Maximizing safety of non-OR anesthesia

June 25, 2019

The Anesthesia Patient Safety Foundation brings us a detailed article focused on safety considerations for Non-Operating Room Anesthesia (NORA). For most hospitals, NORA represents the most rapidly growing area of need for anesthesia services. Closed claims data show that NORA patients have a higher frequency of severe injury and death than those treated in the main operating room. In 50% of closed claims from a NORA setting, monitored anesthesia care was the chosen technique. NORA-specific challenges are described in the article and include remote locations, sharing the airway, a high incidence of coexisting disease, limited workspace, older equipment, and inadequate support staff. Recommendations to improve safety include adequate preoperative preparation, standard ASA monitoring, assurance of functioning equipment, availability of emergency equipment and medications, and the creation of protocols and checklists. The authors conclude that anesthesia professionals should guide a multi-disciplinary team approach to safe NORA care in order to be at the frontline of this rapidly evolving and expanding service area.

EHC NOTE:  Based on our experience we concur that demand for anesthesia coverage out of the operating room is outpacing all other anesthetizing sites. This rapid increase in demand brings with it the quality challenges described in this article as well as a host of efficiency challenges. Regarding the quality issues, we feel that the recommendations described by APSF should be supported.  In addition to ensuring proper medication, equipment and support personnel are available, written protocols and checklists are especially compelling since we see dramatic variability in practice among both anesthesia providers and proceduralists.  

Efficient support of NORA requires integration of scheduling, written guidelines for allocation of anesthesia personnel, potential block allocation of providers and a mechanism to communicate across all anesthetizing sites as add-ons and emergencies change anesthesia availability throughout the day.  Efficient allocation of expensive anesthesia resources is challenging in many out of OR locations where anesthesia coverage is requested for only a subset of cases due to patient or case complexity. As NORA grows, perioperative and anesthesia leaders will be increasingly required to balance the desire for expanded anesthesia capacity against the dual constraints of financial support for poorly utilized locations and of limitations in provider availability. In fact, we see the creation of an integrated scheduling mechanism across all anesthetizing locations becoming a more frequent component of our OR efficiency projects.