Episode #83 Keeping Patients Safe During NORA, 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. For the past couple 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 Medtronic, a major corporate supporter of APSF. Medtronic has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Medtronic – we wouldn’t be able to do all that we do without you!”

Our theme today is NORA patient safety. We have reviewed a recent article from the October 2021 APSF Newsletter about time-out checklists and an article between the episodes about massive hemoptysis in the CT suite and the development of an emergency response protocol for this rare and catastrophic event. Last week, we dove into the APSF archives…[water splash] to discuss an article called “Safety in Non-Operating Room Anesthesia.” We are going to return to that article later today, but first we are going to take a closer look at the Statement on Non-operating Room Anaesthetizing Locations guidelines from the ASA. I will include a link to the statement in the show notes as well.

The American Society of Anesthesiologists Committee on Standards and Practice Parameters provides guidance for providing anesthesia for NORA procedures. The original statement on non-operating room anesthetizing locations from 2013 was reaffirmed on October 17, 2018. The guidelines set the minimum standards for monitoring equipment as well as the type of monitoring required for NORA procedures. It is not surprising that this includes oxygenation, ventilation, circulation, and temperature. Anesthesia professionals are called upon to ensure that the anesthesia equipment is set up in the NORA location and 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 and working appropriately to deliver safe care. Are you ready for the NORA procedure? 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.

These guidelines are from the American Society of Anesthesiologists and set the minimum standards for anesthesia care with anesthesiology professionals for procedures that are performed in non-operating room locations. Remember, these guidelines are the minimum standard and additional monitoring and precautions may be necessary depending on the patient and the procedure. Being familiar with these guidelines is an important step towards providing safe patient care in the NORA setting. Let’s run through them now.

The first requirement is for a reliable oxygen source for the duration of the procedure.  A backup oxygen supply must be available as well. What are the capabilities, limitations, and accessibility of the primary and backup oxygen sources? It is important to address these question prior to initiating anesthesia care. Whenever possible, oxygen from a central supply that meets the appropriate codes is the preferred primary source. A full E cylinder is the minimum for the backup oxygen supply.

Next, make sure that suction is available from a reliable source. The suction equipment and function should be similar to what is available in the operating room.

If you are providing general anesthesia with inhalation anesthetics, then an adequate and reliable gas scavenging system should be used.

Here are some critical supplies that are needed in NORA locations: A self-inflating hand resuscitator bag that can provide positive pressure with at least 90% oxygen; anesthesia drugs, supplies, and equipment for the planned anesthesia care; monitoring equipment that follows the standards for basic anesthetic monitoring, and an anesthesia machine that is maintained at the current operating room standards anywhere that inhalation anesthesia is administered; a code cart with a defibrillator, emergency drugs, and other equipment to provide cardiopulmonary resuscitation. This is not the time to compromise om equipment and supplies.

Now, let’s take a look around your NORA location. It is important to make sure that there are electrical outlets dedicated to the anesthesia machine and monitoring equipment as well as labeled outlets that are connected to an emergency power supply. If you are providing NORA in a “wet” location such as for cystoscopy or arthroscopy procedures or in a birthing room on the labor and delivery unit, it is important to have isolated electric power or electric circuits with ground fault interrupters. This is required as part of the National Fire Protection Association Health Care Facilities Code 99.

Let’s shine a light on the next requirement since adequate illumination of the patient, anesthesia machine, and monitoring equipment is needed and a back-up battery-powered source of illumination is needed as well. You might be thinking that you could use your laryngoscope for this, but that doesn’t count and does not provide adequate illumination in an emergency. While you are looking around with adequate illumination, the next requirement is for enough space for the equipment and personnel with access to the patient, anesthesia machine, and monitoring equipment. It is hard to provide safe anesthesia care if the space to do so is lacking.

Another critical requirement for NORA locations is that adequately trained staff are available to support the anesthesia professional as well as two-way communication that can be used to request additional support when needed.

The next one is pretty straight forward, but each off-site anesthesia locations should be in a place where all building and safety codes as well as facility standards are observed.

Finally, after the NORA procedure, the post-anesthesia management needs to be considered and appropriate for the procedure and type of anesthesia provided. The patient may need to be transported to the PACU and trained staff and equipment must be available to do this safely.

We made it through the guidelines so now it is time to return to the APSF archives and our featured article. Head over to ASPF.org and click on the Newsletter heading. 5^th one down is Newsletter archives. Then, click on June 2019 and scroll down until you get to the article, “Safety in Non-operating Room Anesthesia” by Jason Walls and Mark Weiss. The authors discuss steps towards improving patient safety for NORA procedures especially as the demand for anesthesia care in non-operating room locations grows. It is so important to make sure that your goals for NORA include patient safety and quality of anesthesia right at the top of the list. What can anesthesia professionals due going forward? The first priority is case preparation and making sure that the anesthesia professionals are familiar with the location, equipment, procedures, and available staff. Teamwork between the anesthesia professionals and the procedural team is crucial. Other priorities may include routine maintenance of all the NORA anesthesia equipment, rescue medications and supplies, and the development of safety protocols tailored to the specific site and procedure and type of anesthesia. Establishing a simple, fast, and effective emergency response for the off-site location is important since the response will likely be very different than the emergency response in the operating room. Prevention of NORA-related complications likely involves careful monitoring…be on the look out for respiratory depression, as well as providing anesthesia care that is at the same standard as operating room anesthesia care. Make sure that you have the equipment to monitor expired carbon dioxide and maintain adequate oxygenation and ventilation throughout the procedure. Creating a standardized workflow and emergency response for NORA procedures helps to provide reliable and safe anesthesia care in these diverse settings. This is especially important when the staff are not used to working together or unfamiliar with the anesthesia or the procedure. The authors leave us with a call to action that I will read now: “Each step of every protocol and pathway must be evaluated to create a consistent, safe, and uniform NORA environment for both practitioners and patients.”

When adverse events occur during NORA procedures, it is important to evaluate the event and the response and apply quality improvement methodology towards effective debriefings, root cause analysis, and continuing education programs going forward.

So, what does the future of NORA look like? There will likely be continued growth in this area with new, complex procedures, with advanced technology available for a wide range of patient populations requiring a variety of anesthesia techniques delivered by anesthesia professionals who are flexible and up to the challenge with patient safety as the number 1 priority. Anesthesia professionals may need to be leaders of these multidisciplinary teams leading to improved anesthesia practice, increased value, and maintenance of patient safety. Additional tasks for the anesthesia leaders may include defining safe practices, establishing appropriate institutional guidelines, developing efficient resource management, and evaluating risk related data. Further education for NORA may be necessary for trainee education as well as continuing educational development. Questions that we need to ask going forward with NORA care include: How can we improve our preoperative evaluation? What is the best way to monitor patients before and after the procedure? What anesthesia plan is most appropriate for the patient and the procedure? This is an exciting area for sure with new challenges and new opportunities 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.

It is February which means it is time for an all new APSF Newsletter articles. We are looking forward to discussing the new articles on upcoming shows. Plus, you could be an APSF Newsletter author too. The APSF Newsletter is the official journal of the Anesthesia Patient Safety Foundation with an audience that includes anesthesia professionals, perioperative providers, key industry representatives, and risk managers. The next deadlines is right around the corner so mark your calendars for March 15^th for the June issue. Some of the types of articles include case reports, Question and Answer, Letter to the Editor, Rapid Response as well as invited conference reports, editorials, and reviews all with a focus on anesthesia related perioperative patient safety issues. For more information, head over to APSF.org and click on the Newsletter heading. The last one down is guide for authors and I will include a link in the show notes as well. Plus, make sure that you click on the Subscribe via email heading as well and sign up to be on the APSF Newsletter email list so that you can get expedited access by email to our current APSF Newsletter issue.

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

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