Section 4: Patient Management Considerations

Developing Regional Anesthesia Pathways

INTRODUCTION

Regional anesthesia is best practiced in the context of a standardized anesthetic and surgical protocols; these plans are generally referred to as anesthetic pathways. For a patient having surgery that uses an anesthetic pathway, many of the decisions about the patient’s care are made not at the bedside in the immediate preoperative period, but instead long before the surgery by carefully considering the risks and benefits of various anesthesia and perioperative treatment options.

When well designed, anesthetic pathways can improve patient care by ensuring that patients receive consistent, coordinated, evidenced-based care. They can also reduce costs by eliminating unnecessary interventions and reducing complications. Of course, pathways should not be indiscriminately adhered to as some patients will require modification to atone for specific medical conditions or patient preferences. Regardless, anesthetic pathways allow clinicians to focus on the unique characteristics of a patient instead of the common characteristics of an entire cohort, which were already examined during pathway development.

At their core, anesthetic pathways (or clinical pathways in any field) are a series of medical decisions. As leaders of the perioperative surgical home, anesthesiologists are best suited to lead their design. There are often many subtle issues that arise in the development of a pathway that may not be familiar to anyone other than a clinician who is frequently and personally involved in patient care. In addition, anesthesiologists’ working relations with surgeons, administrators, and the entire operating room team are paramount in development and success of patient pathways. Interspecialty coordination is vital to the successful development of anesthetic pathways. Anesthetic decisions will frequently affect patients’ ability to rehabilitate in the immediate postoperative period, so anesthetic and surgical pathways must be designed by a team effort.

Because there is evidence that use of regional anesthesia may affect the mortality and morbidity^1,2,3,4,5 of common surgeries, and because pain control in the postoperative period is often challenging, regional anesthesia (either neuraxial or peripheral block) is often a key feature of anesthetic pathways. Therefore, development of pathways is of particular interest to practitioners whose clinical practice includes regional anesthesia.

Designing and implementing clinical pathways require skills often not taught during residency training. Physicians tailor their treatments with the unique characteristics of each patient in mind. This is related to physician training designed to elicit and synthesize data for a specific patient. Clinical pathways, in contrast, must be designed to optimize the average experience of a cohort of patients, often making trade-offs and compromises in the process. Knowledge of epidemiology and statistics are vital to effective clinical pathway design. Numerically estimating probable outcomes, and choosing those that rate most favorably, is central to the development of the pathway.

Benefits of an anesthesia pathway will of course depend on the peculiarities of the pathway itself, the institution, ...