Episode #178 Keeping Anesthesia Professionals Safe in NORA locations, PART 2

November 28, 2023

Subscribe
Share Episode
SHOW NOTES
transcript

Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

We are opening the October 2023 APSF Newsletter again today. Our featured article is “Clinician Safety in NORA” by Candance Chang, MD, MPH; Jens Tan, MD; Patricia Fogarty Mack, MD; and Diana Anca, MD.

An important consideration for clinician safety in NORA is to ensure that there is enough space for the anesthesia equipment in the correct configuration to the right of the patient’s head and for the anesthesia professional to have easy access to the patient. There is support for this from the ASA Statement on NORA Locations. Here is the citation:

  • Statement on Nonoperating Room Anesthetizing Locations. American Society of Anesthesiologists. 2018. https://www.asahq.org/standards-and-guidelines/statement-on-nonoperating-room-anesthetizing-locations Accessed August 3, 2023.

Here are some practical recommendations for room design that the authors provide in the article:

  1. Patients should enter on the side of the room opposite the anesthesia machine, gas lines, and cords.
  2. Rooms should have two doors to promote easy access for equipment and personnel for regular workflow and during an emergency.
  3. If there is only 1 door, the anesthesia professional and the patient’s head should be positioned closest to the door which allows for immediate assistance in case of an emergency.
  4. Gas lines should be piped close to and behind the anesthesia machine with a dedicated line for waste anesthesia gas disposal. This is a recommendation from the National Fire Protection Agency that states that a waste anesthesia gas disposal inlet should be in any location where nitrous oxide or halogenated anesthetic gas are administered. This is not a legal requirement, but it is a consensus standard that is referenced by the Joint Commission.
  5. There should be appropriate pre-procedure and post-procedure recovery locations that are close to the procedure room.
  6. There should be a designated pathway for safe patient transfer to the intensive care unit from the procedure room when needed.

Thank you so much to Candance Chang for contributing to the show today.

Subscribe to our YouTube Channel here: https://www.youtube.com/@AnesthesiaPatientSafety
Be sure to check out the APSF website at https://www.apsf.org/
Make sure that you subscribe to our newsletter at https://www.apsf.org/subscribe/
Follow us on Twitter @APSForg
Questions or Comments? Email me at [email protected].
Thank you to our individual supports https://www.apsf.org/product/donation-individual/
Be a part of our first crowdfunding campaign https://www.apsf.org/product/crowdfunding-donation/
Thank you to our corporate supporters https://www.apsf.org/donate/corporate-and-community-donors/
Additional sound effects from: Zapsplat.

© 2023, The Anesthesia Patient Safety Foundation

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. We have talked about keeping patients safe in Non-Operating Room locations on the show before. There are many challenges to working in these often off-site areas. Today, we are going to switch the focus to talk about keeping another important person in the non-operating room locations safe…that’s right, we are talking about keeping anesthesia professionals safe when they are providing patient care in non-operating room anesthesia locations.

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

Let’s open the October 2023 APSF Newsletter again today. Our featured article is “Clinician Safety in NORA” by Candance Chang and colleagues. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well.

Before we get to the article, we are going to hear from one of the authors. Here she is now.

[Chang] “My name is Candace Chang and I’m an Associate Professor of Anesthesiology and the Director of Non-Operating Room Anesthesia at the University of Utah.”

[Bechtel] To kick off the show today, I asked Chang why she feels so passionate about this topic. Let’s take a listen to what she had to say.

[Chang] “Working in non-operating room anesthesia, also known as NORA, already presents several challenges that cannot be altered. While the room setup may be awkward, it shouldn’t be dangerous to those working there. Haphazard clinician safety, distracting the anesthesia provider from patient care. Rather than just hoping we don’t trip, hit our heads, or receive excess radiation exposure, we should work with our colleagues in these areas to implement common sense solutions to ensure all of our safety so we can focus on our patients. We have to tell hospital administration that these adjustments are crucial to safe and efficient patient care. Anesthesia is being requested for an increasing number of procedures and we should be the leaders to ensure a safe, ergonomic working environment for all involved.”

[Bechtel] Does your clinical practice include NORA locations? There are many challenges to keeping patients safe during NORA care and we did a whole series on the podcast last year following the 2022 APSF Stoelting Conference, “Crucial Patient Safety Issues in Office-Based and Non-Operating Room Anesthesia (NORA). Go check out episodes #117 through 121 to learn more about the important considerations. This will also be something that we continue to talk about on this podcast because it is challenging to keep patients safe in NORA locations and there is more work to be done. But today, our focus is on clinician safety in NORA and this is just as important. Did you know that according to the Occupational Health Safety Network, 1 in 5 nonfatal occupational injuries occur in the health care and social assistance industry and healthcare workers develop musculoskeletal disorders at 7 times the national rate? The most frequent documented injuries include patient transport and “slips, trips, and falls.”

Keep in mind that when we are talking about NORA locations, this includes interventional radiology suites, electrophysiology and catheterization labs, endoscopy suites, and magnetic resonance imaging suites. The occupational hazards of working in these areas has not been studied, but we do know that musculoskeletal pain is more common in health care workers in interventional laboratories and is highest in nonphysician employees. We need to keep anesthesia professionals safe in order to provide safe anesthesia care. The authors provide a review of the key occupational hazards that anesthesia professionals face in NORA locations and importantly, offer ideas to help create a safer working environment.

First, let’s talk about room setup. Have you ever walked into a NORA location and been confronted with obstacles such as equipment, lines, and wires blocking your way to the patient or the anesthesia machine? Many NORA suites are small spaces that have been retrofitted to try to fit the anesthesia machines, automated medication dispensers, and other necessary equipment. It is often the case that clinician movements to access the patient, airway, and injection ports are awkward and nonergonomic. In addition, the dimmed lighting that is necessary for fluoroscopic imaging and lack of pathway lighting increase the risk for trips and falls as well as sustaining a concussion from a head strike on the radiology screens or booms. Another threat to clinician safety is during procedures that require the proceduralist and anesthesia professional to change location and move equipment depending on the imaging modality and anatomic site. Raise your hand if you have ever been involved in moving the anesthesia machine and drug dispensing system from one side of the room to the other all while remaining vigilant to keep your patient safe as well.

Many anesthesia professionals and proceduralists have had these rather unpleasant and potentially dangerous experiences.

Let’s look a little closer at the example of moving the anesthesia machine which can weigh a whopping 100-165 kilograms. Even though these machines are on wheels, it is important to pay attention to proper body positioning and be aware of any obstacles such as cords that may impede movement. Plus, the risk is increased when there is an increased frequency in moving the anesthesia machine to accommodate different room layouts.

Other notable hazards resulting from the variable placement of the anesthesia machine includes the attached cables, hoses, and lines. There are at least three hoses attached to the anesthesia machine for oxygen, air, and scavenger waste gas. There is a power cord. There may also be the following connections depending on the anesthesia machine: vacuum hose for suction, nitrous oxide, computer cords, and data cables. Check out Figure 1 in the article which depicts tripping hazards in NORA location. Have you ever provided anesthesia care in a NORA location with these tripping hazards? Have you every tripped and fallen while providing anesthesia care? At least two anesthesia professional at MD Anderson have reported falling and sustaining injuries in the past 10 years. Figure 2 depicts facial injuries that an anesthesia professional sustained after tripping and falling over exposed cables.

There are some strategies that might help to decrease the risk of tripping including commercially available cable “sleeves” and specially designed mats, like the one in Figure 3 in the article. These solutions may help, but there is also the potential for increased bacterial contamination and the mat slipping. Other options may be to place “anti-fatigue” mats over the cables, but this requires investment from team members to place the mats at the beginning of every case. Braiding the gas lines may also help and you can see an example of this in Figure 4 in the article. Keep in mind that the best solution is to design procedure rooms with the gas and electrical outlets on the mobile overhead booms to that the gas lines remain behind the anesthesia machine. Check out Figure 5 for an example.

From room setup, let’s turn out attention to room design in NORA locations. It is important that anesthesia professionals are involved in the design, planning, and construction of any new procedure suites. Well-designed procedure rooms decrease floor tripping hazards, hanging obstacles, and reduce the overall physical strain on clinicians who need to provide anesthesia care in this space.

What does a well-designed room look like? The first priority is the placement of the anesthesia machine with all of the related gas lines, suction, electrical outlets, and internet ports.

“There should be in each location, sufficient space to accommodate necessary equipment and personnel and to allow expeditious access to the patient, anesthesia machine (when present), and monitoring equipment.”3

I will include the citation to the entire ASA Statement in the show notes as well.

There are some examples of specific design dimensions. Weill Cornell Medicine’s Department of the Anesthesiology states that the minimum space for anesthesia services in all new procedure or operating room designs must be 12 feet by 7ft. This means that a minimum of 84-square foot area must then be reserved for the anesthesia machine, medication and equipment cart, IV pole, and chair to allow for the anesthesia professional to maneuver safely in the space. Many anesthesia professionals have been in imaging suites designed for the imaging equipment and patient movement without considering the workflow for the technologists, nurses, and clinicians who are providing patient care during the imaging procedure. It is vital to reserve space for patient beds with easy accessibility for mobile and immobile patients.

Here are some practical recommendations for room design that the authors provide in the article:

  1. Patients should enter on the side of the room opposite the anesthesia machine, gas lines, and cords
  2. Rooms should have two doors to promote easy access for equipment and personnel for regular workflow and during an emergency.
  3. If there is only 1 door, the anesthesia professional and the patient’s head should be positioned closest to the door which allows for immediate assistance in case of an emergency.
  4. Gas lines should be piped close to and behind the anesthesia machine with a dedicated line for waste anesthesia gas disposal. This is a recommendation from the National Fire Protection Agency that states that a waste anesthesia gas disposal inlet should be in any location where nitrous oxide or halogenated anesthetic gas are administered. This is not a legal requirement, but it is a consensus standard that is referenced by the Joint Commission.
  5. There should be appropriate pre-procedure and post-procedure recovery locations that are close to the procedure room.
  6. There should be a designated pathway for safe patient transfer to the intensive care unit from the procedure room when needed.

That authors remind us of the following: “Too often not enough space or thought is given to these important aspects of patient care that can significantly impact safety and efficiency.”

We have more to talk about when it comes to clinician safety in the NORA locations and we are going to hear from Candance Chang again, so mark your calendars for next week. In the meantime, the next time you are providing patient care in a NORA location, take a look around the room. Are there any safety hazards that you can identify? How is the room designed? Next week, we will be talking about patient transfers and invisible hazards too. It is so important that clinicians are safe in these areas in order to provide safe anesthesia care.

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. We’ll be back next week for Part 2 on Clinician Safety in the NORA locations.

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

© 2023, The Anesthesia Patient Safety Foundation