Briefest Time to Perform a Series of Preoperative Nerve Blocks in Multiple Patients: A Simulation Study

Introduction To mitigate first-case delays in operating rooms, sufficient additional time must be allotted when anesthesiologists perform preoperative nerve blocks in multiple patients who are scheduled as the initial cases of the day. We used spinal anesthetics performed in dedicated block rooms located just outside the operating room suite to estimate the briefest times needed to complete a series of spinal, epidural, peripheral, or other regional nerve blocks. We followed this approach because even though the studied hospital had a busy regional anesthesia service, sample sizes were insufficient and electronic data were not available to directly study the time to perform the many other nerve blocks they perform. Methods We studied a historical cohort of 8,462 adult patients undergoing spinal anesthesia between 2005 and 2017. Preoperative evaluation, consent, and holding area tasks were completed before entering the block room; the times to complete these tasks were not available for study. Upon block room entry, the electronic anesthetic record was started, a timeout conducted with patient participation, vital signs taken, and the spinal performed. The interval from entry until intrathecal injection was the spinal block time. Because fits of these times to probability distributions previously used for anesthesia times were poor (p < 0.001), percentiles of times to perform one or more spinal anesthetics were calculated using Monte-Carlo simulation (100,000 samples with replacement) from the empirical distributions. Results The mean spinal block time was 8.8 minutes. The 90% upper prediction limit for one block was 14 minutes, with progressively decreasing times for each subsequent block for a 90% chance of finishing on time. For example, for three first-case regional or neuraxial blocks performed outside the operating room by one anesthesiologist, the first patient needs to arrive at least 38 minutes earlier than non-block patients to mitigate operating room start delays. Conclusions These minimum time estimates can help nursing leadership ensure that sufficient time will be available after patients are ready for anesthesia to avoid first-case delays when preoperative regional anesthesia is performed outside the operating room. Given that inadequate sample size and documentation issues likely exist universally for the various non-neuraxial preoperative nerve blocks, we recommend that hospitals use our estimates as a minimum starting point rather than try to calculate times using their own data. Then, as a systems-based metric to assess all steps in the process, track the percentages of days for which all blocks were completed in sufficient time to avoid a first-case delay for those patients. Adjustments to the arrival times would then be implemented, if needed, to meet hospital objectives for on-time starts.