Evidence-Based Medicine
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Nov 18, 2021; 12(11): 899-908
Published online Nov 18, 2021. doi: 10.5312/wjo.v12.i11.899
Implementation science for the adductor canal block: A new and adaptable methodology process
Nikhil Crain, Chun-Yuan Qiu, Stephen Moy, Shawn Thomas, Vu Thuy Nguyen, Mijin Lee-Brown, Diana Laplace, Jennifer Naughton, John Morkos, Vimal Desai
Nikhil Crain, Bowman Gray Center for Medical Education, Wake Forest School of Medicine, Winston-Salem, NC 27103, United States
Chun-Yuan Qiu, Perioperative Service and Anesthesiology, Kaiser Permanente Medical Center, Baldwin Park, CA 91706, United States
Stephen Moy, Shawn Thomas, Vu Thuy Nguyen, Mijin Lee-Brown, Diana Laplace, Jennifer Naughton, Vimal Desai, Department of Anesthesiology, Baldwin Park Medical Center, Southern California Kaiser Permanente Medical Group, Baldwin Park, CA 91706, United States
John Morkos, Johns Hopkins University, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States
Author contributions: Crain N and Desai V contributed equally to the work; Qiu C, Moy S, Thomas S, Nguyen VT, Lee-Brown M, and Laplace D contributed to study conception and research design; Naughton J contributed to study design and data collection; Crain N performed statistical analysis; Crain N, Qiu C, Morkos J, and Desai V drafted the article; Moy S, Thomas S, Nguyen VT, Lee-Brown M, Morkos J, and Desai V made critical revisions; all authors have read and approved the final manuscript.
Conflict-of-interest statement: Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/Licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist. See attached document.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Vimal Desai, MD, Doctor, Department of Anesthesiology, Baldwin Park Medical Center, Southern California Kaiser Permanente Medical Group, 1011 Baldwin Park Blvd, Baldwin Park, CA 91706, United States. vimal.desai@kp.org
Received: April 1, 2021
Peer-review started: April 1, 2021
First decision: June 7, 2021
Revised: June 18, 2021
Accepted: September 27, 2021
Article in press: September 27, 2021
Published online: November 18, 2021
Abstract
BACKGROUND

Following the successful Perioperative Surgical Home (PSH) practice for total knee arthroplasty (TKA) at our institution, the need for continuous improvement was realized, including the deimplementation of antiquated PSH elements and introduction of new practices.

AIM

To investigate the transition from femoral nerve blocks (FNB) to adductor canal nerve blocks (ACB) during TKA.

METHODS

Our 13-month study from June 2016 to 2017 was divided into four periods: a three-month baseline (103 patients), a one-month pilot (47 patients), a three-month implementation and hardwiring period (100 patients), and a six-month evaluation period (185 patients). In total, 435 subjects were reviewed. Data within 30 postoperative days were extracted from electronic medical records, such as physical therapy results and administration of oral morphine equivalents (OME).

RESULTS

Our institution reduced FNB application (64% to 3%) and increased ACB utilization (36% to 97%) at 10 mo. Patients in the ACB group were found to have increased ambulation on the day of surgery (4.1 vs 2.0 m) and lower incidence of falls (0 vs 1%) and buckling (5% vs 27%) compared with FNB patients (P < 0.05). While ACB patients (13.9) reported lower OME than FNB patients (15.9), the difference (P = 0.087) did not fall below our designated statistical threshold of P value < 0.05.

CONCLUSION

By demonstrating closure of the “knowledge to action gap” within 6 mo, our institution’s findings demonstrate evidence in the value of implementation science. Physician education, technical support, and performance monitoring were deemed key facilitators of our program’s success. Expanded patient populations and additional orthopedic procedures are recommended for future study.

Keywords: Total knee arthroplasty, Femoral nerve block, Adductor canal block, Physical therapy, Oral morphine equivalent, Action-related information gap

Core Tip: This study showed improved immediate postoperative outcomes of total knee arthroplasty patients through effective anesthetic management, specifically in regard to increased mobility (4.1 vs 2.0 m) and decreased oral morphine equivalents (13.9 vs 15.9) by employing adductor canal block instead of femoral nerve block. Our data supports the value of implementation science to generate institutional change though the application of guidelines from the modified Consolidated Framework for Implementation Research. It is proposed that the key enablers of implementation success, and in our case achieved a “knowledge to action” gap closure in 6 mo, are physician education, technical support, and performance monitoring.