Preaching beyond the choir: implementation science is the missing piece to widespread adoption of ultrasound-guided regional anesthesia

During the early years of emergency medicine, procedural analgesia was an afterthought which probably contributed to patient anxiety when managing fractures or dislocations (1). Fortunately, emergency medicine became attuned to patient comfort and adapted emergency department (ED) procedural care to include systemic analgesia and procedural sedation. Current American College of Emergency Physician Clinical Policies provide guidance on procedural sedation medication choices and safe monitoring practices (2). Although procedural sedation is generally safe and well tolerated, multiple ED personnel are often required for monitoring including a nurse for charting and medication administration, one clinician for the sedation and another for the procedure, and often a respiratory therapist—which can be ergonomically problematic in a busy hospital with competing demands on time and a constant stream of potentially critically ill patients in a sea of waiting room patients (3,4). Ultrasound-guided regional anesthesia (UGRA) offers a promising alternative to procedural sedation for a variety of painful procedures ranging from fracture/dislocation management to wound repair, abscess drainage, rib injuries, and more. However, implementing this alternative at scale requires effort that trains ED clinicians to identify the appropriate anatomy via sonography and safely administer local anesthetics while monitoring for potential adverse events. A role for Implementation Science is undeniable.

The Institute of Medicine once estimated a 17-year delay for just 14% of practice-ready research evidence to reach the bedside, a reality that the Society for Academic Emergency Medicine depicted during the 2007 Consensus Conference via the Knowledge Translation Pipeline (Figure 1) (5). UGRA in an ED setting was first described by Blaivas in 2006 and contemporaneously most academic settings report using regional anesthesia (6,7). That said, the training provided to trainees in this tool is variable, and therefore, the extent to which all physicians can provide this option in routine care is debatable. Farrow et al. highlighted the potential benefits of UGRA while simultaneously noting the challenges of implementing such programs across diverse EDs (8). UGRA offers several advantages over traditional methods. The real-time visualization of anatomical structures allows for more accurate needle placement, reducing the risk of complications and improving the success rate of nerve blocks (9). Theoretically, regional anesthesia reduces exposure to opioids in an era when reducing use of opioids has been acknowledged as a priority for emergency medicine (10,11). Additionally, ultrasound guidance enables a more targeted and lower-dose administration of local anesthetics, minimizing the risk of systemic toxicity.

Figure 1 The knowledge translation pipeline. PDA, personal digital assistant; EBM, evidence-based medicine; ED, emergency department.

Farrow et al. reported the results of prospectively collected data exploring the outcomes of ED UGRA at their community teaching hospital in Florida and two associated free-standing EDs. After their ED ultrasound director and orthopedic surgery leadership coordinated with anesthesia and pharmacology to create an UGRA protocol, participating ED physicians were credentialed. It is unclear whether the investigators leveraged existing guidelines for competency in ultrasound-guided nerve blocks (12). In total, 21 emergency medicine residents, two ultrasound fellows, and 25 ED attending physicians worked clinically across these three sites but only 18 performed UGRA. The authors do not report whether the other 30 physicians chose not to participate or had not become credentialed (or why they did not become credentialed), or simply did not encounter patients in whom regional anesthesia was indicated. To become credentialed physicians needed to perform and record 20 ultrasound-guided nerve blocks with quality assurance monitoring by the ultrasound division. These individuals also had to maintain five credits of ultrasound specific continuing medical education (CME) annually. The authors do not report the median length of time required per physician to accrue 20 ultrasound-guided nerve blocks that met quality assurance purposes, nor do they contemplate the expense entailed in maintaining the CME requirement or the lost opportunity cost neglecting other procedural, educational, or scholarly activities in order to attain and maintain this proficiency. They used a variety of probes and ultrasound machines across the three sites. Most ultrasound-guided nerve blocks (68.6%) were performed for orthopedic injuries, including for procedural anesthesia as well as non-procedural pain control. The vast majority of ultrasound-guided nerve blocks (202/229 or 88%) were performed by ultrasound fellowship trained attendings (n=141) or ultrasound fellows (n=61). Realistically, this does not paint the picture of uptake of ultrasound-guided regional nerve blocks to the entire faculty.

If the overall objective is for 100% of the ED faculty to be capable of providing UGRA around-the-clock confidently and safely, this study does not demonstrate feasibility. Exploring the path to a more generalizable feasibility through the lens of Implementation Science is imperative because the investment in time, CME funds, and personnel career development is probably worthwhile for emergency medicine because efficient and effective pain relief not only improves patient satisfaction but is also linked to reduced hospital length of stay and lower healthcare costs (13,14). Some “leaks” in the Knowledge Translation Pipeline that can be gleaned from Farrow et al. include:

• Training and education: the investigators reported a multidisciplinary protocol and rigorous quality assurance program upon which the UGRA intervention was built, but they note problems with some orthopedic surgery consultants who did not permit regional anesthesia for their patients. This is also a common scenario at our institutions and highlights the need for transdisciplinary education (not just ED physicians) as well as local opinion leaders within orthopedic surgery, anesthesia, and pharmacy to overcome this acceptance barrier before it occurs during a clinical encounter (15).
• Skill acquisition and maintenance: as noted, 88% of the ultrasound-guided nerve blocks were performed by ED physicians with formal ultrasound training. Most ED physicians do not pursue ultrasound fellowships, so closing gaps in the “able” leak of the Knowledge Translation Pipeline mandates creating impactful and sustainable pathways for those non-fellowship trained ED physicians to attain minimal proficiency. Farrow et al. reported on 26 different types of blocks and assume that 20 total blocks confer proficiency, but does this quantity of UGRA exposures consistently confer competency? How many ultrasound-guided nerve blocks are required to attain proficiency? How do we know that number is appropriate for every physician? How do sites that lack an ultrasound champion attain that number of observed nerve blocks and how do they maintain proficiency without quality assurance processes in place? Since about six of the nerve blocks would have sufficed for the vast majority of scenarios, why not have sites focus on a handful of nerve blocks rather than striving to learn 20 different procedures? Most pointedly, ED physicians are frequently asked to obtain annual CME requirements for trauma, stroke, cardiology, pediatrics, geriatrics, and a constellation of other acute care scenarios and American Board of Emergency Medicine specialty maintenance. Since time is finite, where should busy ED physicians carve the time from to develop ultrasound-guided nerve block proficiency? Another approach would be to train enough UGRA experts to staff every ED around-the-clock, but ACEP now lists UGRA as within the scope of every emergency physician (like airway management, cardioversion, and procedural sedation) and creating UGRA proceduralists available at every size ED seems less achievable than striving for minimal competency for all emergency physicians.
• Comparative efficacy: the observational design of Farrow et al. lacked comparator arms such as procedural sedation or alternative analgesic strategies for non-procedural nerve blocks such as ketamine as a non-opioid alternative for chronic pain (10,11). Lacking these comparators, many of the benefits of UGRA like decreased adverse events related to procedural sedation or reduced ED length of stay are only theoretical. The role of UGRA in reducing opioid administration in the ED or prescribing after the episode of care is uncertain (16).
• Safety and patient values: UGRA investigators continue to define the relative safety of regional anesthesia in the ED setting (17). Quantifying the potential harms of this evolving approach when a significant and undefined training curve exists is essential to provide meaningful context for shared decision-making with patients in selecting the analgesic approach most aligned with their preferences and circumstances (18).

While the article by Farrow et al. represents a commendable step forward to understand the effort required within one ED system to promote UGRA (mostly by a handful of ultrasound focused clinicians), myriad Implementation Science unexplored barriers impeding widespread adoption across EDs worldwide exist. Preferably, comparative efficacy trials comparing UGRA to procedural sedation become available to promote acceptance among individuals who have not invested their career in ultrasound. If comparative efficacy trials subsequently demonstrate a balance of benefit versus harm favoring UGRA, then Implementation Science can provide a reproducible pathway to ensure scalable practice change with high fidelity, sustainability, and local adaptability to ensure that ED patients with pain amenable to regional anesthesia have the option of this approach anywhere and anytime (19).

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Public Health and Emergency. The article has undergone external peer review.

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-39/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-39/coif). C.R.C. reports grants supported by NIA’s R61AG069822, and received support for attending Clinician Scientists Transdisciplinary Aging Research Annual Meeting from U24AG065204. C.R.C. serves as Chair of the American College of Emergency Physician’s Geriatric Emergency Department Accreditation Advisory Board, and serves on the Society for Academic Emergency Medicine Foundation Board of Trustees. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med 1989;7:620-3. [Crossref] [PubMed]
2. Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 2014;63:247-58.e18. [Crossref] [PubMed]
3. Bellolio MF, Gilani WI, Barrionuevo P, et al. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2016;23:119-34. [Crossref] [PubMed]
4. Bellolio MF, Puls HA, Anderson JL, et al. Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis. BMJ Open 2016;6:e011384. [Crossref] [PubMed]
5. Diner BM, Carpenter CR, O'Connell T, et al. Graduate medical education and knowledge translation: role models, information pipelines, and practice change thresholds. Acad Emerg Med 2007;14:1008-14. [Crossref] [PubMed]
6. Blaivas M, Lyon M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am J Emerg Med 2006;24:293-6. [Crossref] [PubMed]
7. Wilson CL, Chung K, Fong T. Challenges and Variations in Emergency Medicine Residency Training of Ultrasound-guided Regional Anesthesia Techniques. AEM Educ Train 2017;1:158-64. [Crossref] [PubMed]
8. Farrow RA 2nd, Shalaby M, Newberry MA, et al. Implementation of an Ultrasound-Guided Regional Anesthesia Program in the Emergency Department of a Community Teaching Hospital. Ann Emerg Med 2024;83:509-18. [Crossref] [PubMed]
9. Lewis SR, Price A, Walker KJ, et al. Ultrasound guidance for upper and lower limb blocks. Cochrane Database Syst Rev 2015;2015:CD006459. [Crossref] [PubMed]
10. Lewis L, Carpenter CR, Schwarz ES, et al. The Opioid Crisis in Missouri: A Call to Action for Physicians, Legislators, and Society. Mo Med 2017;114:440-6. [PubMed]
11. LaPietra AM, Motov S. A Country in Crisis: Opioid Sparing Solutions for Acute Pain Management. Mo Med 2019;116:140-5. [PubMed]
12. Brown JR, Goldsmith AJ, Lapietra A, et al. Ultrasound-Guided Nerve Blocks: Suggested Procedural Guidelines for Emergency Physicians. POCUS J 2022;7:253-61. [Crossref] [PubMed]
13. Stone MB, Wang R, Price DD. Ultrasound-guided supraclavicular brachial plexus nerve block vs procedural sedation for the treatment of upper extremity emergencies. Am J Emerg Med 2008;26:706-10. [Crossref] [PubMed]
14. Blaivas M, Adhikari S, Lander L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med 2011;18:922-7. [Crossref] [PubMed]
15. Carpenter CR, Sherbino J. How does an "opinion leader" influence my practice? CJEM 2010;12:431-4. [Crossref] [PubMed]
16. Carpenter CR, Lewis L, Jotte RS, et al. A Bridge to Nowhere? Challenging Outpatient Transitions of Care for Acute Pain Patients in the Opioid Epidemic Era. Mo Med 2018;115:241-6. [PubMed]
17. Stickles SP, Kane DS, Kraus CK, et al. Adverse events related to ultrasound-guided regional anesthesia performed by Emergency Physicians: Systematic review protocol. PLoS One 2022;17:e0269697. [Crossref] [PubMed]
18. Nielsen KT, Rasmussen MU, Overgaard AF, et al. Identifying values and preferences around the choice of analgesia for patients with acute trauma pain in emergency and prehospital settings: using group concept mapping methodology. BMJ Open 2020;10:e031863. [Crossref] [PubMed]
19. Carpenter CR, Pinnock H. Starry Aims to Overcome Knowledge Translation Inertia: The Standards for Reporting Implementation Studies (StaRI) Guidelines. Acad Emerg Med 2017;24:1027-9. [Crossref] [PubMed]