Our obsession with providing the latest clinical interventions and technologies for our patients is both a blessing and a curse. As we have seen in previous posts, our attraction to the shiny new, the technically sophisticated, the next best thing results in our losing sight of the basic care processes that provide the critical support to innovation. Aside from the fact that we have never really learned how to implement and integrate new technologies using systems-thinking, our disregard for the basics repeatedly sabotages the success of any new intervention or technology.
As I was rounding on the post-operative pain service this week, I hit upon a great example of the new being implemented upon the crumbling old. We manage a large percentage of our post-surgical patients’ pain with epidurals and with peripheral nerve catheters. Regional anesthesia is particularly useful for major thoracic, abdominal and orthopedic cases, and by the end of the week we are usually managing pain for thirty to forty patients. Patients with epidurals and peripheral nerve catheters are generally very appreciative of the pain control provided with this modality, which validates and reinforces our use of regional anesthesia.
Regional anesthesia has been around for a long time and traditionally blocks were placed without direct visualization. When I did my regional anesthesia fellowship eleven years ago, we relied on superficial anatomic landmarks, tactile and verbal feedback from patients to guide our block placement. To reduce the risk of injury and to improve the success of the peripheral nerve block, we started using electrical nerve stimulators, which served as a type of homing signal and provided visual feedback as the nerve to be blocked was approached. The sophistication of the nerve stimulator increased but this was not good enough, so along came the next technology: Ultra-sound guidance. Now the possibility exists for direct visualization of the nerves to be blocked, presumably with another jump in successful pain control and a reduction of complications.
On the post-surgical side, the technology focus was on the pumps used to deliver the local anesthetics. What started out as adaptations to pumps used for intravenous medications evolved into sophisticated, patient controlled pumps designed specifically for local anesthetics. They were safer and provided the opportunity patient-centered pain control. The technology development for these devices continues.
Enter the snafu. In the fifteen years that I have been doing regional anesthesia and acute post-operative pain management, I would be hard pressed to say that the quality of pain management with nerve blocks has improved significantly. How can this be? We have better techniques for placing nerve catheters, the pumps are better, the technology in these areas keeps advancing. There are numerous reasons, but the one that jumped out at me was in the picture above: the connector piece between the block catheter and the pump tubing. The technical challenge is to secure the small bore nerve catheter to the large bore pump tubing such that it will be resistant to disconnection; disconnection disrupts the continuous delivery of local anesthetic, resulting in pain, and disconnection contaminates the nerve catheter end, resulting in an increased risk of infection. Catheter disconnects occur on an almost daily basis and in spite of this, look at the technology applied to this problem: safety pins, three way stop-cocks, tongue depressors, tape, more tape. This method of connection has not changed in at least fifteen years, not because we can’t improve upon it but because it just isn’t sexy enough to grab our attention! The absurd juxtaposition of the high tech supported by the primitive is not lost on the patients, who frequently let out a nervous chuckle as we jerry rig their lifeline for pain control.
What struck me about this example is how analogous it is to the current condition of healthcare. Technology advances and the focus of most quality initiatives occur on top of an invisible infrastructure of basic care processes that are barely being held together by creative repair jobs. When they break, we add more tape. They get our reactive attention only when something catastrophic happens. Usually we add more tape…
Until we make these basic care processes visible and important (the critical 20%), quality improvement will remain marginal and expensive.
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