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Ambulatory
Anesthesia
Clinical Program
The Division of Ambulatory Anesthesia is responsible for the delivery of all anesthesia services at the Ambulatory Surgery Center (ASC), which opened to patients on July 13, 1998, in the North Pavilion. The Center has nine operating rooms with eight presently functional. From July 13, 1998, through December 2004, our division provided anesthesia coverage to 39,129 patients and postoperative acute pain management services to 5,540 overnight patients in our eight-bed 23-hour Recovery Care Center (RCC).
The Division of Ambulatory Anesthesia offers a wide variety of novel regional anesthesia techniques that enhance the options available to patients for both their intraoperative experience and for the management of postoperative pain. Our ultimate goal is to offer preoperative education, advanced regional anesthetic techniques, prolonged postoperative pain management, and improved perioperative outcomes.
Approximately 58.7% of our patients had surgery in 2004 under regional anesthesia or combined technique in 2004 (4,103 of 6,987; see Figure 1). Most notable is our emphasis on the predominant use of non-central, neuraxial regional anesthesia techniques for both upper and lower extremity and truncal surgery when possible. The peripheral nerve regional anesthesia techniques allow the most flexibility and stress-free recovery for our ambulatory surgery patients. The excellent postoperative analgesia that results by using single injection and continuous peripheral nerve blockade is unparalleled. Ninety-eight and a half percent of the patient population at our Center rate their experience with anesthesia and pain management as very satisfied or satisfied 24-hours postoperatively. Seven days postoperatively, 94.9% of patients were either satisfied or very satisfied with their care (see Figure 2).
The division has developed a successful protocol for a home perineural catheter infusion system for managing postoperative pain. A large number of patients has been sent home with continuous catheter infusion for 72 hours. Patients and their families are carefully educated about this program. By using continuous catheter technique, our division is improving health outcomes, including superior analgesia and high patient satisfaction. The success of this protocol continues to be tremendous. In 2004 we sent 163 patients home with infusion pumps. Of those 163 patients, there were no adverse events reported. The satisfaction scores for this patient population are excellent. Our research nurses closely monitored these patients by telephone follow-up interviews during the home infusion experience, offering assistance with patient questions or concerns.
The Breast Imaging Center continues to offer our breast surgery patients a less stressful option of having needle placement and surgery performed in the same building. Relieving this patient population of the anxiety of transport for off-site needle placement prior to surgery has been a huge improvement in the delivery of care for these patients. We continue to improve our protocol for breast procedures by performing paravertebral blocks not only for surgical procedures but also for diagnostic procedures including needle localization. The collaboration between Ambulatory Anesthesia and the Breast Imaging Center has provided a much less stressful, more accessible, and more efficient treatment course for breast patients. Many of our patients who undergo mastectomy and other breast procedures and who opt for regional anesthesia do not require postoperative narcotics for pain control and experience no postoperative nausea and vomiting. The ASC performed approximately 200 needle localizations this year.
Training Program
The division provides one-month rotations at the ASC for CA-2 and CA-3 residents. Fellowships in regional and ambulatory anesthesia are also available for perioperative clinical patient care, which includes preoperative patient evaluation, operative ambulatory regional and general anesthesia, and acute pain management in the RCC. After our fellows complete their training, they may expect to have a broad expertise in regional and ambulatory anesthesia. We receive inquiries regarding our fellowship program on a regular basis, and candidates undergo a stringent selection process to ensure a maximum benefit for all those involved in the fellowship program.
The Division of Ambulatory Anesthesia is distinguished as a Center of Excellence in regional anesthesia. Our Center is one of five centers across the nation who have earned this distinction. This meritorious recognition promotes interest in training at our Center from other institutions around the world.
Since 2001 the anesthesia staff has partnered with the U. S. Army in support of the Army Regional Anesthesia Initiative. Our collaborative goal is to bring our cutting-edge, advanced regional anesthesia techniques to the U.S. Armed Forces for use in times of peace and war. Two recent fellows, Lt. Col. Chester Buckenmaier, MD, HS ’01-’02, and Maj. Scott Croll, MD, HS ’03-’04, have studied these techniques in one-year fellowships at the ASC. Immediately prior to his July 2003 arrival at Duke, Dr. Croll served in Operation Iraqi Freedom at a combat support hospital near Baghdad, Iraq. Dr. Buckenmaier recently returned from a three-month field trial, where he demonstrated that the continuous peripheral nerve blockade techniques he mastered at Duke can be performed on the modern day battlefield for a newly fallen soldier. This provides the soldier continuous state-of-the-art pain control from the time of injury on a foreign soil throughout the air evacuation process, back to the continental United States. Exciting testimonies and publications continue to evolve from this incredible use of regional anesthesia. Our staff takes great pride in having indirectly comforted and cared for American soldiers injured on a battlefield halfway around the world through the hands of Drs. Buckenmaier and Croll. This collaborative relationship involving education and training continues between the Division of Ambulatory Anesthesia and the military.
Highlights of 2004
In April, Dr. Susan M. Steele provided a live videocast from the Center to the Society for Ambulatory Anesthesia’s Annual Meeting in Seattle. The video of patients undergoing a variety of peripheral nerve blocks in a live setting provided a perfect format for demonstrating our expertise in the preoperative area with block placement all the way to delivery of the patient to the operating room. Several surgeons interviewed during the videocast gave testament to their high rate of satisfaction with the perioperative process at the ASC and their appreciation of regional anesthesia. This was an extremely exciting and innovative teaching resource and provided an excellent showcase for the safe and efficient use of regional anesthesia. The entire staff and faculty of the Division of Ambulatory Anesthesia and the ASC was involved in this initiative. A back up video was made and now serves as an educational resource. At the conclusion of the videocast, breakout workshops held under the direction of Dr. Susan M. Steele and five other world-renown regional anesthesiologists continued to provide regional anesthesia education to clinicians from around the world.
Filming of the live videocast from the ASC to the SAMBA workshop in Seattle, April 2004.
Another highlight this year was a textbook publication. Susan M. Steele, MD, Karen C. Nielsen, MD, and Stephen M. Klein, MD, were editors of a textbook released for publication in December of 2004. As editors, the coordination, proofing and review of the many chapters of the textbook was a timely and tedious work for more than two years. Upon release in December of 2004, the beautifully illustrated and written textbook, entitled “Ambulatory Anesthesia and Perioperative Analgesia” promises to be a “must have” for those clinicians interested in the increasingly utilized and important subject of ambulatory anesthesia. A distinguished group of authors, many from our own Duke family, contributed chapters to the textbook. A recently released review from Doody’s Book Review rated the textbook with five stars, which is defined as “[an] exceptional title with nearly flawless execution.” With more than 17,500 books reviewed by Doody’s 1993 to 2004, only 8% of the titles have received five stars.
GOALS
The ASC celebrated its sixth year of operation in July of 2004. We continue to envision goals for the future that will enhance and strengthen our mission. Our statistics continue to reveal that we are achieving excellent patient satisfaction: this remains our first and foremost goal.
We provided regional anesthesia to almost 60% of our patient population this year. We will continue to offer a wide variety of anesthesia options to our patients with special focus on advanced regional anesthesia. Our status as a Center of Excellence in regional and ambulatory anesthesia techniques has allowed us to offer training to fellow anesthesiologists throughout the country. We continue to develop the division at Duke as a guiding force in education and training for regional anesthesia both nationally and internationally.
We continue to integrate our outcomes data with patient satisfaction and have expanded it to look at the cost of care delivery. As we broaden and hone the outcomes database, we are establishing a model in the field of outcomes for ambulatory surgical centers. Improved technologic enhancement to our database systems will improve the deliverance of vital information regarding ambulatory surgery and patient satisfaction. We are now including data from patients who spend time in our RCC. This will broaden our data collection even further to record the entire patient experience.
As volumes increase at the ASC, it is our goal to open our ninth operating room in 2005. This will enable the Center to continue to grow our volume while providing safe anesthesia options to our patients.
Dr. Ricardo Pietrobon has involved the Division of Ambulatory Anesthesia both nationally and internationally in exciting research projects. His expertise in grant writing and networking has opened doors for our division to expand our research interests. It remains our goal to participate in research that defines the art of regional anesthesia and its benefits to healthcare--not only for promoting patient safety but also in establishing a reduction in healthcare costs.
We continue to strive to identify patient populations appropriate for the ASC that will benefit from clinical pathways aimed to improve patient outcomes and decrease healthcare costs.
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Steven M. Klein, MD
Associate Professor of Anesthesiology
Chief, Division of Ambulatory Anesthesia
Medical Director, Ambulatory Surgery Center
Office: (919) 668-2056
E-mail: klein006@mc.duke.edu
Faculty
Susan M. Steele, MD
Stephen M. Klein, MD
Karen C. Nielsen, MD
Marcy S. Tucker, MD, PhD
Ricardo Pietrobon, MD, PhD
Fellows
Reginald Julien, M.D.
Fernando Altermatt, M.D.
CRNA Coordinator
Paula Alford, CRNA
CRNA Staff
Paula Alford, CRNA
Narda Croughwell, CRNA
Fred Fesel, CRNA
Robert Foy, CRNA
Patricia Hill, CRNA
Ronald Iacone, CRNA
Carolyn Knoop, CRNA
David Lee, CRNA
Mary Murphy, CRNA
Flora O'Brien, CRNA
Tammy Schaeffer, CRNA
Kena Sigman, CRNA
Susan Tomso, CRNA
Steve Ziegler, CRNA
Support Staff
Kathy Clifton
Heather Elliott
LuAnne Latta
Featured Publication
Steele SM, Nielsen KC, Klein SM, eds. Ambulatory Anesthesia and Perioperative Analgesia. 1st ed. New York, NY: McGraw-Hill, 2005.
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