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Development of a Regional Model of Care for Ambulatory Total Shoulder Arthroplasty

A Pilot Study

  • Symposium: New Approaches to Shoulder Surgery
  • Published:
Clinical Orthopaedics and Related Research

Abstract

Total shoulder arthroplasty (TSA) has traditionally been performed as inpatient surgery to provide adequate postoperative analgesia via intermittent opioid administration. We developed a regional model for ambulatory TSA using continuous brachial plexus nerve block (CBPNB). We asked whether this regional model would allow us to select patients to undergo outpatient TSA using CBPNB while providing similar outcomes to those patients who were managed with CBPNB and a one-night or longer inpatient hospital stay. Of 16 selected patients, eight underwent outpatient TSA/CBPNB while the other eight had an overnight hospital stay. Outcome measures included readmission, duration of CBPNB use, pain scores, adjunctive analgesia use, range of motion, and patient satisfaction. There were no readmissions. Patients used CBPNB for an average of 6 days. The average postoperative pain score was 1/10. One patient required oral analgesics while using CBPNB. All patients were very satisfied (Likert scale) and would have the surgery again. Although these data are preliminary, the development of a regional outpatient model for TSA using CBPNB permitted integration of community care and patient satisfaction and decreased length of hospital stay.

Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

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References

  1. Berger RA, Sanders S, D’Ambrogio E, Buchheit K, Deirmengian C, Paprosky W, Della Valle CJ, Rosenberg AG. Minimally invasive quadriceps-sparing TKA: results of a comprehensive pathway for outpatient TKA. J Knee Surg. 2006;19:145–148.

    PubMed  Google Scholar 

  2. Bergogne-Berezin E. Treatment and prevention of antibiotic associated diarrhea. Int J Antimicrob Agents. 2000;16:521–526.

    Article  PubMed  CAS  Google Scholar 

  3. Boezaart AP. Continuous interscalene block for ambulatory shoulder surgery. Best Pract Res Clin Anaesthesiol. 2002;16:295–310.

    Article  PubMed  Google Scholar 

  4. Bryan NA, Swenson JD, Greis PE, Burks RT. Indwelling interscalene catheter use in an outpatient setting for shoulder surgery: technique, efficacy and complications. J Shoulder Elbow Surg. 2007;16:388–395.

    Article  PubMed  Google Scholar 

  5. Canadian Institute of Health Information (CIHI) Web site. Fiscal 2005 CMG Description for Total Shoulder Replacement. Available at: http://www.cihi.ca. Accessed on 7 Sept 2007.

  6. Capdevila X, Pirat P, Bringuier S, Gaertner E, Singelyn F, Bernard N, Choquet O, Bouaziz H, Bonnet F; French Study Group on Continuous Peripheral Nerve Blocks. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology. 2005;103:1035–1045.

    Google Scholar 

  7. Carlsson A. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain. 1983;16:87–101.

    Article  PubMed  CAS  Google Scholar 

  8. Cohen NP, Levine WN, Marra G, Pollock RG, Flatow EL, Brown AR, Bigliani LU. Indwelling interscalene catheter anesthesia in the surgical management of stiff shoulder: a report of 100 consecutive cases. J Shoulder Elbow Surg. 2000;9:268–274.

    Article  PubMed  CAS  Google Scholar 

  9. Drinkwater BL. A comparison of the direction-of-perception technique with the Likert method in the measurement of attitudes. J Soc Psychol. 1965;67:189–196.

    Article  PubMed  CAS  Google Scholar 

  10. Hutchison RW. Challenges in acute postoperative pain management. Am J Health Syst Pharm. 2007;64(6 Suppl 4):S2–S5.

    Article  PubMed  Google Scholar 

  11. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Continuous interscalene brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesth Analg. 2003;96:1089–1095.

    Article  PubMed  Google Scholar 

  12. Ilfeld BM, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Chmielewski TL, Spadoni EH, Wright TW. Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology. 2006;105:999–1007.

    Article  PubMed  Google Scholar 

  13. Ilfeld BM, Wright TW, Enneking FK, Mace JA, Shuster JJ, Spadoni EH, Chmielewski TL, Vandenborne K. Total shoulder arthroplasty as an outpatient procedure using ambulatory perineural local anesthetic infusion: a pilot feasibility study. Anesth Analg. 2005;101:1319–1322.

    Article  PubMed  Google Scholar 

  14. Klein SM, Evans H, Nielsen KC, Tucker MS, Warner DS, Steele SM. Peripheral nerve block techniques for ambulatory surgery. Anesth Analg. 2005;101:1663–1676.

    Article  PubMed  Google Scholar 

  15. Klein SM, Nielsen KC. Brachial plexus blocks: infusions and other mechanisms to provide prolonged analgesia. Curr Opin Anaesthesiol. 2003;16:393–399.

    Article  PubMed  Google Scholar 

  16. Nielsen KC, Greengrass RA, Pietrobon R, Klein SM, Steele SM. Continuous interscalene brachial plexus blockade provides good analgesia at home after major shoulder surgery—report of four cases. Can J Anaesth. 2003;50:57–61.

    Article  PubMed  Google Scholar 

  17. Russon K, Sardesai AM, Ridgway S, Whitear J, Sildown D, Boswell S, Chakrabarti A, Denny NM. Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure. Br J Anaesth. 2006;97:869–873.

    Article  PubMed  CAS  Google Scholar 

  18. Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoral nerve block versus continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery within an established clinical pathway. Anesth Analg. 2006;102:1234–1239.

    Article  PubMed  Google Scholar 

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Acknowledgments

We thank the Departments of Anaesthesia, Surgery, and Rehabilitation at Rouge Valley Health System, Ajax Site, for their ongoing support. We also wish to acknowledge the dedication of the staff at the Durham Regional Community Care Access Centre, without whose support this project would not be possible.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Rouge Valley Health System, 601 Harwood Avenue South, Suite 200, Ajax, Ontario, Canada, L1S 2J5

    S. H. Gallay MD & J. J. A. Lobo MD

  2. Department of Nursing, Rouge Valley Health System, 601 Harwood Avenue South, Suite 200, Ajax, Ontario, Canada, L1S 2J5

    J. Baker RN

  3. Department of Anesthesia, Rouge Valley Health System, 601 Harwood Avenue South, Suite 200, Ajax, Ontario, Canada, L1S 2J5

    K. Smith MD & K. Patel MD

Authors
  1. S. H. Gallay MD
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  2. J. J. A. Lobo MD
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  3. J. Baker RN
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  4. K. Smith MD
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  5. K. Patel MD
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Corresponding author

Correspondence to S. H. Gallay MD.

Additional information

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution has approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

Appendices

Appendix 1

Service Pathway: For Durham Access to Care (DATC) and Rouge Valley Health System (RVHS) Continuous Brachial Plexus Nerve Block (CBPNB)

Pre-op consulting hospital

OR Day 1

PM of OR Day 1

OR Day2

OR Day 3 (and ongoing until d/c)

Anesthetic consult completed.

Client assessed for eligibility in relation to the Nerve Block Protocol by DATC Hospital Case Manager

Eligibility Criteria:

•    Resident of Durham Region

•    Family member available during first 24 hours of post-op period

•    Client and family competent and capable to understand all education criteria

If eligible, client admitted to DATC and nursing secured.

ACU staff introduce client to Service Pathway and provide information related to the post-op period.

Nerve Block catheter placed and monitored until client’s discharge home.

DATC Hospital Case Manager confirms service plan and receives completed pre-printed orders from Surgeon/Anesthesiologist.

Orders are faxed to Coram and Nursing Provider.

DATC Hospital Case Manager provides supplies for 1st dressing change.

Discharge instructions given to client and family/significant other by Day Surgery staff.

Nerve Block checklist completed by hospital staff and faxed to DATC and copy provided to client upon discharge.

Community Nurse visits client after 6 p.m. and completes assessment.

Continuous infusion of Nerve Block medication initiated in the home.

Education of client/family continues.

2nd p.m. visit may be required.

Nursing visit in a.m.

Assessment of client

Ensure client has booked ACU appointment for catheter removal as ordered. Informs DATC Case Manager of ACU appointment and client condition.

Dressing change as ordered.

Community Nurse contacts Anesthesiologist with update on client’s condition.

Ongoing assessment and client teaching.

Client visited by nurse the day prior to expected discontinuation of block.

Report for ACU visit completed by Community Nurse.

Client assessed in ACU by Anesthesiologist and catheter removed if appropriate.

Client to contact nursing agency with ongoing care/discharge needs.

Client discharged by nursing agency and DATC when treatment completed and catheter removed.

Nursing agency contacts Coram to pick up pump in client home.

Appendix 2

Appendix 3

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Gallay, S.H., Lobo, J.J.A., Baker, J. et al. Development of a Regional Model of Care for Ambulatory Total Shoulder Arthroplasty. Clin Orthop Relat Res 466, 563–572 (2008). https://doi.org/10.1007/s11999-007-0083-5

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  • DOI: https://doi.org/10.1007/s11999-007-0083-5

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