title: Transformation of anesthesia for ambulatory orthopedic surgery: A mixed-methods study of a diffusion of innovation in healthcare.
abstract: BACKGROUND
  To provide insight into how an innovation in healthcare is implemented and diffused, we studied the transition from routine use of general anesthesia to peripheral nerve blocks (PNBs) for ambulatory orthopedic extremity surgery. Rogers' diffusion of innovations (DOI) theory was used as our theoretical framework. We identified themes that would be helpful for others attempting to diffuse innovations into healthcare settings.
  
  
  METHODS
  A mixed quantitative and qualitative methodology was used. We retrospectively reviewed operative and anesthesia records of patients who underwent ambulatory repair of distal radius fractures or arthroscopic knee meniscus procedures from 1998 to 2012 to identify whether general anesthetics or PNBs were used and the time course of the innovation. We interviewed orthopedic surgeons, anesthesiologists, and a nursing administrator working in the ambulatory surgery unit during the innovation to identify key themes associated with the adoption of PNBs.
  
  
  RESULTS
  From 2003 to 2012, use of PNBs increased from less than 10% to 70% of cases studied. The adoption timeframe followed an S-shaped curve. Key themes included improved safety, quality, efficiency, physician leadership and trust, organizational structure, and technological change. The innovation involved an optional decision-making process and took root in a satellite facility and generally fit with Rogers DOI theory.
  
  
  CONCLUSIONS
  The adoption and diffusion of PNBs provides a useful model for understanding innovations with optional decision-making in healthcare. Critical elements in our case were the characteristics of the innovation, which facilitated the decision-making process, and the positioning of the innovation in a peripheral structure away from core clinical facilities.
authors.affiliation: School of Medicine, University of New Mexico, MSC09 5040, 1 University of New Mexico, Albuquerque, NM 87131, USA. Electronic address: KTLeggott@salud.unm.edu.
authors.forename: Kyle T
authors.initials: KT
authors.lastname: Leggott
authors.affiliation: Hand & Plastic Surgery Centre, Grand Rapids, MI, USA. Electronic address: matthewmartinmd@gmail.com.
authors.forename: Matthew
authors.initials: M
authors.lastname: Martin
authors.affiliation: Department of Emergency Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA. Electronic address: DSklar@salud.unm.edu.
authors.forename: David
authors.initials: D
authors.lastname: Sklar
authors.affiliation: Department of Family and Community Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA. Electronic address: Helitzer@salud.unm.edu.
authors.forename: Deborah
authors.initials: D
authors.lastname: Helitzer
authors.affiliation: Department of Anesthesia & Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA. Electronic address: RRosett@salud.unm.edu.
authors.forename: Randy
authors.initials: R
authors.lastname: Rosett
authors.affiliation: Department of Emergency Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA. Electronic address: CCrandall@salud.unm.edu.
authors.forename: Cameron
authors.initials: C
authors.lastname: Crandall
authors.affiliation: Department of Anesthesia & Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA. Electronic address: FVagh@salud.unm.edu.
authors.forename: Firoz
authors.initials: F
authors.lastname: Vagh
authors.affiliation: Department of Orthopaedics & Rehabilitation, School of Medicine, University of New Mexico, Albuquerque, NM, USA. Electronic address: DMercer@salud.unm.edu.
authors.forename: Deana
authors.initials: D
authors.lastname: Mercer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000556:Ambulatory Surgical Procedures; D000768:Anesthesia, General / Q000379:methods* / Q000639:trends; D000776:Anesthesiology; D001291:Attitude of Health Personnel; D003657:Decision Making; D003695:Delivery of Health Care / Q000592:standards*; D004059:Diffusion of Innovation; D006801:Humans; D007407:Interviews as Topic; D008875:Middle Aged; D009407:Nerve Block; D009516:New Mexico; D009936:Organizational Innovation / Q000191:economics; D019637:Orthopedic Procedures; D061214:Patient Safety; D010525:Peripheral Nerves / Q000187:drug effects; D058996:Quality Improvement / Q000458:organization & administration; D012189:Retrospective Studies; D013997:Time Factors; D055815:Young Adult
keywords: Diffusion of innovation; Healthcare innovation; Orthopedic surgery; Peripheral nerve block; Quality improvement