December 2002: Ken Wade MD, a CA-2 year resident placed several round ‘green dots’ next to the patient’s names on the paper schedule board to indicate which patients he was planning to block during the course of his day on the regional anesthesia rotation. At that time, a 'blue dot' on the paper schedule board meant the patient had arrived in the OR holding room and a 'red dot' meant the patient had arrived in the operating room. Green was the next easily available color. This practice caught on. Routinely, these 'green dotted' patients were then labeled as ones who we would arrange to send for early to place regional anesthetics prior to being called for by the operating room. In 2002, our Regional Rotation consisted of a single resident and attending placing blocks in the inpatient operating room. Since then our practices have evolved but the 'green dot' became more crucial for the coordination of care by anesthesia personnel, operating room nurses, transporters and schedulers. A ‘green dot’ meant that the patient would likely be 'all numbed up' for his or her surgery.
Below are some additional vignettes characterizing milestones of regional anesthesia and acute pain practices specific to our academic institution. In the process of passing each of these milestones, our operating rooms become more expansive, or care better developed, but always our need for preparation, planning, and communication that much more immediate. Our printed operating room schedule’s ‘green dots’ have since been 
superseded by access to an electronic schedule we can update remotely from our RAAPM area. However, the green dot remains in the allnumbedup logo.
July 1995: Despite excellent training in anesthesia, the average anesthesia resident performs 10-15 peripheral nerve blocks during an entire 3 year residency.
September 1999: We begin using regional anesthesia routinely as part of a resident Regional anesthesia Rotation (RAR) during which a single resident (when available) places blocks in the holding room under the supervision of several anesthesiologists.
October 2000: Use of cPNB increases with the exclusive use of stimulating catheters from the start of this practice at WFU.
November 2001: The use of cPNB for total knee replacements instead of our previous standard approach using lumbar epidural analgesia is gaining favor on a case by case basis. Introduction of fondaparinux by one surgeon prompts us to convert from epidural to a CPNB technique on a routine basis. This change corresponded with a multi-disciplinary approach to decrease LOS which was very successful. DVT therapy and our success with LOS lead us to a adopting a systems-based approach over case-by-case management whenever possible.
April 2002: A resident on his RAR places more blocks on a single day than he would have during his entire residency if he had completed his residency here seven years ago.
May 2002: Our Acute Pain Service begins to receive frequent consults for guidance with opioid therapy when pain following ankle surgery prevents discharge from our 23 hour stay facility. We move to routine use of ambulatory subgluteal catheters for 2-3 days after an overnight stay. This was the first patient group that prompted us to formalize policies, procedures, forms and equipment for ambulatory cPNB.
January 2003: Closure of our chronic pain clinic leaves one of our surgeons who previously referred his CRPS patients for cervical epidural therapy and inpatient admission with one less therapy option. He begins referring patients for our services utilizing outpatient cPNB for up to two weeks. We discharge an especially responsible patient with a cPNB from our facility to a local hotel in North Carolina then to her home in Texas.
April 2003: Our department starts a section of regional anesthesia and acute pain management eventually growing to be made up of seven interested faculty.
May 2003: The resident rotation grows to four/month with coverage of the acute pain service 24/7 by members of the RAAPM faculty and these residents. A service previously covered by our chronic pain service now becomes integrated with preoperative regional anesthetics as integrated RAAPM perioperative care.
June 2003: Wake Forest University Medical Center's operating room complex expands from 24 to 40 operating rooms at the same time as regional anesthesia practices are becoming well established. A preoperative Regional Anesthesia Area with supplies, resources and room for patients is created from a group of four patient care bays and a store room originally planned for storage of operating room equipment. A structured system of clinical care with a home base at its core begins from this makeshift area we will occupy for the next four and a half years.
January 2004: Our Visiting Clinical Preceptorship begins formally by the RAAPM section, modeled on our department’s already successful preceptorship in cardiac echocardiography.
February 2004: We begin to use extended release epidural morphine as part of a constantly re-evaluated practice—focusing on hip arthroplasty and gynecologic abdominal surgery.
September 2004: A second RAAPM RN is hired by the hospital to support our increased clinical volume.
January 2005: Our TSA surgeon notices we have used a posterior approach to brachial plexus catheter placement on the very first instance in which we change from catheter placement using the anterior approach to posterior to help achieve 23 hour stays.
July 2006: We work with the hospital to develop admission, scheduling, and charge capture procedures for our RAAPM Area to help document our patient interactions for the facility.
September 2007: We get are second dedicated ultrasound machine, increasing the utility of U/S in our practice.
December 2007: Combined use of neuraxial anesthesia, low dose extended release epidural morphine, lumbar plexus blockade, and resurfacing hip arthroplasty begins to allow for 23 hour stay for a portion of these patients.
July 2007: Our first RAAPM fellow graduates from WFU.
January 2008: An anesthesia information management system (AIMS) designed specifically for regional anesthesia is designed for a planned remodel of our existing RAAPM area. It combines automated data, an electronic time out, detailed regional procedure note, and attending attestation with an automated touch screen RAAPM area census board and centralized vital sign monitoring.
March 2008: Our remodeled RAAPM area opens with six bays and integration of our existing infrastructure with the goal of efficient expansion of regional and acute pain management to more patients.
