Episode #82 Keeping Patients Safe During 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. For the past two weeks, we have been out of the operating room to discuss important topics related to non-operating room anesthesia or NORA. Well, we are going to stay right here at our NORA location to discuss an article from our archives.

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

For the past two weeks, our theme has been NORA, and we have reviewed recent articles from the October 2021 APSF Newsletter about time-out checklists and an article between the episodes about massive hemoptysis following a CT-guided biopsy and the development of an emergency response protocol for this rare and catastrophic event. Today, we are diving into our archives…[water splash]. Our featured article today is from the June 2019 APSF Newsletter by Jason Walls and Mark Weiss, called “Safety in Non-Operating Room Anesthesia.” To follow along with us, head over to APSF.org and click on the Newsletter heading. Fifth one down is the Newsletter Archives. Then scroll down to click on June 2019 and the second article from the top is our featured article today. I will include a link in the show notes as well.

The authors start with a summary to remind us that providing anesthesia care outside of the OR is becoming a common part of anesthesia practice with a wide variety of sites and procedures. The expansion and growth of NORA may be due to the following: more options for less invasive procedures, aging population with significant comorbidities, new technology, and healthcare economics with the goal of more valve for lower cost. Anesthesia professionals may be asked to provide deeper levels of sedation as well as general anesthesia with invasive monitoring at off-site locations where there is a risk for patient harm. Keeping patients safe in these different environments and during the wide range of procedures may be difficult. This is where protocols and interdisciplinary teamwork may be necessary to provide safe, efficient, and cost-effective care.

Next up, let’s review the closed claims databases related to NORA procedures. Most of the closed claims cases took place in the gastrointestinal endoscopy suite, but keep in mind this is a large percentage of NORA procedures as well. It is alarming that there is a higher frequency of severe morbidity and mortality for NORA cases compared to operating room procedures. Appropriate monitoring is vital for safe anesthesia care and in over half of the closed claims cases, patients had substandard anesthesia care due to inadequate monitoring techniques. In fact, most poor outcomes were due to suboptimal care and unsafe anesthesia practice leading to inadequate oxygenation and ventilation, especially during monitored anesthesia care. One third of the closed claims were related to oversedation combined with under-monitoring, with lack of end-tidal CO2 and respiratory monitors, leading to respiratory depression.

So, is it safe for patients to have NORA-based procedures and are they at higher risk for these procedures than they would be in the operating room? Let’s look at the National Anesthesia Clinical Outcomes Registry and the results from the 2018 study by Chang and colleagues published in the Journal of Patient Safety. I will include the citation in the show notes as well. Overall, NORA-procedures had a lower rate of complications as well as decreased morbidity and mortality compared to operating room procedures. Keep in mind that there is a wide variety of NORA procedures. Different locations have different rates of adverse events with more complications and higher risk for mortality in cardiology and radiology sites compared to the operating room or GI. One of the limitations of the study was lack of controlling for age and comorbidities, so that is something to keep in mind.

In order to review the safety of NORA, we must review the threats to patient safety in these unique venues. Check out Table 1 in the article.

First, what are the NORA-specific challenges? These include the following and they will likely sound very familiar to anyone practicing in a NORA-setting.

• Remote location far away from pharmacy and additional supplies
• Noisy environment
• Limited anesthesia workspace within a small procedure room
• Inadequate lighting
• Minimal temperature regulation
• Electrical or magnetic interference
• Older or different, unfamiliar equipment
• Lack of skilled anesthesia support staff
• Limited patient access during the procedure
• Inadequate power supply
• Radiation safety

In addition, there are challenges that may occur for NORA and operating room anesthesia procedures that include:

• Supply of equipment
• Appropriate monitoring devices
• Inadequate Support Staff
• Patient-related illness
• More cases after normal working hours
• Increased percentage of “emergency procedures”

Let’s take a closer look at the last two challenges from the list. NORA-procedures are more likely to start during off-hours compared to operating room anesthesia cases. This means that the anesthesia professional will be off-site during off-hours leading to limited availability of additional help and resources which may require unfamiliar staff to provide assistance with the procedure and anesthesia. Plus, more of the NORA cases are emergency procedure compared to operating room anesthesia cases. Further investigation is required to evaluate the impact of off-hour starts and emergency status for NORA outcomes.

We are going to tackle a few of these challenges including patient issues, personnel and support team issues, and equipment and monitoring. Let’s start with patient-related concerns and compare NORA patients to patients undergoing care in the OR. NORA patients are older, and the average age is increasing more rapidly off-site when compared to operating room patients. In addition, NORA patients have more comorbidities and are more likely to carry an ASA physical designation status of III or IV when compared to operating room patients. These older and sicker patients may not be candidates for surgical procedures in the operating room making the NORA procedure the only option for treatment.

An important consideration for keeping patient safe during NORA starts before the patient even gets to the NORA location. It is the pre-procedure evaluation. Some of the challenges with pre-procedure evaluations include lack of pre-procedure clinic availability or a dedicated space for this. Even if it takes place immediately prior to the procedure, anesthesia professionals need to perform a pre-procedure evaluation keeping in mind the patient-specific comorbidities related to the unique NORA setting and procedure. The authors provide several examples including the evaluation of an “esophageal stricture or reflux prior to endoscopy, the significance of heart failure prior to an electrophysiology study, or the severity of obstructive sleep apnea prior to an MRI study in which the ability to rapidly address airway obstruction may be limited.” Anesthesia professionals may need to consult with the ICU team for critical care patients who need an emergency NORA procedure to develop an appropriate and safe anesthesia plan. For these cases, obtaining informed consent from the patient may be challenging. Other considerations for safe NORA patient care include:

• Utilizing invasive monitoring when needed
• Evaluating NPO status
• Performing an airway exam and developing an appropriate airway management plan depending on the patient’s position, access to the patient, or if there is a shared airway during the procedure.
• Communicating with the proceduralist, nursing staff, and technicians in the room prior to the procedure to review the anesthesia plan and safety concerns. This can be followed with a pre-procedure NORA time-out. Go check out episode #80 for more information. It is vital that communication continue throughout the procedure and recovery phase as well.

Now, let’s turn our attention to personnel and support team issues. The operating room is often a place where there are clear roles and routine practices and anesthesia professional receive the majority of their training in this space. Moving off-site to NORA locations, each setting is different depending on the specialty. Anesthesia professionals may be unfamiliar in these areas and the NORA personnel may be just as unfamiliar with anesthesia care, anesthesia-related problems, and emergency protocols and even the anesthesia professionals. This is the time for open communication on the entire healthcare team to provide safe care to the patient. If open communication does not occur, then the barriers need to be identified and steps taken to improve communication which may take on the form of an email huddle sent out prior to the procedure or an in-person huddle in the control room prior to the start of the procedures. Regular patient safety protocols need to be followed at NORA locations and may require further instruction and evaluation of compliance.

Inadequate monitoring was a common thread in the closed claims NORA cases review, so it is vital to maintain the same standards for monitoring and equipment in NORA cases as in operating room cases. This is a threat to NORA patient safety since these off-site locations may not have been designed with anesthesia workspace requirements in mind and the equipment may be outdated or retro-fitted. Have you ever provided NORA care and struggled with the monitoring cable organization or the access to the patient or the anesthesia workstation or pyxis? We can turn to the American Society of Anesthesiologists Committee on Standards and Practice Parameters for further guidance. The original statement on non-operating room anesthetizing locations from 2013 was reaffirmed on October 17, 2018. I will include a link in the show notes as well. The guidelines set the minimum standards for standard monitoring equipment similar to the OR and monitoring oxygenation, ventilation, circulation, and temperature be required for NORA procedures. Anesthesia professionals are called upon to ensure that there is appropriate time to set up the anesthesia equipment and to check that the equipment is functioning correctly. Many times, the anesthesia machine is brought to the location just prior to the case and it needs to be set up correctly and working appropriately to deliver safe care. Do you have all the equipment you need including suction? Are your monitors working correctly and can you see the monitor display? There is a call to action to address improperly functioning equipment, suboptimal workspace, and inadequate support at NORA locations.

There is more to talk about in this article, and we are going to return to the Statement on Non-operating Room Anaesthetizing Locations guidelines from the ASA in more detail, but you are going to have to tune in next week when we continue the discussion. In the meantime, if you find yourself practicing in a NORA location, let us know my tagging us on twitter @APSF.org and let us know what you are doing to help keep patients safe during anesthesia care. Other topics for next week include strategies for improving patient safety for NORA procedures and the future of NORA.

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.

Calling all patient safety researchers dedicated to improving anesthesia patient safety and preventing morbidity and mortality from anesthesia mishaps! The Letters of Intent for the APSF Investigator Initiated Research Grants are due by February 17, 2022. The awards are made to the sponsoring institution for up to $150,000 for 2 years duration for 10-30% research time depending on the project. For more information, head over to APSF.org and check out the Grants and Awards heading, second one down is Investigator initiated research grants. I will include a link in the show notes as well. We are looking forward to your submission!!

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

© 2022, The Anesthesia Patient Safety Foundation