Episode #118 Requirements for Safe and Effective Anesthesia Patient Care in NORA

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show. Did you attend the 2022 APSF Stoelting Conference in person or on zoom? If not, then you are in the right place because we are in the middle of our series all about the 2022 APSF Stoelting conference, “Crucial Patient Safety Issues in Office-Based and Non-Operating Room Anesthesia (NORA).” The conference was directed by Shane Angus, JW Beard, Emily Methangkool, Lynn Reede, Patty Reilly, and Richard Urman. This is the second episode in the series and we will be picking up right where we left off in the first session.

Before we dive into the episode today, we’d like to recognize Masimo, a major corporate supporter of APSF. Masimo has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Masimo – we wouldn’t be able to do all that we do without you!.”

The 2022 Stoelting Conference is all about anesthesia patient safety outside of the operating theatre. Last week, we just put our toes in the water of the first session by defining NORA and introducing safety concerns in these unique areas with Basem Abdelmalak. Remember, NORA is any anesthesia service provided in a location outside the main OR. NORA safety concerns may be related to the space, equipment and monitoring, staff, patients, and procedures. Today, we are diving all the way in to the rest of Session 1, moderated by Emily Methangkool called “Is All NORA Created Equal? Requirements for a Safe and Effective Anesthetic Regardless of Location.”

Our next speaker is Brent Dunworth to talk about, “Space Planning for Safety and Efficiency in Non-Operating Room Anesthesia?” Many anesthesia professionals may have found themselves in a crowded room with limited access to the patient, the anesthesia machine, medications, and supplies. While operating rooms may be designed with surgery and anesthesia equipment in mind, this is not always true in NORA locations.  There may be existing infrastructure challenges that are a threat to anesthesia patient safety. Before it was a NORA location, it may have just been a procedure room. Then, the anesthesia team is brought into the suite, and the anesthesia equipment must be brought in as well leading to lack of access to the patient, equipment, and help. Another important consideration is access to the NORA location during an emergency such as a initiating a massive transfusion protocol or an unanticipated difficult airway. Other challenges include equipment limitations in certain NORA locations. Is there even an anesthesia machine present or is it a different anesthesia machine than the ones in the operating room? Field avoidance is another consideration in this area and you may find yourself without having easy access to the patient’s airway. There may also be the idea in NORA locations that intubating is too invasive or takes too long and that the procedure can be done with just a little propofol and an unsecured airway.

Here are some other threats to patient safety in NORA locations:

• Is the team prepared for an emergency? Where are the code buttons? Is the staff able to assist in an anesthesia emergency? This may be addressed with education and training for the procedure team including on-site simulations.
• Is the appropriate equipment available including airway equipment, code cart, invasive lines, access to bloods and fluids?
• Does the NORA locations look familiar and reflect the equipment in the operating room?
• Is the NORA location easy to find in the hospital or difficult to locate? This may be improved with signs to help direct staff in case of an emergency.

The good news is that there are opportunities to improve the space in NORA locations and thus improve patient safety. Anesthesia professionals can have a big impact on patient safety by getting involved in the NORA planning committee to help build relationships and make sure that safety is a top priority. Remember the ergonomics in the NORA location can also have a big impact on operational efficiency as well as patient safety. Dunworth provides the example of a typical GI suite which may be a small room, only about 300 square feet, to contain the patient stretcher and procedural and anesthesia equipment that also takes up floor space and limits access to the patient and supplies. With the goal to prevent field avoidance and allow the anesthesia professional to have access to the patient’s airway throughout the procedure, the room was redesigned with ceiling mounted equipment and larger suites. In addition, when thinking about designing the space in NORA locations, standardization of rooms and maintaining similarity with the operating room in terms of layout and equipment and resources is helpful especially for anesthesia professionals who practice in multiple different locations.

We are moving on to another important consideration for patient safety in NORA locations: Teamwork. Diana Anca is the next presenter to talk about, “Best Practices: Working Collaboratively with the Proceduralist to Improve Patient Safety.”

Anca opens up with several well-known case scenarios such as an unanticipated difficult airway, a patient with significant comorbidities, working in a new suite, or starting a new transplant program and highlights that in NORA locations these challenges may lead to increased morbidity and mortality. This increased threat to patient safety may be related to the following “curve balls” including

1. The procedure which may be diagnostic and therapeutic procedure
2. The equipment which may be complex and sensitive
3. Staffing in NORA locations who may not know the anesthesia professional and this is especially challenging for new hires
4. The culture that providing NORA care is unpopular with members of the anesthesia team
5. The heterogeneity of NORA locations that are very different from each other with different equipment and in different locations

Let’s meet the team that will need to work together for NORA care.

• First up, we have the patients who desire to be comfortable and safe during the procedure.
• Next, the proceduralist who wants a motionless patient and perhaps time to teach trainees during the procedure.
• Then, we have the anesthesia professional who would like a clear plan for the procedure, no complications, and to be done on time so that they are not working at a NORA location in the evenings or overnight.
• The nurses on the NORA team may prefer for procedures to be done with anesthesia and would also like no complications and to complete the procedures on time.
• Finally, we have the administration who are keeping an eye on the budget and desire no increase in costs.

The good news is that we can make these goals align with 3 crucial C-words: Communication, collaboration, and coordination. This may require a multidisciplinary teamwork approach. So, let’s dive in to more specific examples.

Keep the multidisciplinary team in mind including proceduralists, anesthesia professionals, nurses, techs, administration staff, and schedulers. Bringing the team together may be facilitated with simulation of the procedures on site.

Creation of appropriate protocols and pathways especially for complex patients, complex procedures, and complications, such as massive hemoptysis during bronchoscopy and massive hemorrhage during lead extraction.

Participation in daily huddles as well as pre-procedural huddles. On the day of, the in-person huddles should discuss any complex cases of the day, optimize workflow, assess resources and staffing, equipment, add-on cases/triage, and priorities, prepare for potential complications. Pre-procedural huddles may be done by email prior to the day of and can be helpful for appropriate staffing and preparation for complex patients as well as making sure that required resources are available.

Creation and consistent use of Checklists including time-out, site-specific checklist, and patient and procedure specific checklists to ensure the correct side. The patient may even be able to participate in the time-out prior to receiving anesthesia.

Appointing a director of NORA who can lead this division of multiple locations and facilitate communication. There may also be consideration for core team of anesthesia professionals who work at certain NORA locations.

Anca describes what her institution is doing to help keep patients safe during NORA at Cornell.

• Weekly and monthly huddles
• daily huddle to discuss add-on cases
• Email chain for complex case planning
• Message chain for same day complex cases
• Emergency contact numbers
• Emergency checklists
• Protocols for complex cases
• Emergency simulation sessions available in person and on video so that it is available to entire multidisciplinary
• Training for emergencies situations with shared conferences and education sessions.

The future of NORA is expanding and demanding. The ICU is quickly becoming a new NORA site. In order to meet the demand and the NORA challenges, we may see the establishment of NORA as a formal division in many hospitals and institutions, the development of institutional NORA committees, and multidisciplinary projects and conferences dedicated to NORA just like this conference.

We made it to the final part of the first session and it is exciting. We have three proceduralist who share their experiences and important considerations in NORA locations. First up is Michael Kochman, a professor of medicine and surgery in the gastroenterology division at the University of Pennsylvania to talk about patient safety in the GI endoscopy suite. A couple big questions that come up include when do. you need to intubate and how do you sedate the patient? The answers are complex and depend on the patient – do they have cardiopulmonary compromise or a gastric outlet obstruction – and on the procedure – will it be a prolonged procedure? Remember, all endoscopists are not the same when it comes to skill set, approach, and communication skills. The same is true for anesthesia professionals. In addition, procedures are not uniform or predictable with different approaches, trainees, and equipment availability. Plus, all patients are not uniform or predictable and you may provide care for patients who are quite sick, especially if they are in the GI endoscopy suite to have a procedure to replace a surgical procedure or attempt to avoid surgery. There are so many variables when providing patient care in the GI endoscopy suite including:

• Emergency vs elective
• Anticoagulation
• Inpatient or outpatient
• Upper or lower endoscopy
• Diagnostic vs therapeutic procedure
• Skill-set variability
• Luminal obstruction
• Sepsis
• Presence of LVADs which may be pre-device placement or post-device placement and both situations have unique considerations

There are some important considerations for the proceduralist which may include:

• Successful and safe completion of the procedure
• Managing unexpected issues
• Maintaining a stable field which depends on procedures and the patient
• Quick turnaround time and quick procedures which are related to institutional constraints
• Ensuring patient satisfaction and lack of recall

Given these variables, concerns, and considerations, it is not surprising that communication is essential. Here is a quick guide for important things to discuss. This may be done first thing in the morning during a huddle with the whole team. Taking the time to prioritize communication can ensure that safety and efficiency are maintained as the day progresses.

1. Goal of sedation and reason for anesthesia support
2. Airway management plan including access and protection and any anticipated airway issues
3. Level of consciousness and cooperation
4. Cardiopulmonary status
5. Anticipated pain and pain management options
6. VTE prophylaxis for prolonged procedures.
7. Anticipated length of the procedure including indication, goal, and operator. This may lead to adjusting the anesthetic regimen accordingly

Our next proceduralist is Thomas Farrell, an interventional radiologist at Northshore University Health system. He stressed the importance of communication and maintaining standards of practice. Let’s look at the example of elderly patients presenting to the interventional radiology suite for vertebroplasty. These patients often have many comorbidities, and the procedure is performed in the prone position. The decision to use sedation or general anesthesia depends on the patient and the anesthesia professional. Monitoring is a crucial part of keeping patients safe and this is one area that anesthesia professionals can have a big impact. A survey in European Interventional Radiology from 2017 revealed that monitoring for pulse oximetry, ECG, and BP occurred in over 90% of cases, but only 46% utilized end-tidal CO2 monitoring.  Monitoring for adequate ventilation is one of the standards for basic monitoring from the American Society of Anesthesiology. Continuous exhaled carbon dioxide monitoring is required during general anesthesia as well as during sedation. When no sedation is used, adequate ventilation may be evaluated with continual observation of qualitative clinical signs. I will include a link to the ASA Basic Monitoring Standards as well.

Our final speaker for Session 1 is Sarah Gualano, a cardiologist and clinical associate professor at the University of Michigan. She starts by reviewing interventional cardiology sites which may include structural heart procedures such as TAVRs and interventions on the mitral and tricuspid valve. These procedures change over time due to advances in technology which has expanded procedures to lower risk patients and changed the need for general anesthesia compared to sedation. Another NORA site is the Cath lab for high-risk revascularization procedures, and anesthesia professionals may be called to provide care for patients with hemodynamic compromise undergoing an emergent procedure. An important considerations for patient safety is who comes to a code in the Cath lab in the middle of the night. During the day, there may be anesthesia professionals who are part of the procedure right from the beginning and it is just as important to have this support for emergent procedures as well.

What a great opening session at the 2022 Stoelting Conference and there is so much more to talk about! What were your biggest takeaways from this session? Let us know by tagging us on Twitter @APSForg and using the hashtag #APSF2022 and #APSFPodcast.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation