Episode #186 Safe NORA Care: Consensus Recommendations, PART 2

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 hope you tuned in last week where we covered the newest consensus recommendations from the APSF for best practices in non-operating room anesthesia, or NORA, care related to facility and location, equipment and supplies, staffing and teamwork, patient selection, periprocedural care, and quality improvement. We are continuing the conversation this week!

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

Okay, lace up those sneakers because we are headed back to the NORA location.

[Footsteps walking]

Our featured article once again today is from October 2023 APSF Newsletter. It is “Consensus Recommendations for the Safe Conduct of Nonoperating Room Anesthesia: A Meeting Report From the 2022 Stoelting Conference of the Anesthesia Patient Safety Foundation” by John Beard, Emily Methangkool, Shane Angus, Richard D. Urman, Daniel J. Cole. To follow along with us, head over to APSF.org and click on the Newsletter Heading. First one down is the current issue. From here, scroll down to our featured article today. I will include a link in the show notes as well.

To kick off the show today, we are going to hear from one of the authors. I will let him introduce himself now.

[Angus] “Hi, my name is Shane Angus, and I am an anesthesiologist assistant with Case Western Reserve University School of Medicine in Washington, DC.”

[Bechtel] I asked Angus, what got him interested in this topic and what led him to writing this article. Let’s take a listen to what he had to say.

[Angus] “So, my interest in NORA was really peaked when I was involved in some really complex procedures in the gastroenterology suite, as well as the interventional physiology suite.  These experiences really underscored the importance of really having some focused training and knowledge in anesthesia in these particular settings and really memorable cases in these areas were where the team worked incredibly well together and When the team did not work incredibly well together and fortunately in my experiences the patient’s outcomes were both okay nonetheless  Much more favorable outcomes when the team was working, collaboratively and understood the roles and the unique areas that each of us played.”

Well, I’m deeply passionate about NORA because I’ve seen it firsthand, and the challenges and rewards of providing anesthesia care in these non-traditional settings. These environments, really, they’re challenging and they demand adaptability, resourcefulness, and a keen understanding of both the procedure and the unique needs of the patient.”

[Bechtel] Thank you so much to Angus for helping to kick off the show today. Do you take care of patients in NORA locations as part of your practice? Are you following these best practices? For a refresher, take a listen to Episode #185 or check out the show notes for a link to a summary of the 42 recommendations. These NORA recommendations may be applied to anesthesia or sedation in non-operating room procedural areas in inpatient and outpatient settings and office-based areas like dentistry.

Now, it’s time to move on to the discussion portion of the show. For starters, the American Society of Anesthesiologists published a statement on Nonoperating Room Anesthesia that provides guidance on NORA safety considerations related to facility and equipment issues. I will include a link to this statement as well. The APSF consensus recommendations build on this to help clinicians improve teamwork, personnel, and preoperative optimization. We know that there are significant risks for patients undergoing procedures and anesthesia in NORA locations related to facility and location, access to equipment and supplies, teamwork issues, periprocedural care, and quality improvement. We have seen the demand for anesthesia services in NORA locations rise rapidly, but many of these sites were not designed with NORA as a priority. This has led to retrofitting these spaces to be able to provide safe anesthesia care. The good news is that these recommendations establish clear expectations for the facility even when the NORA locations are on different floors or even in different buildings. Key considerations include grouping procedural areas close to one another and the main operating room when possible, establishing scavenging capabilities and adequate oxygen supply, and ensuring sufficient electrical outlets and lighting to facilitate safe care. You can also use these recommendations to make sure that you have sufficient equipment in your NORA location to provide safe anesthesia care. Do you have emergency airway equipment and the capability for resuscitating patients with malignant hyperthermia or local anesthetic toxicity in your NORA location? Also, do you feel safe as a clinician providing care in NORA locations? Sufficient protection from radiation is required when procedures are performed with fluoroscopy.

How does your team function in NORA locations? It is often the case that the proceduralist and nursing team may not know that anesthesia teams which can lead to unfavorable team dynamics, lack of belonging, and poor communication. This may seem like a little thing, but it can have a big impact on patient safety and lead to adverse events. Since it may be hard to change the physical space, location, and ergonomics, implementing changes in how the team functions and communicates may be a great first step towards improving NORA patient safety. This can be done with team training, creating smaller more dedicated teams, and sharing knowledge about complex cases.

Do not underestimate the impact of production pressure in NORA that can lead to shortcuts and negatively impact patient safety. Following the recommendations will ensure a thorough preoperative workup, standardized communication such as a formal timeout, utilizing appropriate periprocedural monitoring according to the ASA standards, and performing continuous quality improvement related to the anesthesia and procedures.

These are not the only NORA patient safety recommendations. Check out the 2021 article by Herman and colleagues, “Morbidity, mortality, and systems safety in non-operating room anesthesia: a narrative review.” This includes recommendations for improvement following an engineering framework. The study found increased death and complications related to inadequate oxygenation and an increased amount of preventable adverse events. Repeated systems safety concerns included poor lightening, increased noise, cramped workspace, limited access to patients, old and unfamiliar equipment, lack of teamwork, and limited preoperative evaluation. Here are some of the recommendations:

More technical training including intraoperative management of older, frail patients and team-based management of anesthetic emergencies and complications

Robust orientation and teamwork training in NORA locations

Use of checklists

Placement of labels, reminders, displays, or handbooks

Ensuring good task lighting, dedicated work surfaces, and standardized organization of equipment and supplies

Using technology that may help to improve workflow, teamwork, and communication such as headsets that could help to improve communication

Supporting reporting and the follow-up response to adverse events as well as using prospective hazard identification methods to maintain patient safety

Learning from “what goes right” in NORA locations to help build resilient NORA teams.

The APSF recommendations use a multidisciplinary approach from clinicians and healthcare representatives with NORA experience to supplement existing literature used in combination with previous studies and recommendations.

The authors report back from the conference that there was extensive discussion related to the scope of the recommendations. Should there be separate recommendations for inpatient, ambulatory, and office-based anesthesia practices? There is a very diverse range of NORA procedures and in some outpatient or office-based areas it may not be possible to follow the recommendations for separate preanesthetic and postanesthetic care areas. Keep in mind that these consensus recommendations are the bare minimum for safe patient care in NORA and meant to be applied to all NORA locations. This is a starting point so that anesthesia professionals can lead the way towards implementing these recommendations. Here are some additional considerations:

1. The content and focus of the conference may not yet be all-inclusive for safe NORA practices.
2. The final draft is dependent on the first draft which was created by a small group of experts who may have their own biases for safe NORA best practices.
3. There may be bias in the content of the recommendations given that the planning committee members and speakers were mostly from academic practices.
4. Only individual specialists from non-anesthesia specialties participated in creating these recommendations and they may not be representative of their entire specialty.
5. The conference attendees self-selected for attending the conference and may not be representative of the general medical community.
6. Finally, there was significant effort put forth to create an inclusive and psychologically safe environment for all participants, but group discussions may have led to suppression of contrary viewpoints and unexpressed opposition or support. The recommendations went through multiple rounds of survey and review with ability for anonymous input as well. However, the breakout, discussion, and voting sessions of the conference may have been influenced by the public nature of the discourse which may have led to participants not sharing their opinions.

The overall goal for these consensus recommendations is to improve anesthesia patient safety in NORA locations and help move the needle towards creating systems and spaces that are designed for decreased medical errors and optimal patient care.

Before we wrap up for today, we are going to hear from Angus again. I also asked him what he hopes to see going forward. Here’s his response.

[Angus] “Well, for the future, I envision a time where NORA is really just seamlessly integrated into the broader spectrum of anesthesia care.  As these medical advancements continue and, and more and more procedures are shifted outside the operating room, I’ve received some really tailored programs that have dedicated teams to Nora that specialize in these unique environments, really just ensuring the best patient outcomes is possible.

I hope to see where more institutions recognize the importance of NORA and really investing in those resources and training and the infrastructure to support the anesthesia care team in these particular settings. You know, collaboration between departments will be key, of course, ensuring that regardless of where this procedure is taking place, the patient’s going to receive consistent, high quality care.

[Bechtel] I also asked Angus to tell what’s next for his future projects. Let’s take a listen now.

[Angus] “My next steps here are really involved into delving deeper into the specific challenges and solutions that are associated with NORA. Really, I aim to collaborate with experts across the medical disciplines and really help continue developing guidelines and best practices. Importantly, training modules, uh, for trainees and, uh, for practitioners that are really tailored to anesthesia care outside the traditional operating room.”

[Bechtel] Thank you so much to Angus for helping to contribute to the show today. We are looking forward to continued improvement in safe NORA 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.

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

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