
      PNBs can be administered as a single-shot block or as a continuous perineural infusion through a catheter.
      • Joshi G.
      • Gandhi K.
      • Shah N.
      • Gadsden J.
      • Corman S.L.
      Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities.
      The advent of ultrasound machine use has improved the safety profile of PNBs, yet serious complications can still occur.
      • Bowling T.
      • Knauft W.
      • Shah N.
      • Sinha S.
      Making the most of ultra-sound guided regional anesthesia.
      Risks of PNBs include bleeding, infection, nerve damage, soreness at the site of injection, and incomplete block.
      • Jeng C.
      • Rosenblatt M.
      Overview of peripheral nerve blocks. In: Post TW, ed. UpToDate. Waltham, MA.
      Disastrous complications include pneumothorax given the proximity of the lungs to the brachial plexus, allergic reaction, and local anesthetic systemic toxicity (LAST).
      LAST is a rare but life-threatening event caused by a significant amount of circulating levels of local anesthetic and is always a potential complication with local anesthetic use regardless of the route of administration.
      • Warren L.
      • Pak A.
      Local Anesthetic Systemic Toxicity. In: Post TW, ed. UpToDate. Waltham, MA.
      According to Premier Perspective Database and Inpatient Sample Database, the incidence of LAST ranges from 1.4/1,000 to 1.8/1,000. Other registries and surveys report incidences 0.04/1000 to 0.8/1000. The inconsistencies noted in the incidence may be related to the interpretation of the definition of LAST.
      • Neal J.M.
      • Barrington M.J.
      • Fettiplace M.R.
      • et al.
      The third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on local anesthetic systemic toxicity: executive summary 2017.
      Studies that included a wider range of symptoms such as central nervous system (CNS) excitation, minor cardiac symptoms, seizures, and cardiac collapse reported a greater incidence of LAST compared to studies that only included seizure or cardiovascular collapse.
      • Neal J.M.
      • Barrington M.J.
      • Fettiplace M.R.
      • et al.
      The third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on local anesthetic systemic toxicity: executive summary 2017.
      The arrival of ultrasound has reduced the risk of LAST by more than 65%.
      • Barrington M.J.
      • Kluger R.
      Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade.
      ,
      • El-Boghdadly K.
      • Pawa A.
      • Chin K.J.
      Local anesthetic systemic toxicity: current perspectives.
      Risk factors for LAST are extremes of age, liver disease, cardiac disease, pregnancy, and the location of injection of the local anesthetic.
      • El-Boghdadly K.
      • Pawa A.
      • Chin K.J.
      Local anesthetic systemic toxicity: current perspectives.
      ,
      • Dickerson D.M.
      • Afelbaum J.L.
      Local anesthetic systemic toxicity.
      Injection sites with higher vascular supply more readily absorb the local anesthetic systemically, thereby increasing the risk for LAST. The injection site absorption from high to low is intravenous (IV), intercostal, caudal epidural, lumbar epidural, brachial plexus, and subcutaneous.
      • Dickerson D.M.
      • Afelbaum J.L.
      Local anesthetic systemic toxicity.
      The classic symptoms of LAST typically occur within 5 minutes of injection and follow a stereotypical presentation. Early CNS signs are metallic taste, numbness around the mouth and/or tongue, auditory disturbances, lightheadedness, and dizziness. The symptoms can progress to disorientation, drowsiness, and ultimately seizures.
      • Dickerson D.M.
      • Afelbaum J.L.
      Local anesthetic systemic toxicity.
      Lidocaine and ropivacaine usually present with CNS symptoms and progress to cardiovascular symptoms with increased toxicity. Bupivacaine toxicity can manifest abruptly with major dysrhythmias and rapid decline.
      • El-Boghdadly K.
      • Pawa A.
      • Chin K.J.
      Local anesthetic systemic toxicity: current perspectives.
      Hypotension, bradycardia, and cardiac arrest occur in severe cases of LAST. Early detection and intervention can prevent or delay progression of the event. Immediate treatment involves maintaining the airway, oxygen administration, administration of midazolam for seizures, and IV lipid 20% rescue therapy.
      • El-Boghdadly K.
      • Pawa A.
      • Chin K.J.
      Local anesthetic systemic toxicity: current perspectives.
      ,

      Stanford Anesthesia Cognitive Aid Group∗. Emergency Manual: Cognitive aids for perioperative critical events. See http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2016 (Version 3.1) ∗Core contributors in random order: Howard SK, Chu LF, Goldhaber-Fiebert SN, Gaba DM, Harrison TK. Accessed July 24, 2020.

      The placement of PNBs with ultrasound guidance has dramatically reduced the occurrence of LAST and pneumothorax, but it has not completely eliminated the incidence. The risk of pneumothorax with brachial plexus blocks via the supraclavicular approach with ultrasound was estimated at 0.04%.
      • Bhatia A.
      • Lai J.
      • Chan V.W.
      • Brull R.
      Case report: pneumothorax as a complication of the ultrasound-guided supraclavicular approach for brachial plexus block.
      ,
      • Kakazu C.
      • Tokhner V.
      • Li J.
      • Ou R.
      • Simmons E.
      In the new era of ultrasound guidance: is pneumothorax from supraclavicular block a rare complication of the past?.
      Symptoms of pneumothorax might not be immediate but include sudden onset of chest pain on the side of the pneumothorax, dyspnea, and decreased breath sounds on the side of the affected lung.

      Stanford Anesthesia Cognitive Aid Group∗. Emergency Manual: Cognitive aids for perioperative critical events. See http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2016 (Version 3.1) ∗Core contributors in random order: Howard SK, Chu LF, Goldhaber-Fiebert SN, Gaba DM, Harrison TK. Accessed July 24, 2020.

      ,
      • Gauss A.
      • Tugtekin I.
      • Georgieff M.
      • Dinse-Lambracht A.
      • Keipke D.
      • Gorsewski G.
      Incidence of clinically symptomatic pneumothorax in ultrasound-guided infraclavicular and supraclavicular brachial plexus block.
      • Imran J.B.
      • Eastman A.L.
      Pneumothorax.
      A tension pneumothorax is a life-threatening emergency that requires immediate treatment.
      • Gauss A.
      • Tugtekin I.
      • Georgieff M.
      • Dinse-Lambracht A.
      • Keipke D.
      • Gorsewski G.
      Incidence of clinically symptomatic pneumothorax in ultrasound-guided infraclavicular and supraclavicular brachial plexus block.
      • Imran J.B.
      • Eastman A.L.
      Pneumothorax.
      The third potential serious complication from PNBs is allergic reaction. True anaphylactic allergic reactions to local anesthetics are rare; less than 1% of patients receiving local anesthetics are noted to have a reaction.
      • Bourdon L.
      Care of the patient receiving local anesthesia.
      Preservatives in the local anesthetics of the paraben-containing antiseptics have been shown to be responsible for the hypersensitivity and allergic reactions.
      • Bourdon L.
      Care of the patient receiving local anesthesia.
      Signs of an allergic reaction such as bronchospasm, rash/hives, hypotension, and dyspnea can occur quickly and warrant immediate intervention.

      Stanford Anesthesia Cognitive Aid Group∗. Emergency Manual: Cognitive aids for perioperative critical events. See http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2016 (Version 3.1) ∗Core contributors in random order: Howard SK, Chu LF, Goldhaber-Fiebert SN, Gaba DM, Harrison TK. Accessed July 24, 2020.

      Health care facilities that monitor patients during PNBs are alerted of respiratory depression and hemodynamic instability by alarms. The standards for nurse anesthesia practice state that patients should be monitored and evaluated appropriately for the anesthetic technique and procedure they are receiving. Standard monitoring includes cardiovascular, ventilation, oxygenation, and thermoregulation when changes in temperature are intended or anticipated. All anesthetics require a minimum of every 5-minute documentation of BP, heart rate, respiration, and continuous monitoring of oxygenation by pulse oximetry. Alarms should be turned on and audible.
      American Association of Nurse Anesthetists
      Standards for nurse anesthesia practice. 2019.
      In addition to monitoring for the block placement, patients should also be monitored during sedation for the block.
      Administration of the PNB must be in areas of the facility that are equipped with standard monitoring capabilities, emergency equipment, and where intralipids are readily available.
      Belgian standards for patient safety in anesthesia. Revision 2019 of the last version published in the Acta Anaesthesiologica Belgica, 2002, 53 (1): 5-9.
      Most LAST events occur within 5 minutes of administration of the block, and therefore, standard monitoring should be in place before starting the nerve block. Continued monitoring is necessary for a minimum of 30 minutes after injection of the local anesthetic because delayed presentations can occur.
      • El-Boghdadly K.
      • Pawa A.
      • Chin K.J.
      Local anesthetic systemic toxicity: current perspectives.
      Vigilance of the patient's level of consciousness and vital signs (VS) during regional anesthesia is critical.
      This QI project was prompted because the author noticed patients were not prepared for PNBs after arrival to the preoperative (preop) area in a three-hospital system. Patients were placed in preop bays that did not have monitoring capabilities. EKG monitoring was not readily available, and oxygen was not administered during the procedure. Patients were monitored with a portable VS machine without EKG capability. No attention was called to PNB procedures without monitoring or oxygen use. A broad gap of knowledge was discovered. Discussing the need for the administration of nasal cannula oxygen, ensuring accessibility to EKG monitoring in addition to BP and oxygen saturation was well received after explanation of the rationale, but would require changes to the workflow and access to supplies. The entire team needed to understand why monitoring and oxygen administration in this patient population were important and necessary. The preop team and anesthesia technicians (anesthesia techs) had to be willing to reorganize the location of materials, be knowledgeable of surgeon preferences, and be aware to place PNB patients in a bay with full monitoring capabilities. No hospital guideline, protocol, or policy existed for care of patients receiving use of local anesthetics for PNBs, and a lack of standardization in PNB practice existed.

      Purpose

      The specific aims of this QI project were to improve patient safety by increasing the consistency of monitoring and oxygen administration during the placement of PNBs, advance the knowledge of perianesthesia staff about PNB safety, and develop a PNB hospital policy. The processes used to achieve these goals were as follows:
      • To demonstrate a need for improvement (lack of proper monitoring).
      • To assess perioperative staff's current knowledge level about PNBs.
      • To provide rationale for the importance of hemodynamic monitoring (three life-threatening complications related to PNBs) and oxygen administration with PNBs through an educational presentation.
      • To develop a PNB policy.
      • To evaluate the effectiveness of the education intervention by observation of monitor application and oxygen administration after the PNB safety presentation.

      Design

      This QI project used the focus, analyze, develop, and execute model. The problem identified was that patients receiving PNBs were not properly monitored and were not receiving oxygen during the PNB procedure (focus). The problem existed throughout the hospital system. The issue was analyzed on how best to obtain information to avoid the Hawthorne effect while collecting baseline patterns of monitor application (analyze). Root causes and other influential factors were contemplated for why the problem existed. A plan was developed to change the culture of current practice and get buy-in from the perioperative staff based on the data examined (develop). First, evidence that the problem existed needed to be substantiated. Second, a plan to educate perioperative staff needed to be developed and deployed (execute). Finally, monitoring practices needed to be re-evaluated after education to determine the effectiveness of the material presented and if there was a change in practice. The execution step put the plans into action. The institutional review board (IRB) was queried as to whether the project required approval. Not all QI projects require IRB approval; however, the author sought to clarify this point with the IRB to ensure protection of all involved. Approval from hospital A's operating room (OR) manager and the quality assurance director was needed to develop and execute the project.
      The knowledge gap related to PNBs was identified within the hospital system. One of the issues was that patients were not monitored consistently during the placement of the PNBs. In addition, many patients received sedation before the placement of the PNB and were not monitored or given oxygen when receiving procedural sedation. The problem was noted in all of the hospitals: A, B, and C. The author chose hospital A to gather baseline data surrounding patient monitoring during PNB placement. Hospital A presented a manageable project site for the author because it was a smaller hospital, had accessible and supportive administration, and had significant volume of orthopaedic surgeries.
      A PNB safety educational presentation was developed and delivered at each of the three hospitals during the perioperative staff meetings. Those present at the staff meetings, registered nurses (RNs), scrub technicians, anesthesia techs, certified registered nurse anesthetists (CRNAs), and physicians, were invited to partake in the pretest and post-test. All members of the team were considered important and helpful in the event of an emergency. The location and contents of the LAST rescue kit were reviewed with the participants.
      Factors that contributed to the current practice and lack of standardization included the following:
      • Systems were not in place to flag PNB patients at check-in; therefore, patients were placed in preop bays that did not have monitoring capabilities.
      • There was a shortage of equipment and supplies in preop bays for PNB procedures.
      • Hospital guidelines, protocol, or policy for PNBs did not exist, and the hospital policy for procedural sedation was not followed consistently.
      • Lack of a notification system to alert staff that patients had received a PNB and were a fall risk.
      More contributing factors were brought to light during the discussion period after the PNB safety presentations.
      The population or problem (P); the intervention or exposure (I); the comparison intervention or exposure (C); and the clinical outcome of interest (O)—(PICO) system—was used to formulate the QI project question for the literature review. The PICO question was: In perioperative staff, what is the effect of a PNB safety presentation on monitoring PNB patients after the presentation when compared with current PNB practices? The goal was improved knowledge of the importance of monitoring during PNBs, increased awareness of potential complications from nerve blocks, and an increase in monitoring of adult orthopaedic patients during the administration of a PNB.

      Literature Review

      A search of the literature was performed using several databases: CINAHL, ERIC, Google Scholar, MEDLINE Complete, Ovid, PubMed, and UpToDate. The search terms used were staff development, clinical education, peripheral nerve block, standards for anesthesia, monitoring, basic monitoring anesthesia, monitoring guidelines for anesthesia, standards, anesthesiology, quality improvement anesthesia, education, perioperative orientation program, professional development, local anesthetic systemic toxicity, adverse effects, nerve block and complications, and nerve block. Boolean operators AND and NOT were used to narrow the search. The language was restricted to English; the period of the search was within the past 10 years.
      Articles were categorized into the following three groups: complications from PNBs, standard monitoring for PNBs, and staff education. Articles were selected to support the need for education, the use of monitors for PNB procedures, and to discuss the life-threatening complications from nerve blocks. In summary, the literature recognized that health care providers working with patients who receive PNBs must be educated and knowledgeable about PNBs to provide safe care. The format and frequency of training is variable and not clearly defined. Vigilance is the key to the detection and treatment of catastrophic events related to PNBs. Collaboration is necessary to educate the perioperative staff about PNB safety, implement changes in monitoring practices, and prepare the staff for complications.

      Methods

      The project examined how adult orthopaedic patients were monitored during the placement of PNBs, instituted an educational intervention, and compared monitor and oxygen application postintervention. Hospital A was selected to conduct the observational portion of the QI project because it was smaller, well organized, had cooperative staff and administration, and did a significant number of orthopaedic surgeries by surgeons who incorporated PNBs into the plan of care. Regional anesthesia was minimally used at hospital B and the total joint surgeons did not use PNBs for their arthroplasties. Although hospital C, the largest of the three hospitals, had the greatest number of orthopaedic surgeries using PNBs, the inconsistencies of the anesthesia techs work schedules and use of pro re nata anesthesia techs made data collection unpredictable and unreliable. The volume and pace of the orthopaedic surgery floor at hospital C made the garnering of support for extra tasks with data collection burdensome. Pretest and post-test designs were carried out for the educational intervention at all the hospitals in the three-hospital system. A QI design was completed for assessing monitor and oxygen application in hospital A. The safety presentation was given in all three hospitals; however, the observation of monitors and oxygen application during PNB placement was conducted only at hospital A.
      The educational intervention evaluated the baseline knowledge level of participants and re-evaluated their knowledge level after the PNB safety presentation. Observation of the type of monitors used and if oxygen was applied during the administration of PNBs in adult orthopaedic surgery patients was completed at hospital A. The baseline observations were recorded for 3 months before the educational intervention. Application of monitors and oxygen preintervention and postintervention was compared.
      Application of monitors and oxygen during PNB placement was observed and recorded during 3 months for 63 patients. The baseline data were obtained and recorded on a block tracking sheet by two anesthesia techs. The review of the data collected during the 3 months found that PNB patients were not monitored consistently with continuous EKG, continuous pulse oximetry, with BP, and were not consistently receiving oxygen therapy during the PNB procedures.
      To track the impact of the PNB safety education effects, pre-PNB safety education monitoring data were compared with post-PNB safety education monitoring data. The anesthesia techs continued to record the methods used to monitor patients and oxygen administration during PNB placement. Three weeks after the PNB safety presentations were completed, the monitoring data collected during those 3 weeks were analyzed. A plan to continue gathering monitoring data and analyze the monitoring data at the 3-month, 6-month, and 1-year mark was made to evaluate the long-term effectiveness of the QI project.

      Intervention

      Context

      Surgical patients were brought from the waiting room into the preop area for an initial VS check, education on the perioperative plan of care, and preparation for surgery. Preop RNs placed patients into bays, filled out the preop checklist, started IV catheters, and reviewed and completed the surgical preop orders. Certified anesthesia techs and RNs assisted with PNBs. A procedural time out was completed before the administration of sedation. Local anesthetic was slowly injected under the direction of the anesthesia provider.

      Education

      Working in an area where PNBs are performed requires knowledge about the practice protocols and standards related to local anesthetics, such as the pharmacology, monitoring requirements, patient responses, adverse events, and treatment for complications.
      • Bourdon L.
      Care of the patient receiving local anesthesia.
      ,
      Belgian standards for patient safety in anesthesia. Revision 2019 of the last version published in the Acta Anaesthesiologica Belgica, 2002, 53 (1): 5-9.
      ,
      • Fencl J.L.
      Guideline implementation: local anesthesia.
      Advanced cardiac life support certification was required for the perioperative RN position within the hospital system. Promotion of awareness, preparedness, and vigilance is crucial in recognizing and treating life-threatening complications.
      • Dickerson D.M.
      • Afelbaum J.L.
      Local anesthetic systemic toxicity.
      Knowledge that although catastrophic PNB complications are infrequent, changes in VSs detected on monitors can be key in recognizing such problems is essential.
      A 25-minute PowerPoint presentation followed by a hands-on exploration of the LAST rescue kit was given at each of the three hospitals during OR staff meetings. Effort was made to capture as many staff as possible with repeat presentations given to small groups that were not able to attend the OR staff meetings. Anesthesia techs, CRNAs, physicians, surgical scrub technicians, perioperative RNs, and OR managers attended the staff meetings. OR staff meetings were mandatory for hospital employees working in the perioperative area; completing the presentation pretest and post-test was voluntary. It was difficult to catch all the anesthesia providers because they rotated between the three hospitals; therefore, a presentation was given at the anesthesia company's regional anesthesia class.
      A knowledge assessment pretest was given to attendees before the presentation. The presentation reviewed background information about PNBs, discussed the potential complications of PNBs, the recognition and management of complications, and the role of nurses with PNBs. Using the Stanford Anesthesia Emergency Manual, a review of LAST, allergic reaction, and pneumothorax was completed. The presentation closed with a discussion period and the administration of the post-test. The education sessions were completed during 5 weeks.
      An important part of the intervention process was gathering information from staff to become aware of the hurdles that contributed to the problem. Two of the hospitals had limited EKG monitoring capabilities in the areas used to preop orthopaedic patients. Hospital A had one preop bay with a hardwired monitor system capable of monitoring EKG, BP, and oxygen saturation as well as a mobile wheeled VS machine without an EKG display that was used throughout the nine-bay preop area. A system to flag patients for PNBs was needed to alert the admitting personnel to place the orthopaedic patients likely to get a PNB in the monitored bay. Concern about fall risks in these patients was raised. Supplies such as EKG pads, EKG cables, and nasal cannulas were not reliably available in the preop area.
      A multidisciplinary approach identified barriers that hindered PNB patients from being fully monitored during PNB placement. Before the PNB policy went for review, changes began to occur from raised awareness. PNB patients were streamlined from arrival to the perioperative area, admission paperwork was flagged by surgeons for PNB requests, and a portable transport monitor was used in a second preop bay until funding becomes available for more hardwired monitors. A suggestion to put PNB patients in recovery area bays for PNB placement was made.

      Instrument

      The pretest and post-test were the same tests and consisted of six questions
      • Ferguson W.
      • Coogle C.
      • Leppert J.
      • Odom-Maryon T.
      Local anesthetic systemic toxicity (LAST): Designing and educational effort for nurses that will last.
      (Table 1). The first five questions assessed the knowledge level of the perioperative staff. The sixth question measured the participants' comfort level in recognizing and knowing their role during PNB emergency complication. Questions examined participants' knowledge of potential complications of PNBs, tasks that need to be completed before the procedure, how to monitor PNB patients, the location of rescue equipment, and recognition of signs and symptoms of a complication.
      Table 1PNB Knowledge Assessment Tool
      PNB Knowledge Assessment ToolName ___________Title ___
      • 1.
        Circle the potential complications of PNBs. (Circle all that apply).
        • a.
          Pneumothorax
        • b.
          Nightmares
        • c.
          High fevers
        • d.
          Hoarseness
        • e.
          Allergic reaction
        • f.
          LAST
      • 2.
        Patients receiving PNBs should be monitored with ____. (Circle all that apply).
        • a.
          Continuous EKG
        • b.
          BP
        • c.
          Pulse oximetry
        • d.
          End-tidal carbon dioxide
        • e.
          Bispectral index
        • f.
          Precordial stethoscope
      • 3.
        What actions should be taken by the nurse before placement of a PNB? (Circle all that apply).
        • a.
          Perform a preoperative assessment
        • b.
          Get baseline VSs
        • c.
          Verify allergies and consent
        • d.
          Establish an IV
        • e.
          Confirm availability of emergency equipment
        • f.
          Place the patient on monitors
        • g.
          Initiate a procedural time out
      • 4.
        When should patients receiving a PNB alert the nurse? If they experience ____? (Circle all that apply).
        • a.
          Metallic taste in mouth, ringing in ears, feelings of excitement, or agitation
        • b.
          Sudden pain in chest, sudden shortness of breath
        • c.
          Loss of sensation and movement
        • d.
          A poke, a burn, and pressure during needle insertion
        • e.
          Dry mouth, headache, and photophobia
      • 5.
        Where are the nearest intralipids kept?
        • a.
          Refrigerator in the core
        • b.
          Anesthesia work room
        • c.
          Pixus
        • d.
          LAST tackle box.
      • 6.
        On a scale of 1-5 (1 is not comfortable at all, 5 is being very comfortable), how comfortable are you recognizing and knowing your role during an emergency related to a complication from a PNB? (Circle one)
        • 12345
      PNB, peripheral nerve block; LAST, local anesthetic systemic toxicity; EKG, electrocardiogram; BP, blood pressure; VSs, vital signs; IV, intravenous.
      A data collection sheet was created to record the following information: block number of the day; the date; the type of block; yes/no if EKG, BP, pulse oximetry was applied; and yes/no for oxygen administration. The tool was kept on a clipboard on the ultrasound machine.
      The project measured the difference in test scores from a knowledge assessment tool given before and after the PNB safety presentation. To compare pretest and post-test results, only people who took the pretest, listened to the entire presentation, and took the post-test were counted. Eighty-three people attended the presentation and took both tests. The project observed how patients were monitored during PNB placement and whether oxygen was administered before and after the safety presentation was completed.

      Data Collection Strategy

      Monitor application and oxygen administration during PNB placement were observed and recorded for 3 months at hospital A by two anesthesia techs. To avoid the Hawthorne effect, the anesthesia techs did not announce that they were observing monitor applications. According to the anesthesia techs, no one asked about the recording of information during the 3 months; however, the hospital staff were aware that a QI project was underway. After the PNB safety presentations were complete, the perioperative staff at hospital A was notified that monitoring techniques for PNBs would be observed and recorded. PNB safety tests were given at all three hospitals. The individual hospital results and collective results were reported back to each hospital.
      The data collected from the PNB monitoring methods and test results were descriptive with quantitative data. The test results were separated into two sections: knowledge results and comfort-level results. The knowledge questions had a maximum score of 15. The comfort level was rated on a scale of 1 to 5, with 1 indicating not comfortable at all and 5 being very comfortable. The pretest results were compared with post-test results. The results were analyzed individually per hospital and aggregately with the three hospitals combined. The tests were developed, administered, and graded by the author. The test questions were further vetted by CRNAs. The results of both the monitoring methods and the PNB safety tests were coded and entered into Microsoft Excel 2013 (Microsoft Corp, Redmond, WA). Descriptive statistics were used to examine the test results, preintervention and postintervention, monitor application, and oxygen administration.
      Baseline data from 63 patients receiving PNBs were collected during a 3-month period. A preliminary 3-week postintervention review of monitoring practices in 18 PNBs was completed at hospital A to compare with the baseline data that were collected at hospital A. As practice models were similar at each of the three hospitals, initial monitoring practices were not collected at the other two hospitals. Only the educational portion of the QI project was carried out at all three hospitals. Statistical analyses were completed based on data from the 18 PNBs that were captured in the 3-week postintervention period at hospital A. The monitoring method results preintervention and postintervention were a comparison of the baseline 63 cases and the 18 postintervention cases. A university biostatistician conducted the statistical analysis.

      Ethical Considerations

      This project was QI in nature and determined not to be subject to IRB oversight by a university IRB. Staff were aware that the author was working on a QI project for patients receiving PNBs.

      Statistical Analysis

      Pretest and post-test presentation knowledge scores were compared. Scores on the knowledge test were compared using a nonparametric Mann-Whitney U test because the data showed skewness. The comfort-level results were analyzed using a two-sample independent t test. Monitoring methods before and after the presentation were analyzed with a Fisher exact test as counts in the contingency table's cells were less than 5. Statistical significance was set at the .05 level.

      Results

      Clinically, the practice of applying monitors and administering oxygen to PNB patients improved after the project's intervention at all the hospitals. The presentation raised awareness about PNB safety. Charge nurses at hospitals A and C were cognizant to put PNB patients in the bays that had full monitoring capabilities. Hospital B had hardwired monitors in each preop bay and performed less PNBs than the other two hospitals. Anesthesia techs and preop RNs collaborated with placing patients on the monitor and administering oxygen in preparation for PNBs. The presentation included pictures of the location of each hospital's LAST kit. The LAST kit was opened and reviewed in each hospital, which improved preparedness.
      An analysis of the pretests showed on average, the raw score for the knowledge portion was 11.7 of a maximum score of 15 (SD, 3.1). The post-test mean was 13.7 (SD, 1.4). The posteducation test scores for all three hospitals aggregately were above 90%. The pretest comfort average was 3.06 on a scale of 5 (SD, 1.2), and the post-test comfort mean was 4.01 (SD, 0.85). Scores on both the knowledge portion and comfort levels were significantly higher after presentation (P < .0001).
      The number of PNBs observed preintervention was 63 and postintervention was 18. The number of patients monitored with EKG, pulse oximetry, BP, and oxygen after presentation was also significantly higher than before presentation (P < .0001 for all monitoring methods). Monitor application with EKG, BP, oximetry, and oxygen administration improved from 2% of 63 patients before presentation to 100% of 18 patients after presentation.

      Policy Development

      To ensure continued adherence to best practices and standardization of practice, clinical guidelines, and standards of anesthesia from the American Association of Nurse Anesthetists, Safety First Guidelines, the Belgian Association for Regional Anesthesia clinical guidelines for PNBs in adults, the Association of periOperative Registered Nurses, the American Society of PeriAnesthesia Nurses, and the American Society of Anesthesiologists were reviewed to develop a hospital policy for PNB adminstration.
      American Association of Nurse Anesthetists
      Standards for nurse anesthesia practice. 2019.
      ,
      Belgian standards for patient safety in anesthesia. Revision 2019 of the last version published in the Acta Anaesthesiologica Belgica, 2002, 53 (1): 5-9.
      ,
      • Sermeus L.
      • Pirson A.
      • Breebaart B.
      • et al.
      Clinical guidelines for the practice of peripheral nerve blocks in the adult.
      • Gadsen J.
      • McCally C.
      • Hadzik A.
      Monitoring during peripheral nerve blockade.
      Association of Perioperative Registered Nurses
      AORN eGueidlines+. Guidelines for perioperative practice: local anesthesia.
      American Society of Perianesthesia Nurses
      ASPAN's Clinical Practice Committee “FAQ” page.
      American Society of Anesthesiologists Standards for Basic Intra-Operative Monitoring. Anesth Patient Saf Found.
      The author created a policy addressing three sections of PNB administration: preparation for the block, performing the block, and monitoring of the block. The preparation portion of the policy outlined patient selection, monitoring type and frequency, and the availability of emergency equipment. The second section of the proposed policy described actions that must be taken such as a procedural time out, verification of the correct side, the preference for patients to be awake if possible, and how to inject the PNB solution. The third section delineated how often VSs should be taken and the duration (Table 2). A draft of the policy was sent to the OR managers for review.
      Table 2PNB Policy
        • Preparation for block
        • Patient selection for PNB to be completed by anesthesia provider
        • Obtain/maintain IV access
        • Emergency equipment must be available. Basic resuscitation medications and intralipid 20% immediately available. Protocol for administration of intralipids immediately available
        • Monitors should be in place before beginning the block and record VS every 5 min. Apply continuous EKG and pulse oximetry, BP, and ETCO2 if available
        • Administer supplemental oxygen either by nasal cannula or face mask
        • Maintain meaningful communication with the patient. Note preprocedure level of consciousness, anxiety, and pain
      • Performing the block
        • Blocks should be performed on awake patients when possible
        • A safety time out should be performed immediately before starting the block with verification of the correct side
        • Continuous 1:1 monitoring and documentation of VS and neurologic status. Monitor level of consciousness. Observe for signs of LAST: dizziness, tinnitus, dysphoria, circumoral numbness, metallic taste, agitation, seizures, confusions, and dysrhythmias
        • Perform skin disinfection similar to surgical procedure
        • A trained individual should be available to assist with the PNB placement
        • Slow injection of the block solution should be done in 3-5 mL aliquots with frequent aspiration
        • Stop the injection if pain, resistance, or paresthesia is encountered. Stop the injection for loss of visualization of local anesthetic diffusion
        • Use of the peripheral nerve stimulator at low intensity increases the detection of intraneural injection
        • Evaluate the block effectiveness
      • Monitoring of the block
        • Qualified personnel must be available to maintain vigilance of PNB patients
        • Maintain communication with the patient and monitor the patient closely
        • Monitor VS every 5 min during the block and a minimum of every 15 min until the patient meets transfer or discharge criteria
      PNB, peripheral nerve block; IV, intravenous; VS, vital sign; EKG, electrocardiogram; BP, blood pressure; ETCO2, end-tidal carbon dioxide; LAST, local anesthetic systemic toxicity.
      The policy was reviewed by the surgical services director at hospital B, and small edits were made. At the subsequent surgical section meeting, approximately 1 month later, the policy was passed as a protocol in hospital B. A draft of the proposed PNB policy was sent to hospital A to be reviewed by the OR manager, quality assurance director, and forwarded to the chief medical officer of the anesthesia group for review. Approval was given to send the proposed policy to the medical executive committee for review at hospital A. Two weeks later, the policy was accepted as a protocol at hospital A. The third hospital (hospital C) did not respond. After review from the surgery section and the medical executive committee, two hospitals accepted the proposed policy as a protocol.

      Discussion

      The pretest knowledge assessment tool revealed that a knowledge deficit existed about PNB complications, standards for monitoring PNB patients, signs and symptoms of LAST, where the LAST rescue kit was located at each hospital, and contents of the kit. Post-test results showed an immediate increase in test scores. The open question and answer period after the PNB safety slide presentation encouraged a relaxed environment for staff to bring up challenges encountered with workflow, hierarchy, and equipment.
      Improvements in monitor application and oxygen administration did occur with PNB placement. Accommodations were made in the perioperative system to accomplish the objective. Preliminary postpresentation observations showed that 100% of patients had EKG, BP, pulse oximetry probes, and oxygen on during PNB placement. The postintervention monitoring application data were only collected for 3 weeks secondary to the author's educational program time constraints; however, positive change occurred.
      The proposed policy served as a reference until it was passed as a protocol. The project had several positive unintended results. Listening to the hurdles, suggestions, and solutions during the QI project built trust. The perioperative staff came up with a list of topics they would like to learn more about. Communication among anesthesia providers, orthopaedic surgeons, perianesthesia staff, and administration was improved.
      Admission paperwork was flagged by surgeons who requested PNBs for their patients; a portable transport monitor was used in a second preop bay at hospital A until funding becomes available to install another hardwire monitor in the preop area. PNB patients were put in the recovery area bays to place the nerve block if monitored preop bays were full.
      Appropriate patient monitoring and oxygen administration became part of the pre-PNB time out. The anesthesia techs added the preop bays to their supply stocking area. To avoid secondary patient injuries such as falls related to the block, a bright laminated sign stating nerve block was placed on patient's stretcher. The conspicuous placement of the nerve block sign alerted staff that the patient may be sedated and that the patient received a nerve block.

      Limitations

      The knowledge assessment tool was developed by the author and not tested for reliability. However, an experienced CRNA vetted the tool for statement and content accuracy. For a better measure of knowledge retention, a repeat test administered at a later time frame would better assess knowledge retention over recall. Administration of a repeat test in the future presents limitations as it would be difficult to gather the same individuals who took the initial set of tests to complete a third test.
      A limitation exists because of the lack of information regarding how many of the 63 PNBs were recorded by each individual data collector and how many anesthesia providers preformed the 63 PNBs. Finally, to fulfill the author's coursework requirements, the project was concluded 1 month after the PNB safety presentations were completed. There is a need for continued follow-up at 3 months, 6 months, and 1 year to determine true change in practice and improved patient safety. In addition, a larger sample would be helpful.

      Conclusions

      PNBs are considered safe and beneficial and frequently incorporated into orthopaedic surgery plans. Although the risks associated with PNB are rare, an adverse event can have serious consequences. A gap in knowledge and practice was identified regarding patient monitoring during PNB administration. A system-wide educational intervention increased knowledge about PNBs and improved patient care as evidenced by the increase in pretest and post-test scores and the increase in monitoring methods applied postintervention in patients receiving PNBs. The project demonstrates the translation of knowledge into clinical practice. Patients are now safer because of the implementation of a PNB protocol, increased monitoring, and oxygen administration.
      The aim of creating a PNB policy was to safeguard the best practices with PNB procedures. Although a hospital policy was not adopted, a protocol to define the steps taken during the PNB procedure was implemented. Opportunities to improve surgical experiences and learn from QI projects can be expanded for use in other contexts. For example, the PNB policy may be applied to other surgical patient populations. In addition, an annual assessment of PNB safety would be beneficial.
      Extension of posteducation monitoring observation at hospitals B and C would be beneficial for evaluating the effectiveness of the applied knowledge. The development of annual PNB safety presentations would raise awareness about standard practices and potential PNB complications and treatments. Creation of a PNB safety training and competency module could be explored for perioperative staff working with PNBs.
      Finally, future projects on this important topic lend themselves to additional research. For example, comparing safety measures and PNB patient outcomes immediately after and in the postanesthesia care unit may help ground practice and future policy development.

      Acknowledgments

      The author acknowledges Shari Burns, EdD, CRNA, professor at Midwestern University Glendale, AZ, for her support, and Amy Stein, PhD, biostatistician, at Midwestern University for her assistance with the data analysis.

      References

        • Cozowicz C.
        • Poeran J.
        • Memtsoudis S.G.
        Epidemiology, trends, and disparities in regional anaesthesia for orthopaedic surgery.
        Br J Anaesth. 2015; 115: ii57-ii67
        • Cozowicz C.
        • Poeran J.
        • Zubizarreta N.
        • Mazumdar M.
        • Memtsoudis S.G.
        Trends in the use of regional anesthesia: neuraxial and peripheral nerve blocks.
        Reg Anesth Pain Med. 2016; 41: 43-49
        • Health Industry Distributors Association
        2018 Ambulatory Surgery Center Market Report.
        (Available at:)
        https://bit.ly/2Lk8j6U
        Date accessed: July 22, 2020
      1. Total knee arthroplasty (TKA) removal from the Medicare inpatient-only (IPO) list and application of the 2-midnight rule. Centers for Medicare & Medicaid Services. Released January 24, 2019. Outreach and publications. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19002.pdf. Accessed July 22, 2020.

        • Joshi G.
        • Gandhi K.
        • Shah N.
        • Gadsden J.
        • Corman S.L.
        Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities.
        J Clin Anesth. 2016; 35: 524-529
        • Bowling T.
        • Knauft W.
        • Shah N.
        • Sinha S.
        Making the most of ultra-sound guided regional anesthesia.
        Anesthesiology News. 2019; 16
        • Jeng C.
        • Rosenblatt M.
        Overview of peripheral nerve blocks. In: Post TW, ed. UpToDate. Waltham, MA.
        (Available at:)
        • Warren L.
        • Pak A.
        Local Anesthetic Systemic Toxicity. In: Post TW, ed. UpToDate. Waltham, MA.
        (Available at:)
        • Neal J.M.
        • Barrington M.J.
        • Fettiplace M.R.
        • et al.
        The third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on local anesthetic systemic toxicity: executive summary 2017.
        Reg Anesth Pain Med. 2018; 43: 113-123
        • Barrington M.J.
        • Kluger R.
        Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade.
        Reg Anesth Pain Med. 2013; 38: 289-297
        • El-Boghdadly K.
        • Pawa A.
        • Chin K.J.
        Local anesthetic systemic toxicity: current perspectives.
        Local Reg Anesth. 2018; 11: 35-44
        • Dickerson D.M.
        • Afelbaum J.L.
        Local anesthetic systemic toxicity.
        Aesthet Surg J. 2014; 34: 1111-1119
      2. Stanford Anesthesia Cognitive Aid Group∗. Emergency Manual: Cognitive aids for perioperative critical events. See http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2016 (Version 3.1) ∗Core contributors in random order: Howard SK, Chu LF, Goldhaber-Fiebert SN, Gaba DM, Harrison TK. Accessed July 24, 2020.

        • Bhatia A.
        • Lai J.
        • Chan V.W.
        • Brull R.
        Case report: pneumothorax as a complication of the ultrasound-guided supraclavicular approach for brachial plexus block.
        Anesth Analg. 2010; 111: 817-819
        • Kakazu C.
        • Tokhner V.
        • Li J.
        • Ou R.
        • Simmons E.
        In the new era of ultrasound guidance: is pneumothorax from supraclavicular block a rare complication of the past?.
        Br J Anaesth. 2014; 113: 190-191
        • Gauss A.
        • Tugtekin I.
        • Georgieff M.
        • Dinse-Lambracht A.
        • Keipke D.
        • Gorsewski G.
        Incidence of clinically symptomatic pneumothorax in ultrasound-guided infraclavicular and supraclavicular brachial plexus block.
        Anaesthesia. 2014; 69: 327-336
        • Imran J.B.
        • Eastman A.L.
        Pneumothorax.
        JAMA. 2017; 318: 974
        • Bourdon L.
        Care of the patient receiving local anesthesia.
        AORN J. 2015; 101: 10-12
        • American Association of Nurse Anesthetists
        Standards for nurse anesthesia practice. 2019.
        (Available at:)
      3. Belgian standards for patient safety in anesthesia. Revision 2019 of the last version published in the Acta Anaesthesiologica Belgica, 2002, 53 (1): 5-9.
        Acta Anaesthesiol Belg. 2020; 71: 5-14
        • Fencl J.L.
        Guideline implementation: local anesthesia.
        AORN J. 2015; 101: 682-692
        • Ferguson W.
        • Coogle C.
        • Leppert J.
        • Odom-Maryon T.
        Local anesthetic systemic toxicity (LAST): Designing and educational effort for nurses that will last.
        J Perianesth Nurs. 2019; 34: 180-187
        • Sermeus L.
        • Pirson A.
        • Breebaart B.
        • et al.
        Clinical guidelines for the practice of peripheral nerve blocks in the adult.
        Acta Anaesthesiol Bel. 2013; 64: 105-108
        • Gadsen J.
        • McCally C.
        • Hadzik A.
        Monitoring during peripheral nerve blockade.
        Curr Opin Anaesthesiol. 2010; 23: 656-661
        • Association of Perioperative Registered Nurses
        AORN eGueidlines+. Guidelines for perioperative practice: local anesthesia.
        (Available at:)
        • American Society of Perianesthesia Nurses
        ASPAN's Clinical Practice Committee “FAQ” page.
        (Available at:)
      4. American Society of Anesthesiologists Standards for Basic Intra-Operative Monitoring. Anesth Patient Saf Found.
        (Available at:)