The Transformation of Ambulatory Orthopaedic Surgical Anesthesia: A Mixed Methods Study of Diffusion of Innovation in Healthcare

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1 University of New Mexico UNM Digital Repository Collaborative works Orthopedics The Transformation of Ambulatory Orthopaedic Surgical Anesthesia: A Mixed Methods Study of Diffusion of Innovation in Healthcare Kyle Leggott Follow this and additional works at: Recommended Citation Leggott, Kyle. "The Transformation of Ambulatory Orthopaedic Surgical Anesthesia: A Mixed Methods Study of Diffusion of Innovation in Healthcare." (2016). This Presentation is brought to you for free and open access by the Orthopedics at UNM Digital Repository. It has been accepted for inclusion in Collaborative works by an authorized administrator of UNM Digital Repository. For more information, please contact disc@unm.edu.

2 The Transformation of Ambulatory Orthopaedic Surgical Anesthesia: A Mixed Methods Study of Diffusion of Innovation in Healthcare Anesthesia and Critical Care Medicine University of New Mexico Health Sciences Center Grand Rounds March 25, 2016 KYLE LEGGOTT, MSIV

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4 Disclosure and Conflicts of Interest None

5 Research Objective To provide insight into how an innovation in healthcare is implemented and diffuses into the system. Specifically, the innovation of transitioning from the routine use of general anesthesia (GA) to peripheral nerve blocks (PNB) for anesthesia during ambulatory orthopaedic procedures on the upper and lower extremities.

6 Research Objective A major challenge in healthcare is to identify and implement innovations that achieve Berwick's triple aim of healthcare. 1 Improve the experience of care Improve the health of populations Lowering the cost of health care After identifying such innovations, another challenge is timely implementation and diffusion of these innovations throughout a delivery system. The time from discovery of a scientific innovation to its routine use has been estimated to be about 17 to 24 years. 2,3

7 Diffusion of Innovations (DOI) Theory Everett Rogers Diffusion: The process by which an innovation is communicated through certain channels over time among members of a social system. Elements of DOI Attributes of the innovation Communication Channels Time Social System

8 Diffusion of Innovations (DOI) Theory Types of Innovation-Decision Making Adopter Categories Optional Innovators Collective Early Adopters Authoritative Early Majority Contingent Late Majority Late adopters

9 Background: PNBs vs. GA Recent studies suggested that PNBs are safer and more efficient and that their use can decrease overall expenses as a result of a reduced hospital stay compared with GA. 5,6,7,8 These advantages may be enhanced by ultrasound-guided administration of PNBs. 6

10 Background: PNBs vs. GA Less post-op pain Jankowski et al. found that patients who received PNBs reported significantly less postoperative pain at 60, 90, and 120 minutes after surgery than those who received GA. 7 Increased patient satisfaction In addition, patients who had GA were less satisfied with the anesthetic technique and pain control than patients given PNBs or spinal anesthesia. 7 Less time in post-op recovery Hadzic et al. observed that patients who received PNBs were more likely to bypass the acute airway recovery requirements after surgery than those who had GA. 8 Patients in the PNB group were discharged to home a mean of 123 minutes sooner than GA patients, although their time in the operating room was similar. 8

11 Study Design We utilized a mixed methods quantitative and qualitative methodology. Quantitative Retrospectively reviewed operative and anesthesia records from 1998 to 2012 at the UNM. Select ambulatory orthopaedic procedures. Distal radius fracture repairs, arthroscopic knee meniscectomies, and arthroscopic knee meniscus repairs. Identifying the type of anesthetic used. GA only vs. PNB only vs. GA + PNB.

12 Study Design Qualitative Research The study of the why and how of decision making We used qualitative methodology to get a comprehensive understanding of the processes that led to the diffusion and adoption of PNBs. Qualitative Study Design Interview guide derived from Diffusion of Innovations (DOI) theory. Interviewed orthopaedic surgeons, anesthesiologists and nursing administrators present at the time of the innovation. Using DOI framework and inductive thematic review of the interviews, we identified key themes associated with the adoption of PNBs at UNM Hospital.

13 Study Design Figure 1 Example of coding matrix used for qualitative analysis of interviews with surgeons, anesthesiologists and nursing administrators present at the University of New Mexico (UNM) Hospital at the time of the innovation.

14 Principal Findings From 2003 to 2012 the use of PNBs increased from less than 10% to over 70%. The adoption timeframe followed an S-shaped curve (Figure 2). Key themes included: improved safety, quality and efficiency, physician leadership and trust, organizational structure and technological changes. The innovation was an optional decision-making process that took root in a satellite facility.

15 Principal Findings 90% Figure 2 Percentage of ambulatory orthopaedic procedures in which a peripheral nerve block was used for anesthesia at the University of New Mexico Hospital, according to year. The error bars represent 95% CIs. 80% 70% 60% 50% 40% 30% 20% Sampling Threshold Outpatient Surgery Center Established (2003) Ultrasound Guided PNB Begins (2005) 10% 0%

16 Principal Findings Figure 3 Percentage of outpatient orthopedic procedures in which a peripheral nerve block (PNB) only, general anesthesia (GA) only, or PNB and GA, were used for anesthesia at the University of New Mexico (UNM) Hospital, according to year.

17 Decision Making Process DOI theory describes 5 stages of the decision making process. 1. Knowledge: Innovator, regional/national conferences and workshops, shared knowledge. 2. Persuasion: 3 anesthesiologists at OSIS, persuasion of orthopaedic surgeons, strong interpersonal communication, trust. 3. Decision: Optional decision, made serially by anesthesiologists and surgeons. 4. Implementation: Trialability, observability, organizational structure (block rooms, block nurses), technological changes. 5. Confirmation: Integration into resident education, continued high utilization of PNBs.

18 Safety, Quality, and Efficiency you don't have to put the whole body to sleep like you do with a general anesthetic the patients do much better because when the surgery is done, they have no pain. They are able to go home much faster than recovery from a general anesthetic. There is a low incidence of nausea and vomiting. Anesthesiologist #1

19 Physician Leadership and Trust I was very nervous, I had no faith. And anesthesia talked me into it. And, I soon fell in love with the sciatic nerve block We followed their [anesthesiologists ] lead, we trusted them. Orthopaedic Surgeon #2

20 Technological Change When we first started doing peripheral nerve blocks in a big way at OSIS, it was before people were doing them with ultrasound; the technology at that time was evolving into using a peripheral nerve stimulator to put the needle near a nerve, stimulate it, get a muscle response, and it was more difficult to probably learn that technology than it is to even learn ultrasound technique. Anesthesiologist #2

21 Interpersonal Communication We had to do a lot of communicating and talking to the surgeons, you know, telling them all the advantages of it, and pointing out that it wouldn t take that much longer And teaching the residents, that was a big part of what we do too. Anesthesiologist #4

22 Organizational Structure I think what made it easy was the way they [anesthesiologists] developed their training for it, and their patience for teaching the nurses who were helping them, and their organization of supplies. Nurse administrator

23 Conclusions PNB provides a useful model to understand the adoption and diffusion of an innovation using optional decision-making in the healthcare setting and has the potential to fulfill the triple aim of better health and healthcare and reduced cost. Critical elements include Characteristics of the innovation, which facilitated the decision-making process. The positioning of the innovation in a satellite facility away from the core clinical facilities.

24 Conclusions Rogers DOI theory is a useful framework for understanding the forces that influenced the diffusion and adoption of PNBs. Our findings may be helpful to others interested in implementing innovations in healthcare.

25 Take Home Messages This project was a collaboration between anesthesia, orthopaedics, emergency medicine, community health, and a medical student. Power of collaboration in understanding this diffusion of innovation in healthcare. Innovations can be identified and implemented to achieve the triple aim of healthcare, without institutional mandates.

26 Questions?

27 References 1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008; 27: Trochim W, Kane C, Graham MJ, Pincus HA. Evaluating translational research: a process marker model. Clin Transl Sci. 2011; 4: Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011; 104: Rogers EM. Diffusion of innovations. 5th ed. New York: Free Press; Duncan CM, Hall Long K, Warner DO, Hebl JR. The economic implications of a multimodal analgesic regimen for patients undergoing major orthopedic surgery: a comparative study of direct costs. Reg Anesth Pain Med. 2009; 34: Chan VW, Perlas A, McCartney CJ, Brull R, Xu D, Abbas S. Ultrasound guidance improves success rate of axillary brachial plexus block. Can J Anaesth. 2007; 54: Jankowski CJ, Hebl JR, Stuart MJ, Rock MG, Pagnano MW, Beighley CM, et al. A comparison of psoas compartment block and spinal and general anesthesia for outpatient knee arthroscopy. Anesth Analg. 2003; 97: Hadzic A, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, et al. Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy. Anesth Analg. 2005; 100: