An interesting concept but troubling in its implementation. I applaud the effort and encourage the expansion of regional anesthesia in the ED. However, as a dual trained EM-Anesthesiologist, I see several issues not mentioned in the approach to this concept:
1. A block service already exists in most institutions, often labeled APS, i.e. Acute Pain Service. While often they do not perform many, if any, consults in the ED, it is substantially easier, more diplomatic and lore streamlined to simply discuss with the existing APS to extend consults in the ED. If there is resistance, then there is the case to be made about allowing EM physicians to join APS and help cover consults, especially those in the ED.
2. There is no mention of the additional staffing needed for such a service. These blocks are never done by a solo provider and need nursing +/- additional provider support.
3. There is no discussion of the ED willing to sacrifice their staff to help man this service. Especially since the only EM providers appropriate for this would be US fellowship trained physicians, at least until regional anesthesia is a core curriculum component of residency training.
4. There is no mention of the service following patients post block. APS typically rounds on patients they have placed blocks or catheters daily for a portion of their inpatient stay.
5. EM clinicians are not trained as of yet for catheter placement.
Overall this concept is appreciated but in its infancy and should be approached with significant more thought and consideration, as well as collaboration with anesthesia and inpatient teams.
Dave,
Thank you so much for your reply, and I think these are all issues that we tried to address but unfortunately ran out of room. It is of utmost importance to us to collaborate with our anesthesiology colleagues to do what is best for patients. Would love to touch base with you to discuss more if you want but in summary:
1. We are a medium community academic center and like many other centers in our situation there is no APS (other than us). There are other background issues that I can discuss with you in regards to this.
2. We actually have dedicated block nurses that assist us with our procedures and monitoring of patients. There are multiple members of our team.
3. I can discuss our staffing model with you if you like.
4. We do follow our inpatients and select outpatients that we have blocked and also have a follow-up process in the rare case of nerve injury.
5. That is correct many are not! However, there are some EM physicians who perform these and often times we are able to significantly help patients by other means. We are excited about the potential to expand to catheter options in the future.
Most importantly this isn’t about trying to invade the turf or take over for another specialty. This is about trying to fill a gap that exists in many non tertiary academic hospitals. I really look forward to meeting/speaking with you. Feel free to reach out!
2 Responses to “The Business Aspects of Establishing a Novel Service Line in the Emergency Department”
February 16, 2025
David LeonAn interesting concept but troubling in its implementation. I applaud the effort and encourage the expansion of regional anesthesia in the ED. However, as a dual trained EM-Anesthesiologist, I see several issues not mentioned in the approach to this concept:
1. A block service already exists in most institutions, often labeled APS, i.e. Acute Pain Service. While often they do not perform many, if any, consults in the ED, it is substantially easier, more diplomatic and lore streamlined to simply discuss with the existing APS to extend consults in the ED. If there is resistance, then there is the case to be made about allowing EM physicians to join APS and help cover consults, especially those in the ED.
2. There is no mention of the additional staffing needed for such a service. These blocks are never done by a solo provider and need nursing +/- additional provider support.
3. There is no discussion of the ED willing to sacrifice their staff to help man this service. Especially since the only EM providers appropriate for this would be US fellowship trained physicians, at least until regional anesthesia is a core curriculum component of residency training.
4. There is no mention of the service following patients post block. APS typically rounds on patients they have placed blocks or catheters daily for a portion of their inpatient stay.
5. EM clinicians are not trained as of yet for catheter placement.
Overall this concept is appreciated but in its infancy and should be approached with significant more thought and consideration, as well as collaboration with anesthesia and inpatient teams.
February 18, 2025
Ricahrd SlamaDave,
Thank you so much for your reply, and I think these are all issues that we tried to address but unfortunately ran out of room. It is of utmost importance to us to collaborate with our anesthesiology colleagues to do what is best for patients. Would love to touch base with you to discuss more if you want but in summary:
1. We are a medium community academic center and like many other centers in our situation there is no APS (other than us). There are other background issues that I can discuss with you in regards to this.
2. We actually have dedicated block nurses that assist us with our procedures and monitoring of patients. There are multiple members of our team.
3. I can discuss our staffing model with you if you like.
4. We do follow our inpatients and select outpatients that we have blocked and also have a follow-up process in the rare case of nerve injury.
5. That is correct many are not! However, there are some EM physicians who perform these and often times we are able to significantly help patients by other means. We are excited about the potential to expand to catheter options in the future.
Most importantly this isn’t about trying to invade the turf or take over for another specialty. This is about trying to fill a gap that exists in many non tertiary academic hospitals. I really look forward to meeting/speaking with you. Feel free to reach out!