Chapter 12 The “Buy-In”: Administration, Anesthesiology, Nursing, and Payers
GENERAL STRATEGIES TO MAXIMIZE THE CHANCES OF SUCCESS IN IMPLEMENTING THE CHANGES REQUIRED TO DEVELOP WALANT IN INSTITUTIONS
Wide awake hand surgery has many benefits for patients, surgeons, facilities, and payers (see Chapter 2). However, making the transition from surgery with sedation requires some adaptation. Developing a strategy to generate institutional buy-in can enhance one′s ability to implement this technique into practice.
Getting buy-in from colleagues, administrators, and payers may require your investing unpaid time to set up meetings with key individuals to show them PowerPoint presentations and appeal to their common sense to do what is best for patients.
It is best to be prepared with a short but compelling discussion of what you wish to do, why you wish to pursue this route, and what you believe the advantages will be. Feel free to show them the next video clip.
Help Administrators, Nurses, Anesthesiologists, and Payers Understand Walant
We have discussed all of the advantages of WALANT versus traditional surgery with sedation and tourniquet in Chapters 2, 8, 9, 10, and 11. Show these chapters and videos to your colleagues, including the references from those chapters, to support the concept.
Seek out and involve chief stakeholders from the start. It is more effective to arrange one-on-one meetings with videos of PowerPoint presentations with key decision-makers before getting into the committee level.
Present a succinct but compelling case for why you think it is better for patients, the facility, and other stakeholders.
Show them the evidence you have for why this is a better way.
Show them the evidence you have for why it is safe and effective.
Present it in a respectful way, being certain to listen carefully to objections and concerns.
Validate their challenges in making change as you address those concerns.
Be open to discussion and ask the stakeholders what they need from you to make this work. This can go a long way toward garnering goodwill and buy-in.
It is best to make it a “win-win-win” situation for the stakeholders as well as for you and your patients. Consider the perspective of your facility colleagues and appeal to their needs.
Be flexible to accept and welcome (or even suggest) small steps toward the desired goal. If leadership will not allow you to start doing wide awake hand surgery in the full extent you desire, but will allow you a trial period or to do so within a more limited basis, that is still a step forward which should be welcomed. As staff and leadership become familiar and comfortable with wide awake surgery, the indications and use can expand.
Some compelling arguments include that you can improve patient satisfaction ratings, bring more work to the facility, increase the number of patients and cases done in a day, decrease the staff count for many procedures, open up ORs for “bigger” cases, and decrease the amount of wasted materials.
In some facilities, suggestion of a “pilot study” or “quality improvement project” or “new patient-centered care initiative” to validate what others have done in the literature may help to dissolve resistance.
Some sample narratives include the following:
“Would it be OK to try this on a few select patients and see how things go?”
“Let′s do all the monitoring you want initially, and then see if we truly need it.”
“Ok, I understand you don′t feel comfortable with this. Can you help me understand why? What parameters would help you feel more comfortable? Why don′t we start from that point and see how it goes with a few cases.”
Next Steps
After meeting one-on-one with key leaders, arrange a meeting of the “convinced” to create an action plan to institute the wide awake alternative for at least some of the patients as a starting point. Doing it in small steps may be wiser.
After you meet with key decision-makers one-on-one, consider creating a WALANT implementation group or committee with all the rest of the stakeholders so they can express their concerns and address them as a group.
Introduction to Nursing Leaders
Introduce the WALANT concept to nursing leaders and key decision-makers in the perioperative areas with one-on-one PowerPoint presentations and documents. Presentations to the rest of the nursing staff can follow later.
You can measure improved outcomes:
Nausea
Vomiting
Staff and material costs and waste
Patient time in hospital/clinic
Patient total cost of surgery
Number of times patient has a needle before the surgery
Pain of the needle(s) for the patient
Did you get to talk to your surgeon the day of surgery?
How long were you with the surgeon in a position that you could ask questions?
Turnover time
Number of patients processed/time
Case delay and cancellation statistics
Discuss cost saving, increased safety with no sedation, increased staff and patient satisfaction, quality improvement, improved efficiency, improved surgeon satisfaction, the overall great experience for the patient and family, and other relevant factors.
Introduction to Anesthesiologists
Explain to anesthesiologists that WALANT can free them up to provide care for the larger surgeries. Point out to these doctors and to nurses that they personally get no monitoring when they go to the dentist. You are planning to give exactly the same drugs they get at the dentist—only lidocaine and epinephrine within very safe doses.
Try working with your anesthesiologist to inject only propofol for the 2-minute local anesthetic injection part of the case. The patient could then wake up and participate in movement of reconstructed parts without a tourniquet. You could still educate patients and they would remember if they are not given amnestic agents, which would void their ability and opportunity to receive intraoperative education. In addition, patients would not need nausea-producing opiates.
Choose quick, uncomplicated procedures to start, such as carpal tunnel or trigger finger surgeries.
Choose tenolysis, flexor tendon repairs, and EI to EPL tendon transfers early. Operative personnel will thereafter easily understand the advantages of patients being awake, cooperative, and pain free without the tourniquet and sedation. Team members will understand how better outcomes can improve patient care in these operations.
Choose the first few patients wisely for their good disposition and cooperative demeanor.
Other good cases to start without sedation are patients with severe medical comorbidities in whom sedation or general anesthesia would be extremely risky.
Early Implementation
Obtain patient satisfaction surveys to demonstrate patient buy-in early in your implementation process. The literature has good examples of high patient satisfaction.1–3
Have staff satisfaction surveys sent out to nurses to get their input and support.
The only current option in your facility may be the main operating room with sedation. There may be no place to perform WALANT for hand procedures. Propose a “quality improvement project” that will compare outcomes of carpal tunnel surgeries performed outside of the operating room in a designated procedure room with field sterility and tumescent local anesthesia.
If there are minor procedure rooms already in existence in which surgeons or dermatologists are removing skin cancers, determine whether you can start by sharing their rooms for carpal tunnel surgery. You can then progress to minor hand trauma.
Insurance Companies and Payers
Find out who the key decision-maker is in the insurance carriers or government payers you deal with.
Request a meeting with these decision-makers and show them the video clip from this chapter and the documents that explain this new approach, which will increase patient satisfaction and safety while increasing productivity and decreasing costs.
Negotiate a facility fee or tray fee to perform carpal tunnel surgeries in your minor procedure rooms at the office, surgery center, or hospital. Explain the cost saving (see Chapter 11) when the surgery is taken out of the main operating room and into the office. Surgeons can benefit from collecting the facility fee, and insurance companies can benefit from paying lower facility fees.
Eventually, insurance companies and governments will understand that sedation and the main operating room are not essential for operations such as carpal tunnel surgery. They will be happy to save the money and increase their client/population safety and satisfaction. It is to their great advantage to negotiate a lower facility fee with you than what they pay the hospital.
PERCEIVED BARRIERS TO ADOPTING WIDE AWAKE HAND SURGERY AND HOW TO ADDRESS THESE ISSUES
General Perceived Barriers
The large number of benefits of WALANT are listed in Chapter 2. Nevertheless, in many practices there will be individuals who perceive barriers to implementation of this technique. We provide suggestions on how to deal with these concerns.
Safe Injection of Epinephrine in the Finger
Many health care workers are still not aware that the old dogma that epinephrine should not be used in the fingers is no longer valid.
Suggestions for Resolution
Provide them with Chapter 3 of this book.
Provide them with reference papers.4–8
Demonstrate the reversal of epinephrine vasoconstriction in the finger with phentolamine in your next simple hand operation, such as trigger finger release, as explained and shown in a video in Chapter 3.
Show them the clip “History of the rise and fall of the epinephrine danger myth” from Chapter 3.
Safety Concerns for Cardiac Responses to Epinephrine Effects Without Monitoring
Suggestions for Resolution
Continue to monitor patients with portable monitors for the first few months of your implementation process. It will eventually become apparent that patients do not need monitoring for lidocaine and epinephrine injection any more than they would at a dentist′s office.
Make the common-sense argument that monitors have not been used for the millions of lidocaine and epinephrine injections that occur every day without problems in dental offices. Ask the objecting person if he ever had a monitor when he personally had lidocaine with epinephrine at the dentist′s.
Point out that there are areas in your hospital where doctors inject lidocaine with epinephrine daily without monitors (Mohs surgery clinic, plastic surgery skin cancer and nevus excision, line insertion, and other instances).
When patients do have cardiac issues, decrease the concentration of epinephrine to between 1:400,000 to 1:1,000,000 and perform the procedure wide awake in the main operating room with monitors.
Give them a copy of Chapter 6, “Dealing With Systemic Adverse Reactions to Lidocaine and Epinephrine.”
“My Facility Is Not Set Up So That I Can Inject Patients Before They Come Into the Operating Room”
Ideally, you should inject the local anesthetic at least 20 to 30 minutes before the incision is done to allow optimal epinephrine vasoconstriction.9 In some facilities, this may present a difficulty in that there is no perceived space available for preoperative blocking.
Suggestions for Resolution
Although 20 to 30 minutes is ideal, you can begin a procedure sooner than that if necessary. You will need to tolerate initial temporary bleeding, which is only mildly annoying.
You can inject patients on stretchers in any preoperative holding area or in the recovery room.
You can inject patients as soon as they arrive in the operating room before you scrub and prepare and drape the patient.
Dr. Robert Van Demark, Jr., of Sanford USD Medical Center, Sioux Falls, South Dakota, recently persuaded his hospital to renovate a location for wide awake hand surgery. See Dr. Van Demark′s comments in this chapter for details.
“My Facility Requires a Witnessed Preinjection Time Out or Pause: This May Be Difficult If I Inject Local Anesthetic Outside the Operating Room”
Suggestions for Resolution
Start by performing the injections in the holding area or recovery room with a nurse there as a witness. They will probably eventually come around to seeing that this may not be necessary in an awake patient.
Point out that we developed the concept of time out in operating rooms mostly to protect patients from the risks of sedative medication. Patients cannot protect themselves while in a sedated state. When a patient is totally awake, he or she can and likely would answer the questions of health care providers. Although still possible, wrong-sided operations are much less likely.
Point out that there are places in your hospital outside the operating room where doctors inject local anesthetics in unsedated patients without time outs.
Patient-Perceived Barriers
It will be essential to change the culture of patients’ expectations: perhaps a family member or friend had sedation for the same surgery and they feel they need sedation.
Most Patient Concerns Arise From Fear of the Unknown
Suggestions for Resolution
A calm, confident attitude with soft-spoken, straightforward explanations of the truth about how simple WALANT hand surgery can be is very reassuring for patients. Explain that the safest sedation is no sedation. Use the strategies discussed in Chapter 7 and point out all the benefits of being awake from Chapter 2.
Fear of Pain
Suggestions for Resolution
Explain to patients that advances in local anesthesia make it possible that smaller local anesthetic needles (27- or 30-gauge) hurt less than the larger intravenous cannula needles commonly used for sedation (20-gauge).
Tell them that the only pain they will likely feel is one little stick from a tiny needle—and then deliver on that promise as outlined in Chapter 5. Score yourself each time you inject local anesthetic so you can consistently deliver minimally painful injections.
Fear of Knowing What the Surgeon Is Doing, Hearing Noises and Conversations
Suggestions for Resolution
Explain to patients that they can chose to know or not know what the surgeon is doing, as they wish. If they would like to be totally “out of the know.” they can bring in music with headphones and ignore the whole event. If they change their mind and would like a “play-by-play” of the surgery, this can easily be accommodated by experienced wide awake surgeons. Many patients do like to see parts of their surgery.
Nurse-Perceived Barriers
It will be necessary to change the culture of nurses: most of their concerns are a result of the fact that they have never tried the wide awake approach. Most of the perceived issues go away quickly after even a short exposure to the technique.
Most Nursing Concerns Come From Fear of the Unknown
Suggestions for Resolution
As a first step, meet one-on-one with key administrative nurses, as outlined earlier in this chapter.
Have the nurses who seem more receptive to the WALANT concept be the first to try a few cases.
Claustrophobia From the Drapes
Suggestions for Resolution
Explain to the nurses that draping is there to protect the patients and decrease the potential of infection, not to drive patients crazy or unnerve them. Draping that leaves the head free of drapes can easily accommodate the concerns of such patients and maintain an ample sterile field.10
What Happens If the Patient Feels Pain?
Suggestions for Resolution
The surgeon can always inject more local anesthetic and the pain will go away. If the surgeon follows the simple guidelines of tumescent local anesthetic administration (see Chapter 4) and minimal pain injection of local anesthetic (see Chapter 5), this should be as infrequent as patients waking up during general anesthesia. The only reasons patients may feel pain during the surgery are that an insufficient volume of anesthetic solution was injected or insufficient time was allowed for the local anesthetic to take effect. Just as airline pilots always make sure they have enough fuel to land at an alternate airport, surgeons or anesthesiologists giving the local anesthetic should always be prepared to be able to inject more local anesthetic volume while staying within the safe dosage limit.
Related posts:
Chapter 3 Safe Epinephrine in the Finger Means No Tourniquet
Chapter 11 Revenues Increase and Costs Decrease With Walant
Chapter 6 Dealing With Systemic Adverse Reactions to Lidocaine and Epinephrine
Chapter 9 Walant Hand Surgery in Infants and Children
Chapter 7 Tips on Talking to Your Patients About Walant
Chapter 16 Minor Procedure Room Setup
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